The Right Care in the Right Place: Partnership Reduces Hospital Readmission for Most Vulnerable Patients

Posted on Dec 16, 2015

Cover Image Web versionDelivering high-quality, patient-centered care doesn’t end when patients leave the hospital. Sutter Health’s Alta Bates Summit Medical Center collaborates with skilled nursing facilities in Oakland and Berkeley to help patients continue healing and return home.

Repeated hospitalizations are stressful — physically and emotionally — for patients and their families. Nationally, about one in five Medicare patients discharged to skilled nursing facilities (SNFs) are readmitted to a hospital within 30 days. SNFs provide round the clock nursing care and rehabilitation services.

In 2014, Alta Bates Summit began partnerships with Elmwood Nursing and Rehabilitation Center, Oakland Healthcare and Wellness Center and Piedmont Gardens. Each facility is committed to high clinical standards to improve care coordination and decrease preventable hospital readmission.

Partnering with Skilled Nursing Facilities (SNFs)

Alta Bates Summit works closely with three facilities, but patients and their families may select any nursing home, home health agency or other provider.

As part of the partnership, SNFs:
Access patient data from Alta Bates Summit’s electronic health record, smoothing the transfer from hospital to post-acute care.
Have hired more rehabilitation and case management staff.

Emphasizing care coordination and communication, hospital and SNF staff work closely to ensure patients return home – not to the hospital.

For instance, Piedmont Gardens has increased registered nurse staffing so that conditions — such as pneumonia — can be treated at the SNF instead of requiring hospital readmission.

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Ursula Boynton, M.D., Alta Bates Summit Administrative Medical Director

“We’re making great progress: The collaboration has shown that together, we can reduce our readmission and ER visit rates for these patients,” says Ursula Boynton, M.D., Alta Bates Summit Administrative Medical Director. “In the past, when a patient in a skilled nursing facility went to the Emergency Room it was almost always an automatic admission. This collaborative effort prevented sending the patient back to the hospital by promoting earlier assessments and interventions in the SNF, such as antibiotics and IV fluids.”

Reducing Readmissions

Since partnering with Alta Bates Summit, all three SNFs have seen a drop in 30-day patient readmissions to the hospital.

In 2015, their combined readmission rate to Alta Bates Summit is 12.3 percent compared to almost 20 percent nationwide.
ER visits and the number of patients readmitted to the hospital within a 48-hour period have also declined.

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Daniel Wittman, Piedmont Gardens Health Services Administrator

“Working with Alta Bates Summit as a partner has improved our patient care outcomes and our readmission rates are steadily decreasing,” says Daniel Wittman, Piedmont Gardens Health Services Administrator. “Alta Bates Summit staff listen to our feedback and understand the challenges that we face in our SNF as we improve the transitions of care from the hospital. It’s a mutual learning partnership.”

SNF-Based Physicians Play a Key Role
Emmons Collins, M.D., focuses on improving the care of SNF residents and reducing hospital readmissions. He oversees a specialized team of physicians and nurse practitioners working with Alta Bates Summit physicians to carry out their recommendations and treatment plans.

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Emmons Collins, M.D., SNF Specialist, Spherical Medical

“The field of skilled nursing care is in transition. Patients are being transferred to skilled nursing from acute hospitals earlier in the course of their recovery than in the past,” says Emmons Collins, M.D. “By focusing our quality improvement efforts on communication between providers at the time of the transfer, we provide a better patient experience, a better clinical outcome and reduce unnecessary readmissions to the hospital.
“We’re especially proud of the work we have done with Alta Bates Summit. They’ve joined us to help improve communication between providers.”

Focus on Palliative Care

SNFs also improve care with early identification, assessment, documentation and communication about changes in patients’ health.

The program includes a focus on palliative care, when needed, to relieve physical and emotional suffering, improve patient-physician-family communication and support well-coordinated care.

“We can now better identify high-risk patients with palliative care needs,” says Ursula Boynton, M.D., Alta Bates Summit Administrative Medical Director  “We partner with our palliative care team to help identify and improve the care of these patients as they move to and receive care in the SNF.”

Improving Quality Together
Each month, Alta Bates Summit case managers, nurses and physicians meet with staff from all three SNFs to review quality data, share best practices and review readmission cases. These sessions offer a great deal of information sharing and collaboration, strengthening the relationship between the hospital and the SNFs.

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Lisa King (center) reviews readmission cases with SNF clinicians

“We review cases with the entire group, talk about why the patient was admitted to the hospital, status at time of discharge and events that occurred at the SNF that led up to the patient’s readmission,” says Lisa King, Alta Bates Summit’s assistant director of Clinical Resource Management. “The purpose is not to blame anyone, but instead to identify gaps and help prevent other patients from being readmitted.”

This collaboration inspires community SNF participation and information sharing.

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Terry McGregor, Executive Vice president of Elmwood Nursing and Rehabilitation Center

“By working closer together on the delivery of care with hospitals like Alta Bates Summit, we’ve seen smoother transfers and better outcomes that are enhancing resident satisfaction,” says Terry McGregor, Executive Vice president of Elmwood Nursing and Rehabilitation Center. “For an example, the integration of palliative care has resulted in a 50 percent reduction in patient readmissions and Emergency Department visits.”

Learn More Online
To learn more about how else Alta Bates Summit partners to help improve patient care in our community, visit

Please see page 21 of the attached link for the Oakland Business Review to see an Op Ed by Ursi Boynton, M.D., on Alta Bates Summit’s partnership with local skilled nursing facilities – “The right care in the right place: partnership reduces hospital readmissions.”

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