Experience and Innovation
• Healthcare utilization (hospital re-admission, ED visits, etc.)
• Patient/family satisfaction
The Avamere Family of companies takes its responsibility as a member of the health care continuum very seriously. With almost 20 years of experience providing post-acute care as a foundation, we developed a comprehensive patient risk assessment tool designed to improve quality of care, reduce hospital re-admissions and improve communication among clinical professionals.
Risk Stratification – PLACES™
After review of multiple patient risk assessment tools in the acute-setting, our team chose to adapt and expand the LACE™ tool to better reflect the realities of current post-acute issues. ***learn how we developed PLACES (opt-in protected link)***
The PLACES™ tool helps to determine the level of risk for hospital re-admission (average, high, ultra high), and what resources will be needed to address specific issues. ***Add charts/stats/results***
• In the first year of PLACES™ use, the overall 30 day re-hospitalization rate for post-acute patients dropped from 24% to 15%.
Patient transitions are a main focus of care management. Our hospital-based Clinical Liaisons are nurses who meet patients and families in the acute setting, ensure physician orders are complete, and prepare the post-acute team for the patient status so that patient transfers are smoother and with less unknowns. The Clinical Liaison scores the patient with the PLACES™ tool, so that facility teams understand the patient risk profile.
With the PLACES™ information in hand our facility-based Care Transition Nurses (Certified Case Manager RNs) have proven to be the heart of our success. They are assigned to high risk and ultra-high risk patients to provide:
• Contact with patient/family within first 24 hours
• Transition planning to give patients easier access to care
• Manage and monitor patients during their SNF stay, through their home health episode and for 30 days beyond the last service
• Daily clinical reviews
• Coach patients on maintaining health
• Coordinate with each provider along the continuum of care
• Communicate with Primary Care Physician to prioritize follow up appointments shortly after arriving home
• Promote continuity of care with home health agency
• Communicate with patient/family at 1-2 week intervals
• Monitor patient progress at home
***Insert chart from The Pearl that JD developed***
Nurse Practitioner Program
Our next care coordination initiative is now underway, NP2U. The goal is to increase the number of nurse practitioners across our system. These professionals will be on-site and available to provide medically necessary assessment and medical management for patients in SNFs, assisted living and memory care communities as well as home health and hospice setting.
The goal of this program is 3-fold:
1.) Improve clinical outcomes – avoid adverse events that may send patients back to the emergency department
2.) Reduce costs to the system by reducing avoidable re-admissions
3.) Improve the patient experience