Continued federal and state movement toward more patient-driven care has had a ripple effect across the care continuum, in a lot of ways changing relationships between health care sectors that are normally siloed.
Nursing homes and hospital systems are no exception, with the Patient-Driven Payment Model (PDPM) prompting relationship building efforts on both ends.
Communication across care settings that is tied to an initiative, or a long-term goal for a resident, helps break down silos and ultimately improves patient care outcomes, according to Marie Cleary-Fishman, vice president of clinical quality at the American Hospital Association (AHA).
“Whether the person comes from the nursing home, or comes from home care services, and they go in through the emergency department … the communication may not be exactly what we want it to be,” she told Skilled Nursing News.
Patient-centered care helps enhance public trust too, a huge component as the post-acute care sector struggles to reimage itself in the public eye after the throes of the Covid-19 pandemic.
“When you start to put these things in place that really look at what matters to those 65 and older, you start to enhance the trust that those folks have in your health care setting,” Cleary-Fishman said. “That only improves the expectations, it improves the satisfaction scores, right? It gets to all of those things, and makes it easier for the workforce to care for those people.”
Cleary-Fishman hopes peer-to-peer learning and sharing between hospital and nursing home staff – and among nursing home staff that work for different operators – will be a positive byproduct of cross-continuum initiatives like the AHA’s Age-Friendly Health Systems.
The idea is to keep a holistic approach in mind when caring for people across the continuum, making sure what the resident wants, and what the family wants, lines up with what staff is doing in that particular care setting, including medication passes and mobility work.
Neil Pruitt, CEO of Norcross, Georgia-based PruittHealth, has already seen the hospital-nursing home relationship get much more collaborative outside of any sort of initiative, and there’s a lot more respect on both sides compared to pre-pandemic.
Patient-driven collaboration often takes the form of partnerships, he said, as hospitals come to terms with the tight cost structure and highly regulated environment of the nursing home sector. Acute care providers are finding it’s better for them to have an operator like Pruitt manage community nursing homes rather than own and operate it themselves, he said.
“We’re able to collaborate with hospitalists to ensure a seamless transition of care and a good outcome for the patient. Those relationships have only strengthened as we return to normal,” added Pruitt.
Direct care workers and hospital staff connect more through the patient, and through initiatives like Age Friendly, as a patient’s goal is passed on from one care setting to the next, according to Cleary-Fishman.
What matters to the resident becomes the glue that informs that next care team, she said; it informs clinicians as they form a care plan for that resident upon admission. It’s also a point where the family gets involved too, so they can be part of that patient’s goal moving ahead in care.
Public trust starts here, she said, when the family is pulled into care planning.
“That aligned communication makes a huge difference when you’re moving someone from place to place along the continuum of care,” she added.
Pruitt has taken collaboration one step further with its hospital partnerships – the operator now develops clinical programs tailored to each individual hospital.
“That allows [residents] to meet their clinical goals while ensuring that we are able to play a meaningful part of the whole healthcare spectrum,” added Pruitt.
After presenting on Age Friendly for several years now, Cleary-Fishman said the feedback from nurses across care settings was positive – the work feels doable for staff-strapped facilities, even in nursing homes.
“I really hope that this helps the workforce feel like they have a community, a common practice that they can learn from, share with,” she said.
The ‘four M’s’ of the AHA initiative, which has no end date, focuses on mobility, medication, mentation and what matters for patients 65 and older. Through these focal points, Cleary-Fishman hopes to fundamentally change how our society and caregivers across the continuum think about aging and aging services.
“The goal is to change the culture, to really change the way we think about caring for those that are 65 and older,” she said. “The evidence tells us if we look at those things together, care is better for the person who is 65 or older.”
The initiative started out as an evidence-based concept put together by the Institute for Healthcare Improvement, the AHA and the Catholic Health Association – and is funded by the John A. Hartford Foundation.
It took a year to get hospital systems and other health care organizations, including nursing homes, to get involved in the pilot program. There are currently more than 400 nursing homes that are recognized as Age Friendly.
Holistic initiatives like Age Friendly help with the satisfaction of the workforce as well, she said.
Direct caregivers can help a resident reach a goal put to paper from the outset, working toward that goal during their stay.
“It’s so much different than just saying, ‘I want to be discharged.’ Most people want to be discharged, most people want to go home. It’s really digging into what brings joy to someone’s life,” noted Cleary-Fishman.
If a certified nursing assistant (CNA) finds out there’s a pet at home a resident wants to get back to, she said, that’s a good example of digging a bit more and connecting with that person in order to help them live a better life – and feel more fulfilled as a clinician in the process.