Cedars-Sinai Medical Center

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Enhanced Care Program offers nurse practitioner for skilled nursing facility patients

Cedars-Sinai is launching a new program aimed at keeping a closer eye on patients who have transitioned from the acute-care facility into a skilled nursing facility (SNF).

As part of the new Enhanced Care Program, a Cedars-Sinai nurse practitioner will be offered to assist attending MDs with the care of their SNF patients. If the attending MD agrees to participate, the nurse practitioner will meet with patients prior to discharge from the medical center and again within 24 hours of their admission into the skilled nursing facility. The nurse practitioner will then work closely with the attending MD and nursing staff at the facility to monitor the patient's progress and condition.

The nurse also will work with staff at the nursing facility.

"We're offering, at no risk and no cost to the attending physicians, a nurse practitioner to help them more closely manage their SNF patients," said Bradley Rosen, MD, medical director of the Enhanced Care Program, which officially launched Nov. 12. "This nurse will frequently be on site to ensure patients stay on track to recovery. … No one is taking over patients; we're simply providing an extra pair of eyes and ears to help their patients stay healthy and on track to recovery."

From a business perspective, the program is designed to save money associated with avoidable or preventable 30-day hospitalizations, for which the medical center will soon no longer be reimbursed, Rosen said.

The Enhanced Care Program was developed out of Cedars-Sinai's Readmissions Oversight Committee, in an attempt to better manage the post-discharge care of high-risk patients. The ECP subgroup is being led by Toni Hubenette, MD, and Kelley Hart. Although they represent a minority of Cedars-Sinai's overall discharges, these high-risk patients can be responsible for a large portion of healthcare expenditures, and some of these expenses can be conditions of this subset of patients is generally more chronic, Rosen said.

Leading up to the rollout of ECP, two six-week pilots of the program demonstrated impressive results, Rosen said.

There was a steady drop in readmissions once the pilot began, and when the pilot program stopped, readmissions spiked back up, Rosen said.

"The nurse practitioner was the common denominator," Rosen said. "It's not rocket science. This is about capturing medical problems earlier so that if someone has a urinary tract infection it can be treated before the patient becomes septic; if someone is short of breath or wheezing, they can be provided with appropriate treatments before they have respiratory failure."

Based on the success of the pilot projects, ECP has hired three nurse practitioners and a nurse educator.

Cedars-Sinai plans to eventually work with six local skilled nursing facilities, in two phases. Phase I, which began Nov. 12, includes the Rehabilitation Center of Beverly Hills, Hancock Park Rehabilitation Center and Sharon Care Center. Phase II, which will likely start early next year, will include Country Villa Wilshire, Country Villa Terrace and Country Villa Pavilion.

Rosen, who wants physicians affiliated with Cedars-Sinai to consider the program as an option, said attending physicians will continue to be the attending of record for their patient, be able to see their patients and document their encounters, and bill for the care of the patients like normal. Any malpractice issues related to the nurses involved fall to Cedars-Sinai Medical Center and Rosen as the program's medical director, he added.

"This new service fits into the larger health system strategy around population health and safe care transitions. The care of the patient doesn't just stop once they are discharged from the hospital," Rosen said. "We as a health system have an opportunity to do a better job making sure patients are doing well throughout their entire episode of care – from acute to sub-acute to home."