Tools for Warm Handoffs
Speaking to a group of long-term care facility senior executives last week at a gathering organized by the Health Facilities Association of Maryland, I was heartened to learn that every one of their organizations makes use of MHA's Skilled Nursing Facility Partnership Development Guide. The executives indicated that the guide is highly valuable in helping them understand hospitals' needs as their organizations work together to reduce readmissions and improve patient experiences.
Released in May, the guide provides information from multiple sources, in a single publication, that helps hospitals identify, develop, and strengthen formal and informal partnerships. It has opened the door for the next phase of these partnerships: skilled nursing facilities transforming their practices to better serve their patients and their partner hospitals.
This early work dovetails with a broader push from the Centers for Medicare & Medicaid Services to overhaul the quality and safety requirements for long-term care facilities and the recent release of star ratings for home health agencies. It has also led MHA to develop two additional publications that will help hospitals build more substantive partnerships with post-acute providers.
The Home Health Agency Partnership Development Guide is similar to the SNF guide in that it can be easily navigated by county and home health agency name and offers a discussion guide to facilitate communication, the INTERACT tool to highlight capabilities, and key quality and cost measures, including all-cause readmissions rates.
The second new tool is the Post-Acute Care Market Profile,which gives hospitals a clear picture of which partners they are referring patients to and how those referrals contribute to the post-acute providers' market shares. This information can clarify your organization's relationship to its post-acute partners and may be used to request regular meetings, encourage greater collaboration and information sharing, and develop innovative procedures together.
If there's one message that post-acute providers seem to want to convey to hospitals, it's that they are not only willing but eager to be a part of Maryland's revolutionary care delivery transformation. They are highly receptive to trying new things to achieve the Triple Aim and to help hospitals meet the goals of the modernized Medicare waiver.
Skilled nursing facilities and home health agencies receive nearly 30 percent of Maryland's hospitals' Medicare discharges. Cooperation among hospitals and post-acute providers will continue to be essential to improving the care we all provide.