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Mount Sinai Health System: transitions of care from SNF to home

CarePort recently hosted a webinar, “Transitions of Care from SNF to Home,” with its client partners at New York’s Mount Sinai Health System. The health system is comprised of eight acute hospitals, 7,000 primary and specialty physicians, more than 3,000 skilled nursing facility admissions per year within its ACO population, and a SNF collaborative with approximately 50 partners in New York City and Long Island. Joining us from Mount Sinai were Esther Moas, MS, RN, Senior of Care Continuum, responsible for the health system’s post-acute care strategy and operations; Arlene Berger, LCSW, Director of Social Work; and Kelly La Terra, LCSW, Associate Director of Social Work.

Below, we share how Mount Sinai took their successful discharge planning practices in the acute setting and translated them into best practices for discharging from SNFs.

The problem: SNF discharges lead to hospital readmissions

At the end of 2018, Mount Sinai Health System realized that one in four ACO patients transitioning to a SNF from Mount Sinai returned to the hospital within 30 days. In analyzing the root cause and speaking with SNF partners, it was evident to Mount Sinai that many patient readmissions occurred following SNF discharge. Mount Sinai hadn’t realized these patients were already discharged, and the SNFs were unaware that patient rehospitalizations occurred after being released from their facilities. Most importantly, primary care physicians were unaware not only that their patients were discharged from post-acute care, but also that they were being rehospitalized; once discharged from SNFs, PCPs lacked sufficient contact with, and clinical information about, their patients.

Discharge planning best practices

Interdisciplinary rounds

Mount Sinai urges SNFs to incorporate interdisciplinary rounds – at least two times per week – with nurses or physicians, a critical component of discharge planning from the hospital. SNF providers should begin discharge planning upon a patient’s admission to the SNF by first identifying  patient goals for his or her SNF stay, determining functional status for a safe discharge – given what the provider knows about the patient’s community resources and family, health insurance and ability to pay, assesses a patient’s home support, and determining the need for Medicaid/long-term or private pay services. Communication is key, and should be established with the patient’s family and PCP from the onset.

Social determinants of health

Social determinants of health should be considered early in a patient’s SNF stay. A successful discharge hinges upon managing expectations: what to expect when the patient is first discharged home, and what to expect from health insurance. Early in a patient’s SNF stay, social workers should address short-term considerations – including home modifications such as necessary equipment, bedbug exterminations and wheelchair accessible housing – as well as long-term considerations – including connecting patients with community-based services, and ensuring that patients and families are equipped to cope and adjust to the patient’s new medical condition.

Provider collaboration and communication

Ideally, transitions of care should involve providers across the continuum – including social workers, care coordinators, PCPs, payers and SNFs – all of which play a critical role in the discharge planning process. For example, social workers should educate families about post-discharge care management to reduce caregiver or patient anxiety and stress, and assist the family with financial planning – including Medicaid applications and elder attorney referrals. Mount Sinai has also encouraged its SNF partners to work and collaborate with its preferred provider network for home health agencies, to ensure that patients receive high-quality care once discharged from the post-acute setting.

Consent to ensure patient commitment

To help ensure a successful discharge, patient consent – or the consent of his or her proxy – is critical so that the patient is involved in, and committed to, their care plan. As part of a patient’s discharge, there should be a reconciliation of all pre-discharge medications with the patient’s post-discharge medications, as well as a post-discharge plan of care indicating where the patient plans to reside, follow-up care arrangements (for example, a patient should have a follow-up appointment with his or her PCP scheduled within seven days of discharge) and post-discharge medical and non-medical services.

By leveraging CarePort Connect to track patients and manage patients across the continuum, partnering with SNFs and implementing collaborative population health improvement efforts, Mount Sinai’s 30-day readmissions following SNF discharge have trended down. Connect has been a critical component of these programs, as without the systems in place to identify where patients receive care and when they are readmitted, none of these initiatives are possible. Originally 14.8% in Q1 2018, its 30-day readmissions had decreased to 11.9% by end of year – a 20% reduction. In summary, discharge planning should always begin upon admission – and it is critical that patients and their families are engaged in the process. To achieve a successful discharge, providers should determine anticipated discharge needs and what a patient’s resources, or barriers, will be once they leave the facility.


You can watch this webinar in its entirety here. Or, click here to learn more about how CarePort can help your organization optimize its discharge planning process.

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