Advancing Post-Hospital Recovery Through Value-Based Models

As hospitals and health systems continue to evolve in value-based care, optimizing the post-acute recovery process has become a top priority. In this episode of Value-Based Care Insights, Diane Shifley, Assistant Vice President of Population Health and Post-Acute Services at a major Chicago health system joins us to discuss how robust transitions-in-care programs can drive better patient outcomes. She shares insights on the critical role of early patient evaluation—whether at hospital admission or pre-surgery—in shaping effective transitions. We explore how transitional care models, including post-acute facilities and home care, can reduce readmission rates, improve patient satisfaction, and control post-acute costs. This episode offers actionable strategies to strengthen your transitions-in-care to support patients through successful recovery. 

LISTEN TO THE EPISODE:

 

 

Daniel Marino: 

 Welcome to value-based care insights. I am your host, Daniel Marino. Well, we have a great topic today. We're going to take a deep dive and talk about transitions of care, and in particular care in the home models. Many hospitals are really focusing a lot of their attention on transitions of care, and also these care in the home models for a couple of reasons. One it provides, if you do it well, really good quality outcomes for the patient. I think it really addresses a lot of needs for the patient as well as the caregivers. But the implications of doing it poorly result in high readmission rates, maybe without the right level of planning. You know you have higher length of stay. Obviously it affects the cost model. And again, it has some major implications to the patient as well as the caregiver. Well, I have a great guest today who has a lot of experience putting these models together has done a great job for her health system. Diane Shifley. She's the Assistant Vice President, population, health and post-acute services for a large health system here in Chicago, Diane, welcome to the program. 

 

Diane Shifley:  

Thanks, Daniel, happy to be here. 

 

Daniel Marino: 

 So, Diane, give me your thoughts and your opinions. As I mentioned in my opening comments, many hospitals, they're really focusing on that transitions of care program that really expands beyond just discharge planning. But many of them have really struggled with it. Why do you think they've struggled with really putting together these programs that have been effective? 

 

Diane Shifley:  

Yeah. So, Daniel, I think a lot of hospital systems have struggled when they think about the transitions of care program. We're being challenged in in new ways to extend services beyond the patient leaving the hospital doors. And one of the struggles I think that hospitals and staff members have is thinking about setting up a plan that is comprehensive for the patient and what I see most, and what we have really looked at in the health system that I work in is, are we setting that patient up for success by ensuring we're choosing the correct discharge disposition to start? 

 

Daniel Marino:  

Yeah, right? And then, and just kind of putting in place or understanding the factors that are going to in really influence, that that discharge plan right? So you know, almost the pre planning piece has to drive the post recovery absolutely. And so kind of elaborate a little bit on that. I think this is a big area that hospitals don't really give some consideration to. 

 

Diane Shifley:  

Yeah. And I think you know, it depends on where the patient is entering the health system and whether it's a surgical procedure, that's, you know, planned, and you have that opportunity to meet with the patient and really talk about not just what's going to happen at surgery. But even more importantly, what's going to happen after surgery and what that post surgical period is going to look like. But talking about, not just the clinical recovery for the patient, but everything else that goes with it. What kind of help are they going to need? Whether that's help, you know, with basic ADLs. What kind of you know, support are they going to need from, you know, therapies in the home and home health services? And then you have another set of patients that they don't have that luxury of where you can meet with them before they come to the hospital. But now they're in the hospital, typically for an acute event. And it's a very short window of time, you know. Typically, patients are in the hospital only for 3 to 4 days. And that's a very short period of time to get a really comprehensive program or a comprehensive plan set for those patients. And this is where I think a strong care management team in the hospital is crucial in their assessments of the patient, not just from the clinical perspective, but also from a social determinants of health or social drivers of health, I should say, perspective. What are the things that are going to impact the patient's health? Not just from the clinical perspective, but what, additionally could be impactful. 

 

Daniel Marino:  

Well, and you know the typical discharge plan focuses on, say, the you know the medications that have been prescribed in the hospital, and maybe some instructions that need to be given that the patient needs to follow post recovery. When you're thinking about, say, the care in the home model or the right transitions of care plan for the patient. How do you balance the needs of the patient? Right the recovery there, but also the requirements of the caregiver right? And what the caregiver needs to sort of, you know, influence that care of the patient. In some cases, I mean, you would hope that patients do have the caregiver at home to be able to help support the recovery. In other cases maybe they don't. How does that come into play as you start to build your program. 

 

Diane Shifley:  

Yeah, so we've really leaned into. And we have in the last year developed a system transitions of program. And we had at the different entity levels, but really brought it to the system level. And we started to think about who are the key players that need to be part of that transitions of care program for the patient. And of course everyone has RNs as part of their typically transition to care program. Right? They're the ones who are calling the patients. But as we started to think more broadly about the needs of our patients, once they're in the community, we added licensed social workers to our team. We also added medical assistance to our team. And the 4th member of our team that, we added, is community health workers. And through those 4 care team members on the transitions of care team, we found that we were able to really comprehensively wrap our arms around that patient. But at the same time from an organizational and a financial responsibility of the organization we were also able to make sure that everybody was then working to the top of their license. So if there was a need that a patient had that could be addressed by a community health worker or an MA, those tasks would be able to be delegated to them rather than having the RN, who is ultimately a more expensive resource addressing those lower needs of the patient. And so they really, comprehensively work together. We're lucky that we use a platform within our EMR that helps us to coordinate that type of service through the different care team members. 

 

Daniel Marino:  

That's great. I think that care team model that you just described is something that is often missed. I am seeing more and more hospitals incorporating, say, social workers. But I really love the community health aspect of that, because I think it's really driving a lot of real effective. Let's say, you know, processes, and just, you know, additional support for the caregivers as well as the patients. 

 

Diane Shifley:  

Yeah. And I think the unique thing, Daniel, I'll just say, is that community health workers I have found have a very unique skill set to make really strong connections with patients, and we can't neglect the fact that patient experience is on everyone's mind. And we want to make sure we're giving the patients the best experience. You know, we are a industry that is all about service and what we're providing to our patients and community health workers because they are members of that community can really connect with patients in a very unique way, and patients seem very satisfied by it. 

 

Daniel Marino:  

Yeah, I think so too. And I think it really just. It resonates more with the patient, with the caregiver, and really where they are in their community. Let's talk a little bit about, you know. Maybe the specifics of your of your program when you think about the things that have driven the success of your program. What are some of those critical components that you've been able to build, that you've been able to really lean on that have driven some of the success? 

 

Diane Shifley:  

Yeah. So a few things come to mind the first, and I'm kind of taking us back a little bit in the patient journey of the patient being in the hospital. And being a physical therapist by training in my background, I'm very focused on patient’s correct discharge disposition. What is the patient's functional level, and where is the most appropriate place to go? And we've created a novel process at our healthcare system to ensure that patients are going to the correct discharge disposition based on their needs. And that has led to very successful number one reduction in our skilled nursing facility usage. So we're able to send more patients home, which home is best. I will, you know. That's definitely a model I live by. But, more importantly, setting patients up to go to the correct discharge, disposition ensures that you're setting them up for success rather than failure. 

 

Daniel Marino:  

Let me let me ask a quick question there, that the discharge disposition is that like the care setting? Is, that is, that care? Is that the home? 

 

Diane Shifley 

Yes, yeah. So the discharge disposition is the care setting? Is the patient going home? Are they going to an inpatient rehab facility? Are they going to a skilled nursing facility? And ensuring they're going to the correct disposition first is vital to ensuring that their post discharge recovery is going to be optimal. 

 

Daniel Marino:  

I imagine you're doing at least some of that planning at the pre evaluation stage, right? Maybe evaluating and identifying their chronic diseases or their risk level, or at least being able to give some consideration to those things that potentially could be a challenge for the patient post recovery. 

 

Diane Shifley:  

Absolutely. Yeah, preoperatively having those conversations. And sometimes they're tough conversations. Our reimbursement models and our, you know, insurances have changed as far as what they'll approve post-surgery, and we have patients who come in, and they will say, Well, you know, 5 years ago I had my knee done, and I went to a skilled nursing facility. And that's where I plan to go now. And it's sometimes a tough conversation to say, you know, you're not going to qualify for a skilled nursing facility. Home is going to be best. And then having that patient number one that's managing their expectations right off the bat. And then they have an opportunity to really understand what do they need to have in place in order to be successful. 

 

Daniel Marino:  

Right? Yeah, absolutely. Well, if you are just tuning in, I'm Daniel Marino. You're listening to Value-Based Care Insights. I'm talking to Diane Shifley, and we are discussing transitions of care models, and really the post recovery stage of a hospital, and Diane is sharing some great insights. I want to talk a little bit about level setting with post-acute. With a lot of the a lot of the hospitals, you know, with some of the programs say, some of the, you know, discharge to rehab facilities or skilled nursing facilities. Sometimes that's where the challenge takes place. And patients, you know, they're not getting the right level of care, and they're going to show up at the emergency room within a couple of days after going to those facilities, alignment with the post-acute facilities, I would think, has to be a critical component of your transitions of care program. Just to make sure the protocols, the processes, med reconciliation, for instance, is aligned. How have you worked through some of the post-acute alignment, with your scaled nursing facilities over your rehab facilities? 

 

Diane Shifley:  

Yeah. So you know, what we have found is, it has been very beneficial for us to create preferred networks for our post-acute providers we have successfully created a skilled nursing facility, preferred provider network as well as home health. And that's vital to what you had stated is that entering into these agreements in this network, we have a shared understanding of the quality of care. We want to provide these patients, but we also align on what our goals are for patients in the post, acute setting, managing those readmissions, managing length of stay, managing, total cost of care, and are many times where networks are developed, and it's the hospital or the healthcare system coming to those post-acute providers and kind of laying down the hammer. This is what you need to do. And we've taken a unique approach at our organization to really come to the table and create a 2-way street with these post-acute providers to say we are invested just like you are in these patients. We want to help each other. We want to understand what your pain points are, so that we can help improve our, you know, connection and our process. And at the same time we want to be able to give you feedback. And so creating that true partnership with the post acute providers, that's where you really get their the engagement. And that's where you're going to start to see a change in performance and the quality of care. They provide their patients because they truly feel that you're not just dictating to them what they need to do, but that you're a true partner in helping ultimately the patient, you know, succeed. 

 

 

Daniel Marino:  

Yeah. And you're working together with them to kind of managing to the same goal. You know, we're doing a lot of work right now with hospitals, with the new team model that CMS has launched, and for some of our listeners who aren't aware of it, there's 5 procedures that are bundled, that are included in the TEAM model that are basically coming up with one episode pricing model that affects 30 days before the surgical activity. And then 90 days after. And when you really dive into this, there's a couple of important drivers there. One is the pre-surgical evaluation. But it's also the post recovery, and how you're handling post-acute. And what we found is as organizations are considering their success around the team model, particularly for the 3 that are musculoskeletal. Those that have a strong relationship with the post-acute providers are seeing much better outcomes those that don't are seeing much higher readmission rates. So to your point, I think, having that aligned network and that ability to really share information, be transparent, have the same clinical protocols, that sort of thing. You're not only doing a great job for your outcomes, you're doing the best job that you can for the patients. 

 

Diane Shifley:  

Yeah, and I think a vital piece to that of when you create that dynamic between post-acute providers of it being a true partnership, You open lines of communication and communication is the key. In order to have patients be successful in that post acute period. If you have a provider in the post acute setting that doesn't feel that number one. They don't know how to get in touch with you. They don't know how to, you know, avoid an ED admission, because they can escalate back to the system to say we have an issue with the patient. We want it addressed immediately. Then you've really, you know, broken down the system. And you're right. That patient's going to just end up right back in your emergency room department. 

 

Daniel Marino:  

Yeah, you're absolutely right. So let's talk a little bit about the care in the home model. One of the big areas. The big growth that we're seeing is the growth in remote, patient monitoring as a mechanism to help support the post hospital recovery. Maybe to then begin to model monitor things such as blood pressure, or, you know, diabetes, or maybe even just to track infection rates. Have you incorporated remote, patient monitoring into your transitions of care program? How is that? How have you adjusted to that? 

 

Diane Shifley:  

Yeah. So, Daniel, we haven't incorporated any remote, patient monitoring yet, but I think it's absolutely a topic that is on the table that we're willing to look at and explore. And I think as our patient populations, you know, continue to grow. We have to think outside the box of How are we going to engage with patients and understand of how we can recognize the patients that are at the highest risk, and that are at rising risk? These type of devices would ultimately elevate to our transitions of care nurses or team members who needs a call today. Who do I need to check in with? And then you're utilizing your resources to the best of your ability, and that's where I see in the future at least, our health system looking to incorporate them. 

 

Daniel Marino:  

Yeah, I think it's just another tool, right? Especially if patients are, you know, being discharged to the home environment. It's just another way of being able to connect with them in more of a real time basis. So yeah, I agree with you. Let's talk a little bit about outcomes. I would imagine that as you're building your processes, and you know, as you initially build your processes and then ongoing, you have to be looking at data, you have to be looking at KPIs. What are the things that you've been tracking just to one identify some potential challenges in the process, but also to be able to, you know, maybe celebrate the successes? 

 

Diane Shifley:  

Yeah. And I think your point to celebrating successes is really important. And what we have developed with our transitions of care program is both leading and lagging indicators. And some of the, you know, leading indicators that we're looking at, which is really important from the staff perspective, right? To understand what they're doing and how impactful it is. But we look at our reach rate. How many patients did we intend to reach out to, and how many were we successful? Additionally, we look at how many patients we enrolled within the program. So after we talked to them, were we able to enroll them in the transitions of care program? And then for our lagging indicators. We're, of course, looking at an all cause readmission. We're looking at the timely follow up. So how quickly did they get into their PCP following a discharge for that follow up of, you know, maybe their acute chronic condition, or even post surgically did they get into their appointment. And then we also track some ed utilization metrics as far as how much, how many times a patient, you know, went to the ED. 

 

Daniel Marino:  

Yeah, those are great. Well, I don't know if you could share any of your indicators, but I can only imagine that your ED readmission rate and all cause readmissions has to have improved. I mean, just in terms of just creating that awareness and that management of the process. I can't help but think you've had a lot of success. 

 

Diane Shifley:  

Yeah. And you know, our system transition of care program is still fairly new as far as for our organization goes. But in the short period of time for one of our value-based care contracts we were able to see, you know, about a 1 in 1.2% decrease in our readmissions, which was which was nice, and we anticipate that as we continue to advance the program, we'll continue to see a decrease. 

 

Daniel Marino:  

Yeah, that's great. So there's a lot of listeners who are obviously very interested in this topic. I'm sure, for any of those that are listening, particularly the providers, any advice that you'd give them? Where? Where would they? Where should they start as they're thinking about? Maybe really expanding their transition to care program, or maybe building out their care in the home program. 

 

Diane Shifley:  

Yeah, So, Daniel, I think the word or the piece of advice that I would provide is sometimes the best thing to do is to start small. A transition of care program can be overwhelming. How do I start it? Who do I call? How do I get folks? But I think most importantly, is, if you identify some key team members that can make some outreach to patients and make that connection with patients, it may not be large scale. But it's somewhere that you can start. The other thing that I would recommend is write out a roadmap of putting yourself in the patient's shoes and understanding what that journey looks like, and where are the points where you want to increase coordination. You want to increase communication, but keeping the patient as your north star, I think, will lead everybody in the right direction. 

 

Daniel Marino: 

 Yeah, that's great. And I and I like what you said about creating your process flow right? Process flow it out. And I think what my big takeaway from our discussion today is you did a lot of pre-planning. Right? You're evaluating the patient, either when they come into the hospital or before they have surgery that's helping them, not only to support the care that's being done in the hospital or in the or, if you will, but that's the beginning part of your discharge plan, and the plan that you need to have in the event that they transition back to their home. And I agree with Diane, I think, to be able to process, flow that out is really critical. And the other thing that I really like is measure it right. You're not going to be 100% perfect on day one. But have your metrics to begin to measure that along the way. 

 

Diane Shifley:  

Yeah. And then, Daniel, the last thing I would say is that I think you know people are complicated, and what I mean by that is that it doesn't just take one discipline to solve the patient's issues or problems. But creating that interdisciplinary team that includes community health workers includes mas includes social workers includes RNs, you're really able to provide comprehensive care for patients, and we'll be able to see outcomes that, you know, are successful. 

 

Daniel Marino:  

Well, and I like the team model that you talked about with the you know the community health worker as well as the social worker and RNs and the medical assistant, because I think if you do it right, you're really able to share that resource the right way, right? So it doesn't all have to be Rn driven, and you probably really get the best possible outcomes that you can. So I really like that. Well, Diane, this has been a fabulous discussion. I really appreciate it. And I'm a firm believer, certainly not only from a value-based perspective, but certainly from a patient perspective, that the more planning we can do, and the more that we can take advantage of these care in the home models, I just think it's the right thing to do for patients, and it just helps the industry overall by reducing costs and creating a lot more efficiencies and better quality outcomes. So I good luck to you. I'm really impressed with what you put in place. 

 

Diane Shifley:  

Thank you so much. 

 

Daniel Marino:  

And to our listeners. I want to thank everybody for tuning in. If you have any questions or want additional information on today's topic, please feel free to reach out to me at dmarino@luminahp.com as well as just luminahp.com, and Diane. One thing I forgot to ask is if any of our listeners today are interested in connecting with you. I'm assuming you're on Linkedin? 

 

Diane Shifley:

I am. And this is a topic I'm very passionate about. So yeah, you can find me, Diane Shifley, on LinkedIn. 

 

Daniel Marino:

Great. Well, thanks again for everybody for tuning in until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners