Case Studies

Readmission Rates Decrease When Hospitalists Follow Patients to a SNF

Saint Francis Memorial Hospital

Hospital Beds 359
Annual ED Visits 32000
ED Beds

For hospitals and providers alike, discharging a patient to a skilled nursing facility (SNF) can be a difficult decision. Nationally, about 25 percent of these patients end up back in the hospital, a setback that distresses patients and their families. To complicate matters further, depending on the payer, the hospital may not be reimbursed for "preventable" readmissions.
In the past, neither hospitals nor SNFs gained much by working together to coordinate care. Fortunately, the shift toward value-based reimbursement is creating new incentives for these facilities to integrate their efforts. One way hospitals can enhance post-acute care is by having hospitalists follow their patients into the SNF setting.
An Innovative Approach
A member of Dignity Health, Saint Francis Memorial Hospital is a 359-bed hospital serving San Francisco’s diverse, downtown neighborhood. CEP America staffs and manages both its emergency department (ED) and hospitalist program.
The Kindred Transitional Care and Rehabilitation – Tunnell Center, a part of Kindred Healthcare, is located just across the street. It’s one of many regional SNFs that Saint Francis discharges patients to.
In May 2014, at Kindred’s request, a group of Saint Francis’ hospitalists began staffing the Tunnell Center. Because Saint Francis discharges many patients to Tunnell, Kindred administrators hoped this arrangement would allow CEP America to seamlessly coordinate care across multiple settings with the goal of discharging patients home.
A Continuum of Care
When a Saint Francis patient is discharged to Tunnell, the sending and receiving hospitalists connect for a verbal handoff, then communicate as needed throughout the patient’s stay. In addition, the receiving hospitalist can access the patient’s medical records via EMR. These communication protocols give Tunnell providers a clear picture of the patient’s clinical and social needs and allow disposition planning to begin immediately.
This continuum of care is especially helpful when a Tunnell patient experiences complications. If a patient is sent to the ED, the CEP America emergency physician can easily access the patient’s EMR and consult with hospitalist colleagues to determine the appropriate level of care.
In many cases, this integrated team approach can prevent a readmission. For example, a patient with an infection may be able to receive IV antibiotics at Tunnell if qualified providers are on duty.
A Win-Win
Early results of the Saint Francis-Kindred collaboration have been promising. Prior to CEP America coming in, over 40 percent of the patients Saint Francis discharged to Tunnell were readmitted. Within a month of the hospitalists’ arrival, readmission rates dropped to 10 percent. Between June and December, the overall readmission rate from Tunnell remained below 12 percent. During this period, Saint Francis also saw a modest decline in inpatient length of stay (LOS).
The new model has also improved transparency. Tunnell’s medical director, a CEP America hospitalist, holds regular quality review meetings to discuss issues like readmissions and patient safety. CEP America also gathers a wealth of quality data on Tunnell's care that can be shared with prospective patients and used to guide process improvement.
Saint Francis, CEP America and Kindred plan to continue exploring new opportunities for collaboration. They hope the lessons they learn can eventually be applied to manage population health across the country.