Transitional Care

A Message to our Valued Providers and Medical Community Partners:

In healthcare, patients commonly receive care in two different settings: first, hospital-based or acute care and, second, post-acute care or care that patients receive after being released from the hospital.  It’s during this post-acute care continuum that home health and hospice play meaningful roles in delivering high-quality care and keeping patients safe wherever they call home.  Generally, once patients have been to the hospital and then return home, they want to do all they can to not return to the hospital again.  The Transitional Care Program is aimed at keeping patients safe wherever they call home and reducing unnecessary re-hospitalizations. Here’s how the Transitional Care Coordinator runs the program in different post-acute care settings:

1. Across the Continuum:
   1. Monitor patients who are at high-risk of re-hospitalization (high-risk) while they are in the continuum (generally monitored for 60 to 90 days)
   2. Assist with assessing high-risk patients for appropriate level of care and facilitate transitions and referrals as needed
   3. Work closely with clinicians, discharge planners, social workers, etc. to identify barriers and come up with solutions to help reduce the risk for re-hospitalization
2. Skilled Nursing Facility (SNF):
   1. Send high-risk LACE assessment scores to key team members at SNF weekly
   2. Serve as a resource for discharge planners for all high-risk patients, as needed
   3. Meet with high-risk patients identified as home health or hospice candidates prior to discharge from the facility to assist with a smooth discharge
   4. Monitor patient progress, after admission to home health or hospice, for 60 to 90 days (post hospital discharge)
   5. Make referrals, as needed, for SNF placement if appropriate (including short-term, long-term and 90 day stays to qualify for other beneficial long-term programs)
3. Assisted Living (ALF) and Independent Living (ILF) Facilities:
   1. Assist with transitioning patients back to SNF, as needed
   2. Make referrals to ALF/ILF if patient needs and qualifies for that level of care
   3. If ALF takes New Choices Waiver/Medicaid Patients educate patients about this option when assessing appropriate level of care
4. Home Health and Hospice:
   1. Identify and track high-risk patients for 60 to 90 days (post hospital discharge)
   2. Meet with high-risk patients prior to discharge from facility to assist with smooth transitions home
   3. Track all patients from SNFs and communicate with SNF if patient needs to return to SNF during the 30-days post SNF discharge or if patient returns to the ER or hospital in the 30 days following SNF discharge
   4. Weekly, send out internal 30-day window report to home health clinical team that identifies patients who fall within the 30-day window to be able to go to/return to a SNF, as needed (this report is also discussed at bi-monthly clinical team meetings)
   5. Work closely with clinicians to help prevent all unnecessary re-hospitalizations and ER visits
   6. Facilitate transitions of care back to SNF as needed
5. Hospital
   1. Serve as a resource for high-risk patients and assist with being a solution for the community as a whole
   2. Meet with patients in the hospital as needed to assist with warm handoffs and safe transitions home
6. Non-Medical Homecare:
   1. Make referrals as appropriate for additional wrap-around services
   2. For homecare agencies that are contracted with Medicaid, refer dual eligible patients who need this level of care or additional support (Medicare currently does not pay for non-medical homecare services, but Medicaid does)
   3. Serve as a resource for high-risk patients and assist with being a solution for the community as a whole
   4. Assist with transitioning difficult-to-place patients into appropriate levels of care, as needed