Katie Miller, Case Management Director at Faulkner Hospital, is passionate about many things. She is passionate about her job and her department, passionate about healthcare reform and passionate about doing the best she can for the patients and families at Faulkner. Which is why she speaks so honestly about the PCC Sole Liaison model, a discharge planning system initiated by Partners Continuing Care (PCC) that pairs the use of 4-Next with 2 liaison nurses who handle all of the post-acute referrals out of Faulkner. One liaison handles all of the facility referrals to rehab, LTAC and SNF, and the other manages all of the home care referrals.
"Originally I was very resistant to trying this new model. Case managers like to be in control of their cases, and this model meant giving up control to the universal liaisons and the 4-Next system", states Miller.
The case managers at Faulkner start the process by identifying patients in need of post-acute care. The two liaisons, Anne Lambert from Spaulding Rehab Network and Kristine Knauf from Partners Home Care, gather pertinent discharge data regarding post-acute care needs and level of care and enter into 4-Next. Because of their experience and the sheer volume of cases that they see, the liaisons are skilled at identifying the relevant information to accurately describe the cases to the receiving facilities. This results in a clear picture of the case to the post-acute entity, which results in faster decisions about acceptance.
"The biggest benefit of this model is that it dramatically reduces the wait time for patients and families gaining acceptance to the next level of care," states Dr. Edward Liston-Kraft, VP of Professional and Clinical Services at Faulkner. "The system sends the necessary information to various facilities in a matter of minutes, which greatly enhances real-time communication between levels of care".
Once the patient has been accepted into a facility or home care agency, the liaisons communicate the choices to the case managers, who then present the options to patients. The Faulkner Hospital case managers are still involved in all aspects of discharge planning, but the process is much more streamlined.
It also allows Faulkner case managers more time to focus on other responsibilities, including physician rounds, quality monitors and managing complex patient and family issues. According to Kristine, "it allows the case managers to focus on other things, and streamlines the whole discharge process. By working as a team, patients don't have to wait so long for their options".
The "Ensuring Safe Transitions in Care" High Performance Medicine (HPM) data, which tracks satisfaction across Partners HealthCare, supports the results of this model as well. Using this model, Faulkner Hospital has had a dramatic increase in satisfaction measures from acute and post-acute reviewers about critical data elements present in the transfer information.
Faulkner's post-acute referral sources also comment on the quality of the evaluations. Brian Murphy, Director of Admissions at Hebrew SeniorLife states, "The evaluations have been complete and honest, so we are able to give an answer about an admission right away." Murphy says, "the timing is fantastic. You do have to learn to trust other people, but you can always follow-up to get more details if you need them".
Because of the benefits it offers to both the acute and post-acute settings, a version of this model will be replicated this fall at Newton-Wellesley Hospital and at Union Hospital. The model will be customized to meet the specific needs of the different institutions, but the same basic premise will remain. Katie Miller advises case managers to keep an open mind, don't pre-judge, and let things work themselves out. "It might help to take an extra beta blocker at the beginning, but you'll learn to love it."
printer friendly