Problem Solvers: Improving Senior Living Transfers From Acute and Post-Acute Care

Senior living providers face myriad problems and challenges, particularly in light of the Covid-19 pandemic. But these problems are not insurmountable, and companies across the industry are devising creative solutions.

In this series, we’re surveying industry leaders to highlight these actionable solutions. For this edition, we asked leaders with Pegasus Senior Living, Cypress Living, Juniper Communities, GenCare Lifestyle and Brookdale Senior Living:

How are you improving transitions from acute, post-acute, skilled nursing and home health settings?

Leon Grundstein, Founder and CEO, GenCare Lifestyle

Seattle-based GenCare’s portfolio encompasses six communities

When one of our residents returns from a hospital stay, a rehabilitation stay or a post-acute care setting, we have in each building a personal trainer that takes that individual to the gym or an open space, to do a bodyweight workout to strengthen. These trainers will work with the resident after, or concurrently, with their physical therapy that’s provided by the health care agency or hospital, so that they continue to strengthen themselves and improve their health. This will minimize the amount of times that a resident has to go back to the hospital because of falling or they didn’t make sure they continue to follow the protocols.

We have a partnership with a hospital group, MultiCare. They have a physical therapy agency we partner with to also come to the building and work with residents, if [the therapy needed is] more advanced than what we can provide or if the insurance is still covering it. The goal here is twofold. First: to get our residents healthier and make sure they can sustain the best life they can. Second: to reduce the amount of recidivism to the hospital or a doctor. When the rehab facilities and hospitals see this, it solidifies our relationship with them and [proves] we’re a good place to send them and keep our patients healthy.

One of the things that we specifically train our team members on and our sales teams is to get to know the person.

Pegasus Senior Living Vice President of Operations Justin Wray

We have an electronic health record system for record keeping, so we can transfer information really quickly and get the diagnosis and protocols that the resident needs when they’re discharged. There is a certain amount of time you have to spend [to learn the system], but we’re very efficient.

With home health care transitions, a lot of it’s more emotional. People are used to being in their own home. It gives them comfort to be around their own possessions; they have a lot of memories of being at home. Getting them over that hurdle and into a more supportive and social environment is an emotional decision for them. What’s overlooked, quite honestly, to a great deal by people stuck at home, is that with home health care, they don’t get to socialize and interact with other people. [People interacting regularly with others are] healthier. The pandemic has been so hard, with isolation. People need to be around other people. We’ve suffered a lot of depression, not just in the senior housing industry, but in general.

Katie Maninno, Executive Director, and Katie Kensington, Senior Director of Community Relations, Juniper Village at Brookline, State College, Pennsylvania

Bloomfield, New Jersey-based Juniper’s portfolio encompasses 21 communities

Kensington: Our Connect4Life program is the key to this.

Mannino: Connect4Life is an integrated care model. It encompasses a big part of care transitions for our communities, both in resident transfers to and from acute and [post-acute] settings. We’re able to use things like our electronic health care database to have one location where resident records and health information is stored.

A big piece of that is all of our ancillary providers and partners also utilize that EHR. If we have everybody using the same documentation platform, we have everything we need in one location. In those situations, where you’re looking for information to serve a resident’s needs, it’s right at your fingertips.

With Connect4Life, we partner with the ancillary providers — some have direct access to our EHR; some will provide us with documentation and we upload it into that. Having that access remotely for our physicians and our providers, to be able to get a hold of what they need in after-hours or on-call situations, also helps to reduce any unforeseen hospital or emergency transfers.

We also have a medical concierge. This person is responsible for helping to navigate and create that connection with the acute care settings, in coordination with our move-in coordinators, to connect the acute care setting, the primary care physician, the accepting wellness department, the physical therapy department — any specialty providers. This person is finding that information, identifying it in the health care record so it’s easily accessible and identifiable for everyone, and then making sure that we’ve got that seamless transition.

The medical concierge is able to follow up after the transition occurred, to see how things went: were we successful; were there any opportunities for us to do better? We’ve seen that through care transitions and Connect4Life, we’re able to reduce that risk for a cost of rehospitalization or a return to a higher level of care.

Kensinger: We call our medical concierges the ringleaders. They make sure everyone’s working from the same playbook, bridging the clinical provider, the resident, the family and the community so that everybody has access to real-time information that they need to be able to make the best decisions for a resident, whether they’re new to our community or longtime residents who are returning from an acute stay.

Justin Wray, Vice President of Operations, Pegasus Senior Living

Dallas-based Pegasus’ portfolio encompasses 39 communities

Most of the challenges that we face personally [involve] making sure that the continuity of care continues from whatever setting [seniors are] currently in.

We have a partnership with Genesis HealthCare. Therapy is one of those things that tends to be one of the nuances that sometimes occurs. Their team helps us ensure that on day one, we have services for the residents from a collaborative standpoint.

As an organization, we’ve focused our clinical team on best [practices]. As anything, it’s constant training and education on understanding what those challenges may be, and what are the workarounds. From my experience, there’s no one size fits all [approach], because a lot of it is geography-based, and specific to the market in which we’re interacting.

From an electronic health record standpoint we are not fully there as an organization. We’re still having to do it more on a manual basis of taking that information, and then transitioning it into our health records. It’s something that I’ve faced in other organizations, as well.

When we compare hospital settings to post-acute settings, we have a little bit more runway. A hospital discharge is an immediate need, especially coming from an emergency room [visit]. Having a runway allows for you to be able to work in a collaborative manner with [a hospital’s] interdisciplinary team as well as ours, to make sure that we understand what that individual resident requires so that we can make sure that we’re planning services appropriately to meet those segments when they transition, either to us for the first time or returning back home.

One of the things that we specifically train our team members on and our sales teams is to get to know the person. It’s so frequent in our industry that we want to get to know people by their health condition. We’re also focused on getting to know who they are, where they come from, their background. It’s such an individual element of each of us, so we get to know that so that we can customize as much as possible. We leave the assessment piece more to our health services team, and working with wherever the individual is transitioning from already.

We are rolling out MatrixCare’s Care Assist program in our communities. It’s a system that allows for us to put residents’ personal preference front and center by having key information sent to handheld devices allowing all staff members to meet those specific resident needs along with individual preferences.

Jeanne Beaulieu, Medical Clinic Manager, Cypress Living; and Matt Lessig, Administrator, The Lodge at Cypress Cove

Fort Myers, Florida-based Cypress Living’s campus offers a full range of care including active adult, independent living, assisted living, memory care, rehabilitation and nursing care

Beaulieu: We have a coordinated care team which includes medical providers, a health care liaison, social workers and wellness nurses — we also incorporate private duty and home health, if appropriate for the residents.

Our health care liaison meets with the residents before they transition out of skilled nursing, if they’re moving to another level of care or going back to the residence which they are in. She coordinates care, whether it be with home health, an aide, and then schedules their follow up visit, usually within three to five days of their discharge, to be seen either through telemedicine or in our on-site clinic. When we’re seeing most of the problems is when they return into their own environment, or they’ve gone to another level of care and they’re adjusting to new medications and different diets in a non-controlled setting.

Lessig: We use PointClickCare for our electronic health records platform. It funnels through all the levels of care that we have. This is important, as far as the collaborative team having access to it and being able to read what’s going on with either notes or on the medical health care side. The team uses DrChrono a ton. That has a lot of good information as far as on the health side of what’s going on with residents across the entire campus.

Reducing readmissions for us is a priority. We also look at other metrics such as length of stay. That’s extremely important for us. We look at reducing the rate of falls. We look at volume metrics: census, overall capacity, our admissions per month.

Beaulieu: Our care team meets twice a week to review transitions of care. At each level of care, we discuss the residents and who might need to make a move and who may not. We prioritize them based on their diagnosis and level of care; if they are utilizing private care or not using private care; if they need to stay long term at the (skilled nursing unit).

We look at things in a very comprehensive way. We make sure that before we move somebody, because we also know that moving somebody can exacerbate the condition that they’re in. So we want to make sure that when we’re making those moves, that it’s in the best interest of the resident.

Brookdale Senior Living

Brentwood, Tennesse-based Brookdale’s portfolio encompasses 720 communities

A Brookdale spokesperson submitted the following response.

We utilize several roles in our local community staff to help residents move from more acute care settings to Brookdale including our executive directors, health and wellness directors, sales managers and caregivers. The first step in creating a smooth transition is completing the pre-admission work, so that the transition into the community allows us to focus on getting them settled in their new home on the day they arrive.

Electronic health records have the ability to be an invaluable tool in transitions from acute care settings. However, in health care there is currently a lack of integration between acute and post-acute systems, limiting the transfer of data between care settings. Post-acute EHR partners are working to help facilitate enhanced integration and allow their technology to eliminate manual steps. The future is no longer to just replace the fax or hard copy with a PDF, but to make sure that the information is able to drive behaviors, make your team more efficient, and ultimately ease transitions of care. In the meantime, there are ways to bridge the gap between care settings such as sharing electronic printed documents and providing remote access to physicians to ensure the transitions of care are seamless.

Through relationships and open communication with key health partners, including the primary care physician/health care liaison and the family, a safe and seamless coordination of care is achievable.

At Brookdale, coordination of care begins the moment we learn of the transfer. Our process includes completing an assessment prior to move-in to a Brookdale community. This assessment helps us to understand the resident and their needs. The initial review provides the information needed to develop a plan of care and identify services required. Prior to discharge from acute care, we discuss with the discharge planner discharge orders, status updates and personalized care needs. Hospital documentation is reviewed and the primary care provider confirms the physician plan of care.

During this time, we engage with the new resident and family to facilitate a seamless transition and holistic plan. We do our best to manage the process to create a smooth transition and coordinate care.