As a senior clinician working full time in the LTC setting, I am fully committed to an interprofessional approach that provides high value care to our vulnerable patients.  I am pleased that the Coalition for Compassionate Care of California recently updated the CARE Recommendations (Compassion and Respect at the End of Life) for SNFs.  I welcome their efforts to help my teams provide optimal care for those with serious illness.  Like Atul Gawande in his book, Being Mortal, walking with our patients, families, and colleagues during these troubling times has value not only for them, but also for us as caregivers.  To a large extent, palliative care advances have occurred as we learn from situations and strive to do better.  I realize there are moments in the care of some patients where patients are overly burdened with unrelieved suffering and the future looks grim.  However, with the extra layer of care that palliative care offers, and with time, sometimes unexpectedly, good things happen.

by Flora Bessey, Pharm.D., CGP

On May 6, 2015 my husband and I will welcome our beautiful baby into this world.  We haven’t found out the gender.  We call the baby Poppy since when we found out we were pregnant, the baby was the size of a poppy seed.  I am sure all the parents reading this can imagine the excitement, hopes and dreams we have for the baby.

With my husband and I both working in healthcare, we are at times overly cautious about things.  Imagine our alarm when we learned of the recent measles outbreak.  On further review, our Poppy can’t get vaccinated against measles until 9 months.  That is when an infant’s immune system can process and build a response to the vaccine.

Delivering care under the Affordable Care Act is changing the healthcare landscape, and requires that post-acute care providers think differently.

Few could have imagined a 50-70% cut in skilled rates, but that’s exactly what unfolded in Southern California. Today providers are contractually obliged to demonstrate measurable outcomes in exchange for volume from managed care organizations (MCO) and accountable care (ACO) partners.

At Shea Family, we re-structured to improve health care delivery and drive outcomes. The migration began four years ago, and the model has been in operation for the past two years.  Teams focused on five areas: care coordination, specialty education, strategic technologies, innovations in care delivery, and $15M+ in renovations.

Key innovations

Today our new model for care has a coordinated network with aligned values and a breadth of service lines across the full continuum. Referrals from partners flow in, because we were able to eliminate layers of management overhead the ACO/MCO would have had to absorb.  The model also aligns with acute hospitals and managed care payors.  

Results

Key to making the model work is the introduction of transition coaches, who follow the patient across settings after discharge.  It’s about engaging patients over their lifetime, not just an episode of care.

Changing the way business is done has resulted in enhanced outcomes, higher satisfaction from members and dramatically reduced expenses to payors.  Change is always tough, but our survival depended on it.