Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations set competition aside to collaborate and reduce rehospitalizations from SNFs.
To solidify their coordinated approach, Henry Ford Health System (HFHS), the Detroit Medical Center and St. John's Providence Health System formed the Tri-County SNF Collaborative with support from the Michigan Quality Improvement Organization (MPRO).
A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics examines the evolution of the Tri-County SNF Collaborative, as well as the set of clinical and quality targets and metrics with which it operates.
In this 25-page resource, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, outlines the roots, framework and results of the SNF collaborative, detailing participation requirements for the more than 130 member SNFs that were developed in tandem with the skilled nursing facilities.
Ms. Craft provides details on the following:
- Tri-County's dozen participation requirements for SNFs, ranging from regular reporting to achievement of specified performance metrics;
- The 14 metrics in four key areas that participating SNFs must report through a dedicated SNF portal;
- The 13-point unblinded quarterly quality scorecard with metrics that the collaborative provides to SNF participants;
- Roles and responsibilities of the multidisciplinary team within Tri-County Collaborative;
- The collaborative's impact on SNF readmissions, length of stay and other key benchmarks;
- Improvements and advancements resulting from Tri-County Collaborative initiatives, including enhanced nurse-to-nurse handoffs and sepsis-focused interventions;
And much more.
Reducing SNF Readmissions: Quality Reporting Metrics
- HFHS Skilled Nursing Facility Collaborative
- HFHS Post-Acute Care Value Council
- Participation Requirements
- Metrics Reporting
- Quarterly Scorecard with Targets
- Process Improvements
- Forming the Tri-County SNF Collaborative
- Barriers and Challenges
- Care Transitions Quality Metrics Dashboard
- Tri-County SNF Collaborative Status
- SNF Performance Results
- Lessons Learned
Q&A: Ask the Experts
- Algorithms of Care
- Top Drivers of SNF Readmissions
- SNF Visits
- Comorbid Conditions and Readmissions
- Nurse-to-Nurse Handoff
- SNF Participation
- C-Suite Support
- Virtual Physician Visits
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