MDNews - Greater Boston

Kindred's Specialty Services Dr. Kuvin represents a satisfied partner. He praises Kindred Healthcare's integrated model of post-acute care. "Tufts, like many academic medical centers, is responsible for treating the sickest of the sick patients," he says. "A point comes in their care when we feel they would benefit from a transitional care hospital where they can focus on specific issues, such as physical rehabilitation and long-term ventilator weaning." Kindred excels at rehabilitative ser- vices, both physical and social, to keep patients transitioning toward success. While many people live full lives while on ventilators, patients often desire to become ventilator free. Weaning is a highly specialized process requiring advanced technical skills and equipment. At Kindred, pulmonologists and respira- tory therapists help almost 50 percent of ventilator-dependent patients wean themselves — up from 4 4 percent in 2009. Medicine reconciliation, another Kindred specialty, also requires meticu- lous attention to detail over time. AHRQ reports that about one-third of patients nationwide experience "unintended medication discrepancies" upon hospital admission, while 14 percent still have discrepancies in their prescriptions at discharge — not taking into account patient and caregiver confusion or error. At Kindred, medication reconciliation, including formal written and verbal hand- offs, is handled in a structured manner at every point of care transition. Providers take steps to ensure patients don't miss a dose of medication should they move between facilities, as well. Transitional care hospitals and longer-term care settings allow ample time to discern and meet patients' psycho- social needs, Dr. Klugman says. Among these needs are self-determination, health literacy and family support. " P s y c h o s o c i a l w e l l - being starts with choice," Dr. Klugman says. "Often as patients move through the system, their expectations may be out of synch with those of their providers." At Kindred, care transitions managers help bring those expectations into align- ment by advocating for the patient. Nurses by profession, these managers are freed from clinical duties, so they have sufficient time to converse with patients and find out what health goals they want to achieve. "Our transitions managers represent the voice of the patient to the rest of the healthcare team," Dr. Klugman says. "They help manage expectations appropriately, resulting in outcomes that are in line with patients' needs." As a result, patients feel empowered and tend to enjoy greater long-term success, Dr. Klugman says. Transitional care hospitals also allow more time for caregiver education and support. Spouses, adult children and others provide up to 70 percent of health care for family members, Dr. Klugman says, but often they are unprepared for the complex tasks they have to take on. From chang- ing bandages to assisting with transfers and maintaining complex medication regimens, family members are crucial to patients' well-being. "Our staff members help interpret physician instructions, ensuring caregivers understand patients' needs," Dr. Klugman says. "A minority of families are sophisti- cated enough to do this without assistance. In general, the healthcare system today does not reach out well to assist caregiv- ers with the transition home. Kindred Healthcare is doing just that." The Numbers Tell the Story Kindred Healthcare's mission is borne out in the long-term recovery of its patients. In the Greater Boston area and across the United States, Kindred patients return to the hospital less frequently than other patients with comparable conditions. They spend less time in the hospital and report high levels of satisfac- tion with their care. Key statistics include: + National readmission rates for high- risk patients: 20 percent; readmission rate for Kindred Healthcare's high-risk patients: 5.6 percent. + Most Kindred patients are discharged to lower-acuity settings. Transitional care hospital patients: 38 percent are discharged to SNFs, 25 percent to home and 6 percent to inpatient rehabilita- tion facilities. Inpatient rehabilitation patients: 77 percent are discharged to home. SNF patients: 56 percent are discharged to home. + Patients at Kindred's transitional care hospitals have experienced decreasing lengths of stays: from 30 days in 2009 to 27 days in 2013. + Patient satisfaction scores are high. Nurses "explain clearly" 95 percent of the time; pain is well controlled 95 percent of the time; and patients would recommend Kindred to oth- ers 96 percent of the time, according to surveys of Kindred patients and their families. "Kindred is working hard to redefine post-acute care and rebuild all the compo- nents of that continuum to restore patients' maximum function," Dr. Klugman says. "We want to return them to their own environment as quickly as possible, and we have devoted substantial resources to that endeavor." "Kindred Healthcare is a pioneer in providing seamless care for the most complex patients," Downey adds. "It is a privilege to help these patients regain function and return to full lives." V i sit w w w.kindredhealthcare.com to learn more about the program. ■ COV ER FE AT UR E Robert Klugman, MD, and Cathy Tracey, RN, Care Transitions Manager, consult with a patient about his upcoming discharge from the hospital. 8 | Greater Boston MD NEWS ■ M D N E W S . CO M

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