Dr. John Schnelle is Hamilton Chair of Geriatrics and Director of the
Center for Quality Aging at Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee.
He and his team have been working to improve transitions of patients from
their tertiary facility to skilled nursing facilities (SNF) for post-acute
care (PAC).
While his team’s creation of standardized data collection has had
success, the biggest barrier they encountered was communication breakdown
with partnering SNFs. “Everyone can agree with the need for a uniformed
communication process for transitions of care,” said Schnelle. “The
problem was that there is such a high turnover rate that makes it very
difficult to get people competent in using those pathways.”
Across the country,
turnover rates for nursing care centers reached 43.9% for all employees and over 50%
for registered nurses, according to the latest American Health Care Association
Staffing Report. Recruitment and retention challenges are common across
rural healthcare entities providing PAC. Empowering and training staff,
maximizing community partnerships, involving community health workers,
and applying new technology are just some ways for rural healthcare leaders
to create incentives for staff to join, or stay on, a healthcare team.
PAC Transitional Care Model Creates a Win-Win-Win
Dr. Mark Lindsay is a pulmonologist at Mayo Clinic Health System in Wisconsin.
In the year 2000, he initiated a proposal to improve transitions from
Mayo’s tertiary hospitals (Eau Claire and Rochester) to their outlying
Critical Access Hospitals (CAHs). Lindsay stated, “Provider handoffs
and transitions between facilities are two of the areas we score the lowest
in healthcare.”
Lindsay referred back to a Transitional Care model he helped develop for
a skilled nursing facility in Chippewa Falls, Wisconsin, for patients
on ventilators. The rate of patients weaned from ventilators with this
program was
over 60%, and nurse assistant turnover rates dropped to
half of the SNF’s normal rate, falling much
lower than industry benchmarks.
Lindsay thought that the team-based concept used in that model could work
just as well for non-ventilator patients in a rural PAC hospital setting.
“Rural hospitals have a positive environment for a patient and their
families,” he said. “[Staff are] very committed and passionate
about rural healthcare and they are really good at what they do. So there
are big opportunities.”
He applied the concepts of enhancing the team experience, expanding on
each clinician’s abilities, and using existing staff and resources
to PAC teams in rural settings. The model proved to be a “win-win-win”:
a win for the tertiary hospital, a win for the receiving CAH, and, most
importantly, a win for the patient.
“We know that staff burnout in healthcare is through the roof. By
promoting a positive culture and creating a positive work environment
that is team-based, we can overcome some of the obstacles to recruiting
and retaining staff in rural communities,” said Lindsay.
So far, this model has been implemented in 11 out of 12 Mayo Clinic Health
Systems’ CAHs. Patient satisfaction rates and willingness to recommend
a Mayo facility reached 92%. Referrals from Mayo Clinic to CAH Transitional
Care improved by 500%. Through a joint venture, Lindsay continues to train
healthcare systems around the country in post-acute care solutions. Outside
of Mayo, an additional 44 CAHs have adopted the Transitional Care model.

A transitional care team visits with a patient at Deer Lodge Medical Center
in Montana. This Critical Access Hospital is one of 44 outside of Mayo
Clinic Health Systems that adopted the Transitional Care model.
Empowering Staff Takes a Culture Shift
Lindsay teaches that creating a positive work environment starts with empowering
staff – especially nurses, therapists, and nurse assistants. “Teamwork,
comradery, the culture – all those things can really make a difference
in recruiting and retaining,” said Lindsay. He recommends every
member of the multidisciplinary team be included in bedside rounds, giving
those working the closest with the PAC patient a say in their care plan
and leveling the hierarchical playing field. Lindsay came up with the
acronym “CREATE” as a tangible and simple way for teams to
implement the CAH Transitional Care model’s key characteristics:

Lindsay explained, “These principles are vital day in and day out
to bring out the best in all team members and to create an environment
where people can continue to grow, expand their skill sets to be the best
they can be, and most importantly, expand the capabilities of the team.”
Take cheerfulness. Lindsay said that the top two reasons why a patient
recommends a hospital is how well the care team works together and the
cheerfulness of staff. Taking the time to recognize jobs done well is
a simple but powerful way to influence staff attitudes.
When Lindsay started the Transitional Care model at Mayo Clinic Health
System in Bloomer and Osseo, Wisconsin, the PAC patient census was around
four, the
average patient census of most CAHs today. Because of the CAH Transitional Care model, Bloomer
and Osseo’s PAC services frequently exceed 14 patients and swing
bed days have tripled. Patient and employee satisfaction rates have been
consistently high and the model has been a point of attraction for recruiting
nurses and therapy staff. At first, the hospital used the staff they had
to run the program. After the patient census increased, they hired more
staff and now offer 24/7 respiratory therapy.
“We are seeing that the model works independent of geography,”
said Lindsay. “This program can expand the capabilities for a rural
hospital to care for these patients locally and to do it as well or better
than anyone else.”
Because Lindsay’s Transitional Care model uses current staff and
available resources, this model can work well for CAHs that already have
a high nurse-to-patient ratio. By spreading the work among other members
of the transitional care team in line of their scope of practice, it can
help ease the burden on physicians. “It really moves a lot of that
work from the physician to the team members and leverages the team. We
know as we deal with physician shortages, this kind of team-based care
is going to become more and more vital.”
Utilizing Community Health Workers to Strengthen Communication
In his white paper,
New Models for Rural Post-Acute Care, Lindsay references studies that show poor communication in a healthcare
setting contributes to medication errors, increased costs, patient harm,
and even deaths. Vanderbilt’s Schnelle said that one solution for
communication breakdown in post-acute care settings is continuous education
of new staff: “It’s not just a matter of training someone
once and then you are done. The training needs to be ongoing – incorporated
in day-to-day activities.” He recommends “hospital huddles”
as an effective practice. “Rather than taking them into rooms and
doing a training with a blackboard, training happens right on the floor.
You don’t need to spend 40 minutes, but only five to 10,”
said Schnelle.
At
Lexington Regional Health Center (LRHC) in Nebraska, hospital huddles are a daily occurrence. Each morning,
transitional care teams meet to discuss their patients’ progress
and goals. Among the clinicians and support staff on the team are community
health workers (CHWs). Hiring CHWs who both understand and can communicate
with Lexington’s growing multicultural population (now 10% Somali
and 67% Hispanic) was one of CEO Leslie Marsh’s top priorities when
she first joined in 2010. “My question was: How can we take care
of patients and be more inclusive?” she recalled. “It was
a matter of ‘we need to be delivering value and we need to be taking
care of our community.'”
Since a beef packing plant opened in Lexington nearly 30 years ago, cultural
differences and language barriers continued to create communication challenges
between staff and patients. Now, CHWs who also serve as interpreters rotate
within transitional care teams to ease the communication between staff
and PAC patients recovering after an acute hospital stay. Marsh referenced
Maria Reyes, a Latina CHW who specializes in behavioral health and has
gained the trust of her population. “She’s really made a difference
in the way that we understand what is happening with our patients,”
said Marsh.

Community Health Worker Maria Reyes (right) and Interpreter Sahra Ali (left)
work to ease communication between patients and clinicians at Lexington
Regional Health Center.
Reyes not only makes regular visits to the patients while they are in the
hospital’s swing bed program following an acute stay, but also meets
with the patient before a planned surgery or clinic visit. She brings
concerns back to the LRHC’s transitional care team in order to set
the patient up for a successful discharge or transition of care. If the
patient is discharged to the local nursing home or home health agency,
Reyes travels on her own time to ensure the patient understood all the
instructions that were relayed before the transition. These extra efforts
to smooth communication makes the transitional care team’s work
with each PAC patient more effective.
Embracing Community Partnerships and Developing New Nurses
VNA Home Health Hospice, a service of Eastern Maine Health System, is continually looking for
ways to maximize the skills of every clinician and keep registered nurses
working at the top of their license. To do so, staff explore partnerships
that can come alongside home health clinicians. Leigh Ann Howard, RN,
MSN, CHFN, is the director of VNA’s home health program and specialty
programs. She helped establish their
Faith Community Nursing Program to engage parish volunteers in providing basic in-home care for their
fellow congregants following an acute hospital stay.
Volunteers can have a medical or non-medical background, but all are vetted
and trained to provide social, psychological, spiritual, and physical
care. The volunteers help meet some of the patient’s needs, allowing
VNA clinicians to provide a higher level of medical care within their
scope of practice, maximizing their time and skill set.
Some partnerships are informal in nature but just as beneficial, like the
lobstermen who ferry home health clinicians to the islands off the coast
of Maine so they can make a home visit. Other partnerships are still being
explored, such as engaging paramedics in delivering PAC in patients’
homes through community paramedicine. “So many things are interconnected
in many different ways,” said Howard. “It takes being very
nimble, meeting the need that’s there, and continuing to offer a
variety of different programs.”
Like many rural healthcare services, Maine’s aging population and
outmigration of youth are top challenges of recruitment and retention
efforts. Currently, the number of nursing graduates in Maine aren’t
enough to fill the vacant nursing positions across the state.
Dr. Alana Knudson, Project Area Director and Co-Director of the Walsh Center
for Rural Health Analysis at NORC, led a
study finding that recruitment of therapists and nurses who were comfortable
going into people’s homes to provide home healthcare services was
a challenge for some agencies.
“Providing care in the home setting is very different than in the
acute setting, particularly when most home health providers go to a patient’s
home alone. Most new graduates have been trained to work in acute care
settings with a team of other staff and do not have the skills and experience
to treat a patient in their home,” said Knudson. “We need
to develop curricula that include the home setting as part of healthcare
education and training so that we have an adequately trained workforce
to meet the growing demand for post-acute care in the home setting.”
In Maine, VNA’s Vice President of Nursing and Patient Care Services
Elizabeth Rolfe has created change on the state level to include strategic
onboarding and in-house training for new nurses to succeed in home healthcare.
She recalled her initial idea: “If everyone is out there trying
to recruit experienced nurses…if we have to compete with all the
hospitals, care management roles, primary care physician practices, then
maybe our solution is to take the opposite strategy and, say,
develop workforce of the future and bring these folks in earlier.”
Until 2015, state law required nursing graduates to gain one year of nursing
experience before they could work in home healthcare. Moved by the state’s
growing nurse shortage and over 30% increase in VNA’s clients, Rolfe
took action. She worked with the Home Care & Hospice Alliance of Maine
to draft changes to the law. The change allowed new nurse graduates to
start home healthcare immediately after graduating and required the hiring
facilities to include onboarding initiatives to ensure a successful start
for new nurses.
After the legislation passed, VNA put measures in place: Responsibilities
are added slowly and under supervision while new nurses can take advantage
of a mentoring program and support groups. Their new externship program
for nursing students is gaining popularity, and VNA has gone from being
short-staffed to having more applications than positions available.
Telemonitoring Cuts Down on Windshield Time
Although home health episodes billed to Medicare have increased by
over 60% since 2001, home health in rural and frontier locations has become more
of a challenge. Knudson links this challenge to reimbursement limitations:
“Delivering home healthcare is cost-prohibitive in many rural and
frontier communities because of windshield time. You do not get reimbursed
from Medicare for the time it takes a healthcare provider to travel to
and from a patient’s home. Covering staff’s travel time to
outlying areas without insurance reimbursement may be very expensive for
rural home health agencies.”
The growing use of telehealth has provided another solution to help far-reaching
patients needing post-acute care services. VNA started a
telehealth home monitoring program to help monitor patients and cut down on some of the PAC home health visits.
Upon receiving a referral, patients are stratified by risk and distance
to qualify for one of VNA’s 400 remote monitoring systems. For instance,
patients living on one of Maine’s islands would have higher priority
than one who lives in urban south Maine.
Transportable machines are installed in a patient’s home to help
monitor vital signs. Every morning, the machine reads their vital signs
and transmits the information to a team of specially trained nurses and
therapy staff. Knudson sees telehealth as an answer not only for overburdened
staff, but also for better patient monitoring: “It may improve outcomes
because it keeps the patient engaged with their healthcare providers on
a consistent basis. Once a change is noted, the home health providers
can determine if a phone call to the patient or a home health visit is
appropriate, and the health issue can be addressed in a timely manner.”

Telemonitors help VNA clinicians detect irregular patterns in patients’
vital signs from a distance.
Telehealth has also been approved as a method of conducting CMS’s
face-to-face requirements between provider and patient, a move that will help reduce
time, cost, and delays. It’s the use of alternative methods that
help VNA deliver services to their growing number of patients. While they
continue to grow relationships in rural regions not yet familiar with
telemonitoring, they have become a model program. In 2017, Medicare Payment
Advisory Commission (MedPAC) conducted a site visit to evaluate VNA’s
telehealth home monitoring program. Information gathered from this visit
informed the research and recommendations presented in the 2018
MedPAC Report to Congress: Medicare Payment Policy.
“You’ve got to embrace them,” Rolfe said of innovative
workforce solutions. “We are a poor, rural state with an aging population
and workforce challenges. So you’ve got to leverage anything you
can to serve these rural communities.”
The article was originally published on the Rural Health Information Hub:
https://www.ruralhealthinfo.org/rural-monitor/post-acute-care-workforce/