David Gillis Design

The Upward Path:
Reducing Readmissions

When patients are ready to leave the hospital, they are not always ready to go directly home. Sometimes they need care in another setting in order to continue to heal. Hospital discharge planners have a challenging task: finding the most appropriate post-discharge care for patients who are well enough to leave the inpatient setting but require ongoing rehabilitation services. Skilled nursing facilities often play this important role in a patient’s recovery. But for discharge planners, determining which facility best fits the needs of a specific patient has been difficult because detailed information about each facility’s capabilities, strengths and expertise was hard to find. The ACO, in partnership with MaineHealth, saw an opportunity to solve this problem with the MaineHealth Senior Living Collaborative, a group of skilled nursing facilities in the MaineHealth service area that shares the ACO’s priority of reducing hospital admissions.
“When we started the partnership, we asked discharge planners what they needed to help patients make informed decisions. They told us that existing resources had narrow search-and-compare capabilities and limited information about specialty care. Their insights helped us design a really robust tool with the information and functionality they requested,” says Melissa Caminiti, RN, the ACO’s Program Manager who coordinated the project.
The result of the partnership’s research and work is the Annual Skilled Nursing Facility Index. Published by the ACO and distributed to MaineHealth hospital discharge planners, the Index provides detailed profiles of 43 Maine and New Hampshire facilities, including their specific clinical and specialty capabilities.
“The Index is a valuable tool for hospital discharge planners,” says Catherine Waterman, RN, Manager of Case Management at Southern Maine Health Care. “Our planners use it to find details about which facility may best meet each patient’s individual needs and to help patients and families make care decisions that are more informed.”
“There’s a clear link between appropriate care in the skilled nursing environment and the 30-day readmission rates that we track as a measure of appropriate utilization,” says Cindy Tack, the ACO’s Senior Director for Clinical Initiatives. “When patients receive care in the facility best equipped to serve them, we’re creating the conditions for a better patient experience and lower likelihood of readmission.”