Our Approach:
TCO (Transitional Care Organization) utilizes a focused model to strategically segment hospitalist programs into three phases to include: Acute, in-patient care; Post-Acute Care (LTACs & SNFs); and Home (ALFs, independent livings, Home Healthcare, Hospice or private homes).
Our approach coordinates care within each segment to improve patient outcomes, provider performance, and satisfaction, all while improving financial performance for all.
The Acute Care Phase includes a restructuring of existing hospitalist groups to improve patient care and satisfaction while consolidating overbite, coaching and goal setting. During this restructure, TCO works closely with hospital leadership and existing groups to identify opportunity for improvement in both KPI, employee satisfaction and productivity.
A few examples of our methods:
- Mentor and educate hospitalists regarding KPI and related financial performance metrics
- Monthly scorecards
- Implementation of hospitalist-lead committees to improve involvement and leadership
- LOS Zoning to reduce unnecessary lengthly stays
The Post-Acute Phase includes the development of a meaningful program with a full-time Post-Acute Medical Director, who is responsible for leading and collaborating with acute care providers and post-acute facilities to coordinate BPCIa care onsite to improve patient outcomes, to reduce RTA, and to bridge gaps with PDPM.
Examples of interventions within this phase include:
- Engaging a HQN of Post-Acute SNFs and LTACs to collaborate and commit to hospital directed outcome goals
- Review of Skilled Nursing Facility Standards (E-Kits, IV Medications, BiPAP, RN staffing, monthly nursing education)
- Monthly HQN Meetings to discuss RTA/LOS
- Direct admit process for SNF and LTAC discharged patients to return within 3 days of exacerbations
The Home Phase includes the development of a formal program to be managed by the Post-Acute Medical Director, who is responsible for the coordination of the identified HQN providers, which included home health, hospice, home medical equipment and home physician services to coordinate BPCIa and PDGM overbite to improve patient outcomes and reduce RTA.
Our model seeks to improve the outcome of discharged patients in a number of ways:
- Engage HQN home care providers to collaborate and commit to hospital directed outcome goals
- Review monthly RTA by HQN Home Care Providers
- Amending Discharge Plans to include collaborative engagement with community health providers or PCPs.
- Advanced Practice Provider visits within 24 hours
- Specialized Programs to track and monitor disease-specific populations (i.e. COPD, CHF, and Pneumonia patients)