Non-hospital care includes both improved access to emergency department alternatives as well as appropriate and efficient use of post acute services (services provided after a hospital stay). Below are several programs that aim to support patients recovering from acute illnesses and prevent readmissions to the hospital.
Improving Access to Emergency Department Alternatives
Partners Mobile Observation Unit
For patients who require more intensive monitoring, we developed the Partners Mobile Observation Unit (PMOU). This program allows patients to stay at home rather than go to the Emergency Room or be admitted to the hospital. A nurse is sent to the patient’s home within 4-16 hours after referral and conducts an intensive, structured visit as a continuation of the patient’s care plan. The care provided includes health assessments home safety assessments, diagnosis, treatment plan, and test ordering. PMOU educates patients on self management and coordinates with the patient’s primary care provider to make sure all providers involved in the care plan are updated. The goals of this program are to improve care coordination for patients, reduce hospital admissions and readmissions. PMOU also prevents unnecessary emergency room visits and hospital stays.
Telemonitoring for Congestive Heart Failure
Telemonitoring requires easy-to-use equipment that allows patients to track their vital signs at home and communicate with a care team on a regular basis. At Partners, patients in our Integrated Care Management Program (iCMP) who are diagnosed with heart failure receive a remote device that allows nurses to monitor their daily symptoms. The program improves patients’ ability to monitor their own behaviors and their quality of life. Other goals include preventing re-hospitalizations and providing increased care coordination with the patient’s primary care and cardiology physician.
Appropriate and Efficient Use of Post-Acute Services
Skilled Nursing Facilities (SNFs) offer short-term care for patients recovering from an illness or injury, as well as long-term care for patients who require 24-hour care in a residential setting. For short-term SNF stays, patients no longer need to be in the hospital but aren’t yet able to care for themselves at home. There are a wide range of rehabilitation and medical services offered at SNFs that are tailored to meet each patient’s needs.
Skilled Nursing Facility (SNF) Waiver
When patients with Medicare are sent to a nursing facility, they may face challenges including delays and unnecessary hospitalizations. This is due to a requirement by Medicare called the “Three Day Rule”, which requires that patients be hospitalized and treated as an inpatient for three consecutive calendar days before being transferred to a skilled nursing facility (SNF). For patients not currently in the hospital (or recently hospitalized but living back at home), this means they need to be hospitalized in order to be transferred to the nursing facility. This can be unnecessary and inefficient for patients and providers. To address this, Partners applied for and received an exception or “waiver” to this rule given our status as a Accountable Care Organization (ACO). This waiver allows us to send patients directly to nursing facilities from an emergency room, a primary care physician’s office, or other setting, therefore avoiding unnecessary and preventable hospitalizations. This program is only eligible for Medicare patients in the Partners ACO.
Skilled Nursing Facility (SNF) Collaborative
To ensure that patients discharged from Partners hospitals to SNFs can choose from multiple facilities offering the highest possible quality of care, we developed a network of approved SNFs across Massachusetts. These SNF facilities were chosen based on specific measures of quality, clinical services provided, and technology. The SNF Collaborative aims to provide better coordination of care through improved transitions from the hospital to the SNF and to enhance communication among the patient’s providers. Partners HealthCare works closely with the SNF Collaborative by facilitating a learning environment to share best practices and help them improve the care delivered in their facilities.
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