Five Stars for Team Based Approach to Patient Care

Avon Health Center, a member of the UConn John Dempsey Hospital preferred post-acute care network, is in the top 2% of skilled nursing facilities (SNF) in the country, receiving 5 stars in all 4 categories from The Centers for Medicare and Medicaid Services (CMS).

Jaclyn Olsen Jaeger DO is a board-certified internal medicine physician specializing in senior health care needs and geriatric medicine in the Center on Aging at UConn Health on June 19, 2018. (Stan Godlewski for UConn Health)

Avon Health Center, a member of the UConn John Dempsey Hospital preferred post-acute care network, is in the top 2% of skilled nursing facilities (SNF) in the country, receiving 5 stars in all 4 categories from The Centers for Medicare and Medicaid Services (CMS). Only 320 of the 15,600 SNFs in the country have received this designation.

“Their success is our shared success,” says Dr. Jaclyn Olsen Jaeger, an internist and geriatrician in the UConn Center on Aging, who is also a transitionist and Associate Medical Director overseeing discharged patients’ post-acute care at the Avon Health Center.

CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions.

The Nursing Home Compare Website features a quality rating system that gives each nursing home a rating of between 1 and 5 stars. Skilled nursing facilities with 5 stars are considered to have much above-average quality.

There is one overall 5-star rating for each facility and a separate rating for each of three sources of information including health inspections, staffing, and quality measures of how well patients’ physical and clinical needs are cared for.

“This is a testament to UConn’s quality transitional care and inpatient programs as well as the quality of care at Avon Health Center,” Jaeger says. “This shared achievement speaks to the team-based approach that is imperative to the delivery of successful transitional care for vulnerable older adults.”

Nearly one in five Medicare patients returns to the hospital within a month of discharge, according to CMS. Readmission to the hospital is costly and sometimes dangerous, especially for seniors.

“Patient transition from one part of the system often results in a breakdown of communication and care, especially with skilled facilities,” says Dr. Patrick Coll, UConn Center on Aging and UConn Health’s medical director of senior health.

This is why in 2016, a team at UConn JDH and the UConn Center on Aging came up with a team-based approach to improve this by embedding physicians known as transitionists who oversee the transition of care from UConn JDH to the post-acute facility.

While patients and families always have a choice of where they go for post-acute care, research found that patients who leave UConn Health to post-acute care typically go to one of five facilities in the area. Currently, UConn has a transitionist at Avon Health Care, McLean, and West Hartford Health and Rehabilitation. The transitionist becomes the patient’s attending physician of record during his or her post-acute care.

“Transitions of care are very vulnerable times for any patient,” Jaeger says. “When you consider the medical and psychosocial complexity of an older adult, add a hospitalization which typically results in a new treatment plan with likely new medication regimen, and ultimately discharge the patient to a new care environment, the opportunity for errors or breakdown in communication is, unfortunately, a concern.”

A successful transition involves coordination with the case manager, nursing staff, and therapy staff at both facilities, and regular communication with hospitalists and subspecialists about matters of medications, follow up appointments, additional support the patient might need during recovery, and any other issues that the patient may need to be addressed for a safe and successful discharge back to the community.

In the second quarter of 2018, the readmission rate at Avon Health Care was zero, meaning not a single patient discharged to the Avon Health Center under Jaeger’s care was readmitted within 30 days.

“We are proud that Avon Health Center is one of our preferred provider network Skilled Nursing Facilities. They have achieved an amazingly low rate of hospital readmissions without sacrificing their other many great outcomes. This is testament to the great teamwork among all those involved in patient care,” says Dr. Scott Allen, Chief Medical Officer, UConn John Dempsey Hospital.

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