Ste. Genevieve County Memorial Hospital, Ste. Genevieve, Missouri
Ste. Genevieve County Memorial Hospital (SGCMH), located in Ste. Genevieve, Missouri, is one of only four critical access hospitals that received national recognition for demonstrating innovative care coordination initiatives to improve population health.
SGCMH has a swing bed hospital-based program for Transitional Care (skilled nursing). Recently, SGCMH implemented an innovative care model, standardized their triage process, and collaborated with select tertiary care centers to transition patients into a short-term skilled nursing program. The Transitional Care goal is to address the needs of patients who are being discharged from acute care but are not ready or it is not safe to go home. As a traditional skilled nursing facility (SNF) alternative, Transitional Care patients benefit from low nurse-to-patient ratios, and receive interventions typically seen in acute care including daily physician rounding, intravenous antibiotics (IVAB), IV medications, wound care, physical and occupational therapy (PT/OT), and palliative care. Differing from nursing homes, SNF have 24-hour per day availability of lab, radiology, and respiratory therapy.
Hirshell Parker, Executive Director of Quality & Risk Management, said, ”We identified a need in our community that led us to further develop our Transitional Care/Swing bed Program, which allows us to get patients back home in a safe and timely manner. By doing so, we have improved the quality of care for patients and reduced hospital readmissions.”
Right to Left: Hirshell Parker, Katie Hogenmiller, Brandie Filer, Tom Keim, Dr. Noguera, Morgan Ritter, Anna Mattingly, Rita Brumfield, Kim Lalumandier
- Swing bed facilitates referrals to community resources and helps ensure that patients are able to stay home once discharged. Decreased variance in metrics demonstrates high-quality care. In the past 12 months, only 6% of patients placed in their Swing Bed Program have been subject to readmission compared to the SNF state average of greater than 21%.
- Over 75% of patients return home in a reduced length of time. Depending on individual needs, patients are generally able to discharge in less than 10 days, compared to 21 days or more in a traditional SNF. A hospital-based discharge planning, five-star Medicare rating is innate evidence of the ability to effectively transition patients home.
- Case management collaboration in several urban acute care centers is instrumental in delivering post-acute care. In June 2018, SGCMH began tracking the volume of external referrals on their scorecards. Since the implementation of this internal metric, they have effectively transitioned over 180 patients from external facilities. This number does not include patients transitioned to swing bed from admissions located within their organization.
TeamSTEPPS-based daily multidisciplinary team huddles have led to the development of a shared mental health model. This helps to identify the care needs of each patient allowing transition back to the prior level of functioning. A quantitative admission high-risk screening was developed and is performed on each patient to identify readmission risk. High-risk determination triggers in-house referrals and includes additional discharge community resources. Patients have a choice, but external case management teams are engaged on an ongoing basis to transition patients based upon skilled need and acuity. Decreased readmissions reduce costs. Finally, follow-up calls are made within 48 hours of Transitional Care discharge to assess the understanding of medications, discharge care, and to ensure a primary care visit 3-5 days of discharge.
“Ste. Genevieve County Memorial Hospital is a valuable asset to the health care system,” Sara Davenport, Chief, from the Missouri Office of Rural Health and Primary Care said. “Through their excellent work, patients are receiving quality care close to home.”
Tom Keim, Chief Executive Officer, said, "We feel we provide real value to our patients and those from larger acute care hospitals to help transition patient care and reduce readmissions by offering a service that allows care to be flexed to meet the needs of each individual patient."