NEEDS-BASED TRANSITION PLANNING

The transition planning process is initiated with a discharge assessment to determine if a patient needs post-acute support. And yet, it can take a long time to find the right post-acute provider and obtain the authorization from the payer.

That’s why it’s so important to start transition planning as soon as possible. In fact, best practice is for case managers to assess a patient’s needs for post-acute care on the first day of their hospital stay.

If the need for post-acute care exists, the case manager should begin the transition planning process, starting with a determination of the appropriate post-acute level of care, such as an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), home health, long-term acute care hospital or hospice.

This determination is based on objective criteria. A few examples: the capacity to make measurable improvement in an IRF setting, medical necessity criteria such as the need for skilled nursing services around the clock, and payer requirements, such as a three-day inpatient hospital stay within the last 30 days required for Medicare reimbursement.

PROVIDING INFORMATION ON POST-ACUTE PROVIDERS TO PATIENTS AND FAMILIES

In discussing post-acute care options, case managers should make a conscious effort to preserve patient choice. However, it is appropriate to provide information to patients and their families to assist in their decision-making.

The case manager should send a referral to facilities that can meet the patient’s post-acute needs and are in-network for their plan. The case manager then provides the list of “accepting” providers to the patient.

It is appropriate to share quality information such as the Star Rating from the Centers for Medicare and Medicaid Services Nursing Home Compare website or the U.S. News & World Report Best Nursing Homes ranking. In addition, case managers should provide information on payer coverage for different post-acute care options.

LEADING PRACTICES OF PREFERRED POST-ACUTE PROVIDERS

Hospital leaders are focused on decreasing length-of-stay (LOS) and reducing costs while expanding their capacity to serve more patients. For most hospitals, discharges to post-acute facilities such as skilled nursing facilities offer the opportunity to do just that.

Post-acute providers who have a timely and efficient intake process help hospitals manage LOS by avoiding delays in the discharge process. Leading practices of post-acute providers who are good partners to hospitals include:

• Automated referrals: This is the ability to accept automated referrals and respond in a timely fashion with an accurate response. If a post-acute facility indicates they will accept a patient, then later reverses that decision, it is detrimental to a positive working relationship.
• Easy intake process: The best post-acute provider partners have clear and efficient processes for communicating the discharge plan and clinical information needed to transition the patient safely to the post-acute care team.
  
  Additionally, it’s helpful to be open to transfers at least 12 hours per day. And yet, there are still many providers that do not accept patients after a certain time, such as after 2 p.m., or do not have admissions staff after 4 p.m.
• Willingness to partner on clinical initiatives: Strong post-acute partners are willing to collaborate with hospitals on improvement initiatives such as understanding and addressing root causes for readmissions. Training may also help to improve their ability to accept patients with clinical needs they may be unfamiliar with, such as special wound care.

Strong partnerships between hospitals and post-acute providers that address barriers and challenges lead to a better transition process and benefit all parties, especially the patient.