Community, Collaboration and Consistency: Identifying Optimal Patient Care Transitions Across the Continuum and Through COVID-19
About the Session
This session will focus on a partnership that has accelerated patient throughput, enhanced medical staff collaboration and improved quality of patient care pre-COVID-19—a partnership that continued during the height of the COVID-19 pandemic and into today as patients recover from COVID-19 and other non-COVID-related medical conditions. A referral hospital may have as many as 4,000 patients screened each year from any given ICU for a clinical determination on referral to SNF (skilled nursing facility), IRF (inpatient rehabilitation facility) or LTACH (long-term acute care hospital) level of care. Innovative opportunities in data analytics, patient identification and organization collaboration that can be implemented across the continuum to effectively identify the right patients at the right time for the right location of care will be provided.
Engagement in vertical and horizontal strategies to drive improvement in the patient care continuum is necessary in the current financial environment of healthcare entities. Multiple case-study examples highlighting safe transitions of non-COVID and COVID patients will be reviewed. Evaluation of the tools utilized to continuously enhance an integrated relationship that drives quality patient outcomes coupled with best-practice results and collaboration examples provides information for program attendees to evaluate their own patient identification and integration opportunities. Understanding how the variety of population health models, ranging from bundled payments to ACO involvement, fit with appropriate utilization of post-acute strategies is a key area of learning. The presentation will review how one academic health system collaborated with a post-acute partner to drive improved value through appropriate patient identification and clinical care collaboration.
Key education focus areas include sharing best practices focused on identifying chronically critically ill patients to receive the right care at the right time; how impact costs can be reduced through appropriate integration strategy implementation; review of post-acute resources and types of clinical care available for collaboration; evaluation of clinical and financial outcomes demonstrated through case-study review and objective sharing. Real-life testimony provides relatable and transparent information to expand attendees’ existing organizational strategies and understanding.
- Evaluate current relationships with post-acute providers to identify opportunities to improve clinical care, length of stay and financial indicators.
- Demonstrate application of learning by implementing improved vertical and horizontal care coordination methodologies.