In the past, post-acute care organizations have operated within silos; but the emergence of regulatory initiatives pushing for improved care transitions and new financial penalties for hospital readmissions has created the need for more streamlined processes and communication. Research shows this also leads to better patient outcomes which falls in line with the gradual transition to a value-based healthcare system. Blue Sky Therapy is uniquely positioned across the post-acute care continuum due to the ability to follow the patient through the different settings and even provide care for patients in the comfort of their home (and now through teletherapy!) Due to the need for more streamlined care for patients, we developed the Bridge to Wellness program – an all-encompassing program that follows patients’ through each part of the continuum of care to ensure they receive the quality of care they deserve.
Bridge to Wellness
Therapists have a unique role in post-acute care settings through developing relationships with patients and understanding their unique needs. With Bridge to Wellness, we ensure they are cared for after leaving the facility with follow-up calls and visits. We see this as an opportunity not only to provide a valuable service that supports the organizations we partner with, but to also provide a better overall patient experience. The program emphasizes and provides some key areas of patient wellness that traditional care delivery overlooks or is unable to fully capture.
Over the past six months, we have followed over 400 patients throughout the continuum of care. We started this program with 19 pilot facilities to beta test. In analyzing patient success after the six-month beta test period, we have seen a dramatic reduction in potential hospital readmissions and an enhanced ability to care for patients at home who continue to need restorative therapy.
Overview of Bridge to Wellness
Care Delivery: Elevated care delivery using our Centers of Excellence, customized care pathways and virtual treatments resulting in exceptional functional outcomes.
Telehealth: Virtual tracking and post-discharge patient telemonitoring to bridge the gap in care transitions.
Patient Care Network: HIPAA compliant communication portal between the patient, POA and care team with accessibility to a full library of discharge resources and recommendations.
Prevention: Promotion of the most effective prevention and treatment practices to reduce the leading causes of hospital readmissions.
Smooth Care Transitions: Seamless integration of SNF, Home Health, Outpatient and In-Home Therapy provided by Blue Sky therapists with opportunities for additional treatment, patient/ caregiver centered education and improved disease management across the continuum.
Data Analytics: Robust data analytics that track patient outcomes, assess trends, and assist in marketing and networking to local referral sources.
Bridge to Wellness Process
Avoiding potential hospital readmissions is an interdisciplinary effort. Blue Sky can identify red flag situations through our telemonitoring calls made to patients 48 hours, 5 days, and 25 days after they discharge from the facility to home/community. These checkpoints, which were timed according to research that shows these intervals are high times that a patient readmits to the hospital, allow us to proactively identify patient clinical needs and issues and then notify the appropriate team member (Director of Nursing, Social Worker, Home Health Case Manager, etc.) to address those concerns immediately.
Post-discharge follow-up procedure:
- Telemonitoring 1: 48 hours post-discharge
- Telemonitoring 2: 5 days post-discharge
- Telemonitoring 3: 25 days post-discharge
We have successfully completed over 800 calls with patients and captured follow-up responses regarding their overall health, safety, and function in their discharge location. 416 patients’ responses have been recorded for a ~49% patient response rate. We have successfully identified and avoided over 75 potential hospital readmissions since the inception of Bridge to Wellness (based on: patient responded yes to a trigger/red flag question and RCM followed up immediately to notify appropriate SNF/HH staff).
Bridge to Wellness Patient Examples
During a 48-hour telemonitoring checkpoint, one patient reported that she had not yet received her prescription medication or the recommended durable medical equipment (DME) of a walker and bedside commode required for safe ambulation and transfers after returning home. We were able to alert the social worker and Home Health Agency for follow-up to ensure the patient received her medication & equipment before a medical issue or fall occurred.
During a 5-day call the patient reported feeling shortness of breath, weight gain, and new onset of extreme fatigue since returning home. She was not able to care for herself independently due to this new onset of medical issues. We alerted the Director of Nursing who followed up with the patient and the team was able to successfully readmit the patient back to the SNF to address these concerns rather than the patient readmit to the hospital.
These discharge follow-up calls also provide an opportunity to enhance patient engagement and reinforce patient needs at home with education about their condition or disease and communicate about all options for follow-up care. We might identify that a new service is indicated (i.e., discharged home without home health services but now have identified that they would benefit from home health) or identify new clinical challenge/medical issues that a patient may be having after they no longer have the support of home health prompting a referral to outpatient services.
We could share on and on about the success stories we have produced since launching Bridge to Wellness, but the bragging rights go to our patients and their improved health and wellness thanks to the implementation of this program.
As an extension of Bridge to Wellness, our team here at Blue Sky Therapy has officially launched our newest service line – In-Home Therapy. If you want to learn more about our In-Home Therapy program, check out our recent blog highlighting how it works and all of the benefits it provides patients.
About Blue Sky Therapy
Blue Sky Therapy delivers innovative physical, occupational, and speech therapy services in skilled nursing homes, assisted living facilities, home health care, in-home therapy, and outpatient therapy clinics. Our newest service line, Teletherapy, allows our therapists to work with patients virtually at home instead of in the clinic.