By Becky Wiese

Got questions about health care? Well, who doesn’t? It’s no secret that the health care system is changing. One of the biggest changes is the role hospitals and other health care facilities will have in patient care.

Heritage Health has long been recognized in Central Illinois for providing nursing and long-term care for the elderly. While still offering long-term residential services, Heritage has refined another part of its service package to better address the new requirements and conditions in health care brought about by the Affordable Care Act of 2010. This enhanced service focuses on post-acute care and therapy services and is referred to as a skilled nursing facility (SNF).

Heritage Health has partnered with both Advocate BroMenn Medical Center and OSF St. Joseph Medical Center through their accountable care organization (ACO) groups to provide seamless, excellent, and necessary medical care to patients. In a notable testament of all three organizations’ desire to provide the best medical care possible, representatives from each group recently met to discuss the changes in health care and explain what their piece of managed care looks like and how they all work together for local communities.

Taking part in the discussion were Colette Gourley, community relations coordinator for Heritage Health; Brenda Moehring, RN, clinical nurse liaison for Heritage Health; Tere Ferguson, RN, BSN, coordinator of the Post-Acute Network (PAN) for Advocate Medical Group; and Jessica Kirby, MSW, LSW, Business Manager of OSF Healthcare’s Skilled Nursing Network.

In large part, the consensus about what is needed most is to change perceptions and re-educate the public about the future of health care. To that end, the discussion centered on terms, explanations, and examples. (Note: Definitions for bold terms can be found in the sidebar “Terms You Need to Know.”)

That the two Heritage Health facilities are included in both the OSF and Advocate ACOs reveals the high standards of the Heritage organization and its commitment to providing the best care possible. Of the four local facilities in the ACO networks for both hospitals, Heritage Health Bloomington and Heritage Health Normal represent two of the four.

With 226 skilled nursing beds in Bloomington-Normal, both Heritage Health buildings are currently the only facilities that have separate sections for post-acute care and long-term residential services. Many of the rooms are private suites. Heritage Health facilities function like a well-oiled machine. They can take admissions 24/7 — when the patient is ready, they are ready.

Changing Perceptions and Re-educating the Public
As health care shifts to meet the requirements set out by the Affordable Care Act, consumers have been hit with a lot of change. What seems overwhelming, confusing, and even scary at times can usually be tempered with a little bit of knowledge. Here are some terms and adages that could use some adjustment:

• Nursing home
Ask anyone over the age of 50 what their impression of a nursing home is and the response is likely to be somewhat negative. Heritage Health, however, is out to change that notion. In short, this is not your grandmother’s nursing home. A more common term today is skilled nursing facility or SNF, however a more appropriate term is post-acute care facility. SNFs offer patients the next level of care when they still need skilled medical attention, especially after a hospital stay.

A physician, called a SNFist, directs the care of the patient admitted to Heritage Health, the post-acute care facility, and sees them on a weekly basis for the duration of the patient’s stay. An advanced practice nurse (APN) and/or a physician assistant (PA), depending on the network, see patients as needed Monday through Friday. In addition, the SNFist, in conjunction with the APN and PA, are on call 24/7. This hands-on approach to care is a key difference in the delivery of care today.

This is a change from the nursing homes of old, where the doctor only saw patients once a month and RNs seemed to constantly be in short supply. Also in contrast, “the nursing quality is at a very high level at a SNF — the level of nursing licensure is much higher than before,” says Kirby. Patients and patient families can be very confident that “complicated medical cases can be easily managed at a SNF, and providers are available if something happens, just like at the hospital,” adds Ferguson.

• Being “booted out” of a facility
Patients may have used this term because of a lack of clear communication. It used to be that the length of a hospital stay was a mysterious mix of physician, insurance, and sometimes patient input. At some point, a decision was made and patients discharged. Without having preset expectations, they often felt they were being “booted out” so the next patient could use the bed. Now communication about length of stay begins immediately when the patient is admitted (or even before, if the hospital stay is due to a scheduled procedure).

“It’s a balance of what the appropriate length of stay is and making sure the patient is ready to move to the next level of care — setting expectations and even goals for the entire process,” explains Ferguson. It’s also about making sure the patient’s information is available for the next team of caregivers.

For example, when a patient has additional needs, such as rehab, after a hospital stay, the social worker at the hospital makes a referral to the clinical nurse liaison. The arrangements are made, the medical information is passed along, and the patient has a seamless transition because the caregivers on both ends have communicated so that nothing gets missed.

Clear, proactive communication from the beginning keeps everyone on the same page regarding timing and transitions. “Every transition [even if it’s within the hospital] is hard on a patient. The unknown and unfamiliar increases the stress level of the patient and the family,” says Kirby. Good communication, especially through electronic medical record (EMR), enables all providers involved in the patient’s care to be up-to-date on what the patient’s current status is.

Communication is essential for good managed care…and no patient should feel “booted out” with the level of communication currently in place.

• “Medicare will pay 100 days”
This attitude no longer applies in today’s managed medical care environment. “Within 48 hours of entering the facility, there is a plan of care with an estimated discharge date,” explains Ferguson. With the goal of moving the patient to their highest level of functioning, today’s advanced surgery techniques and rehab capabilities do not require 100 days.

Expectations for the patient are based on the information provided by the skilled care team during their weekly meetings to discuss the patient’s progress. There are no black holes of communication, no black holes of care with this system. The likelihood of falling between the cracks is practically non-existent.

Long hospital stays for routine surgeries or medical issues (e.g., cardiac, hip or knee replacement, stroke, COPD) are also a thing of the past. Most patients who do not have other complications will be released to the next level of care — such as a SNF — after just a few days. In fact, the goal is for patients to leave the hospital as soon as is safely possible (and to reduce the possibility of being re-admitted) because of the increased risk of illness and infection.

The data has shown that skilled nursing facilities decrease readmission rates and follow-up visits to the Emergency Department (ED), decrease lengths of stay, keep better track of patient progress, and overall result in better outcomes. Care at a SNF also allows for cost savings, which helps everyone. Patients can be re-admitted directly back to a SNF from home if necessary, thus avoiding an expensive and unnecessary hospital stay.

A Simplified Example
Let’s say Aunt Mary has fallen and broken her hip. Her physician tells her she’ll have hip surgery and stay in the hospital 1-3 days, depending on the procedure used and her prior health history. She does well after surgery under the care of a hospitalist, but will need some rehab. While in the hospital, the case manager or social worker meets with her and her family to discuss post-acute care options. This is a move to the next level of care, which could be anything from home health, a skilled nursing facility, assisted living, or long-term care — wherever Aunt Mary would receive the highest quality of care at the most efficient and effective facility to provide that care.

She was still living on her own prior to surgery, so the most likely options would be home health or the skilled nursing facility. If she doesn’t have a lot of available help at home, or if the post-surgical care would be overwhelming for whomever is at home, the best choice is likely to be a skilled nursing facility. She is given a list of options about where she can go (some of which is dependent on her payor status), and is encouraged to consider going to a preferred provider, such as the Heritage Health SNF. Once she has decided to transition to the Heritage Health SNF, the clinical nurse liaison from Heritage meets with the patient and family to answer questions and ensure the admission process goes smoothly.

After she has been admitted to the SNF, she meets the SNFist, APN and/or PA as well as the therapists she’ll be working with. Her progress, medication, and any changes are noted in the EMR, which can be accessed not only by the necessary personnel but also by her primary care physician (PCP). This communication allows the PCP to be informed at all times regarding the patient’s status.

Once Aunt Mary has met her rehabilitation goals and is ready to go home, she is assigned to an extended care manager (ECM) who follows up with her after discharge to make sure her transition to home is successful. She “ties the bow” and makes sure appointments are made, prescriptions for medication are filled, and questions are answered. Finally, the handover back to the PCP takes place verbally and with a summary of care fax, highlighting any changes that have been noted in the EMR.

Looking to the Future
Why is this network of care important? Basically because specific quality measures are now in place that focus on patient outcomes. Cost savings is also a focus, which means that the less time a patient spends in the hospital, the better.

As part of an exclusive group of preferred providers of both ACO groups for Advocate and OSF, Heritage Health stands out as an excellent example of what health care will look like in the future: A highly skilled network of medical care providers who focus on moving the patient to the next level of care resulting from an improved medical condition.

If you have questions about the post-acute care services provided by Heritage Health, please call Colette Gourley, community relations coordinator, at 309-825-1409. She would be happy to provide information that will enable you to make the best decision for you and your family before you have an urgent need.

Terms You Need to Know

ACO — Accountable Care Organization — A preferred network of medical care providers that includes physicians, mid-level practitioners, RNs, and therapists at a skilled nursing facility.

APN — Advanced Practice Nurse (often called a nurse practitioner) — A highly skilled nurse who, under the supervision of a physician, is qualified to practice medicine, diagnose, prescribe medication, and make other medical decisions for patients.

ECM — Extended Care Manager — The designated person who follows up with a patient to ensure that the patient’s transition to the next level of care is successful by making sure subsequent appointments are made, medications are obtained, questions are answered, and the patient is achieving goals.

ED — Emergency Department — The section of a hospital that focuses on immediate medical care due to trauma or crisis.

EMR — Electronic Medical Record — A patient’s medical information stored electronically. EMR allows higher levels of communication for a patient’s medical team as they are able to access the record immediately and have the most up-to-date information with which to make medical decisions.

Hospitalist — Physician who oversees a patient’s care while in the hospital and communicates with your PCP.

Level of Care — Refers to the necessary amount of medical care that a patient needs for a particular period of time. Stepping down to the next level of care simply means that the patient no longer needs the same amount of medical supervision because their health status is improving.

Managed Care — The effort of a network of providers who work together to ensure a patient successfully moves through the continuum of health care levels based on their physical needs and that each transition is smooth and successful.
PA — Physician’s Assistant — A medical professional who is educated, qualified, and certified to conduct medical functions such as physical exams, diagnoses and treatment of illnesses, order and interpret tests, prescribe medications, and other similar
medical tasks.

PAN — Post-Acute Network — The network of providers (including physicians, APNs, PAs, therapists, and nurses) and facilities that offer short-term intensive rehabilitation services in a skilled nursing facility.

Payor Status — What your insurance covers as far as medical care.

PCP — Primary Care Physician — A patient’s “regular” doctor who oversees medical care.

Post-Acute Care — The medical care provided after a hospital stay either in the home or in a specialized facility.

Post-Acute Care Facility — A health care provider specializing in post-acute care.

Preferred Provider — A member of the network of providers (hospital, physicians, facilities) who fulfill the standards of care and work together to provide seamless patient care.

SNF — Skilled Nursing Facility — A facility that offers patients the level of care needed for their continued rehabilitation, usually after a hospital stay.

SNFist — A physician who monitors a patient’s progress on a weekly basis in a skilled nursing facility.