“Through love serve one another.” Galatians 5:13

Stonerise Care Blog

What Is Transitional Care?

By David H. Gardner, Chief Development Officer Stonerise Healthcare

What is “transitional care”? I’ve been writing about “transitional care” since 2014 and to be honest, the answer varies widely based on who you ask. One formal answer is “transitional care is defined as a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” (Source: healthaffairs.org).

Hospitals talk a lot about transitional care, but the focus is more often than not about the transition of care and care settings within the hospital itself, not among all healthcare providers. Stonerise has relied on the above Health Affairs definition from the very beginning, as it has some key words applicable to our evolving mission and our role as a healthcare provider. Key words such as continuity, preventable outcomes, and transfer among settings were all important words that needed to be part of our definition and application of “transitional care.” However, we added one more critical component to our definition: “Patient Experience.”

The reason “patient experience” is so important when we talk about transitional care, is that the patient is at the center of everything we do. And you need look no further than our guiding principle, “through love serve one another” – Galatians 5:13. To understand why transitional care is so critical to Stonerise’s mission today, you need a couple of healthcare facts to set the basis of why transitional care and what transitional care is to Stonerise. To answer both those questions, let’s look at what’s changed for the industry in general and Stonerise in particular, because as we often say when describing the Stonerise experience, this ain’t your grandmother’s nursing home any longer.

Nursing Home Patient Evolution

Due to a host of factors and changes within healthcare in general, “nursing homes” are evolving. It’s easy to see the evidence of what’s driving this change.

  • On the skilled nursing center “short-stay” side, we admit and treat today very complex, acutely ill patients due to hospitals being forced to discharge patients sooner. The average length-of-stay today in a hospital in the U.S. is less than 100 hours. These “short-stay,” also called “transitional care,” patients are getting younger and younger – as young as in their 40s.
  • On the skilled nursing center “long-term care” side, we see a shift as well, due to expanded stay-at-home services from companion-care and an expansion of senior assisted living and independent living facilities and options. This can present patients to our long-term care units with comparable health complexities as our short-stay patients. However unlike “nursing homes” of the past, some long-term stay patients improve to the point they can return home.

The lines between the two, short-stay and long-term, have been blurring for several years.

The most significant and alarming change both to Stonerise and the healthcare system overall is readmissions. By 2013, 1 in 5 admissions over the age of 60 were readmitted within 30 days of discharge from the U.S. healthcare system, primarily hospitals, according to Centers for Medicare & Medicaid Services (CMS). In 2015, CMS declared that unnecessary hospitalizations were costing Medicare $27 billion annually. Of that amount, CMS identified $17 billion was viewed as totally avoidable. Additionally, CMS indicated that these readmissions added $42 billion in additional costs to the nation’s hospitals.

Though the CMS data demonstrated that these unnecessary hospitalizations and readmissions are a national problem, their conclusion was it could only be solved locally between providers. So that’s the why, or a large part of the why, healthcare providers simply weren’t keeping patients out of the healthcare system and subjecting them to sometimes two, three and even four readmissions back into a system no one really wants to be in unless absolutely necessary. And West Virginia was no better than anyplace else. West Virginia’s rate is 133% of the national average for preventable hospitalizations and almost 150% of the national 30-day readmission rates.

Patient Transitions: The Missing Link

So that brings us to the “what” – what is transitional care? To be honest, that’s evolved too, for both Stonerise and the healthcare industry. With the alarming rate of readmissions, it was evident there wasn’t much “transitioning” or coordination from one level of care or care setting to another. Remember what CMS/Medicare said about readmissions, “it could only be solved locally between providers.”

In the mid-2000s many providers interpreted transitional care as a physical concept, a separate center, a dedicated facility. Patient acuity was moving decidedly downstream to Stonerise’s front door. We were expected to stabilize, recover and transition more complex, high-acuity, multiple comorbidity patients to home and keep them at home. That included our long-term care patients because we started to see more of them go home, which continues today as well. Home is where the heart is. Home is where you want to be. Home is where my loved ones are. Home is where my life is. Home is where Stonerise wants to help you go.

Stonerise defines transitional care as ensuring a patient-centered plan with warm hand-offs to improve care coordination, patient engagement, patient experience and clinical outcomes as a patient transitions between one care setting or provider to another. We knew that to truly get the patient outcomes and healthcare impact we wanted, providing skilled nursing centers would not be enough. Over the past seven years, we have made substantial investments in talent, infrastructure, technology, and acquisitions to stand up a Stonerise network of care that gets people back to health and back to life. Today, the Stonerise Network spans service lines: transitional and skilled nursing centers, therapy, and home health. We want to stay with patients as they transition between one care center or provider to another.

We provide transitional care in each of our service lines and centers. In some centers, like Charleston Transitional Care at Eastbrook in Charleston or Mapleshire  in Morgantown, it has a more physical definition. But for all Stonerise-supported centers and service lines, transitional care is part of our daily model of care and our patient obligation. We are meeting this new high-acuity and medically complex patient with the necessary tools, care center facilities, resources, and clinicians to achieve this goal. “Transitional care” is upping our game to meet the challenges of 21st century healthcare. And it is creating a covenant with each person who entrusts their health and care to us that we will follow this patient-centered plan to get them back to home – and keep them there.

Transitional Care Takes Us All

When CMS said solving readmissions was a local problem, what they were saying is every provider owns the patient’s outcome. Not just Stonerise and not just your community hospital. Transitional care is about all of us being patient-accountable and all of us working toward the best patient experience we can provide. Every “transition” needs to be a “warm hand off” no matter if within our own centers or between providers. When we do that, we have drastically improved the patient experience.

This transitional care model assures “warm handoffs” through clinician-led teams dedicated to care coordination, patient navigation, and patient accountability. We believe this model better prepares each patient for a return to home and helps keep them home, all while promoting value-based outcomes, reducing avoidable hospital days and a patient’s length of stay while reducing readmissions.

This is why Stonerise Therapy and Stonerise Home Health are so critical to our network of transitional support. Stonerise Therapy enables patients to become strong enough to get home. Stonerise Home Health is the transition mechanism from our centers to the patient’s home. It’s also a mechanism to help keep patients from avoidable readmissions and to proactively manage co-morbidities to hopefully avoid a hospital stay altogether. It’s executing on the patient commitment that once we get you home, we want to keep you there while continuing to provide quality care.

Our vision is to send every Stonerise-supported skilled nursing center patient home with a continuation of our commitment to their recovery and outcome. It is our vision that we return each patient back to the highest quality of their life possible. That’s what transitional care is. And that commitment to our communities and partners is the Stonerise difference.

Find out more about the Stonerise Network.

About the Author
David H. Gardner is Chief Development Officer at Stonerise. He is passionate about transitional care and reinventing traditional models to improve patient experience. Connect with David here.