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Carla Wilber, DNP, RN, NE-BC, Senior [email protected]
Optimizing Your Swing Bed Program:Design and Growth Strategies
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Overview
Swing Bed Volume Growth
Swing Bed Design
Case Studies
Questions
Agenda
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Overview – What Is a Swing Bed?
Picture borrowed from Colorado Rural Health Center, 2015
Swing beds are defined as beds that can be used for skilled nursing care or acute care.
Rural hospitals with less than 100 beds, including Critical Access Hospitals, with a Medicare agreement are allowed to use their beds for acute or skilled services.
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Overview – Why Swing Beds?
• Access to services- Can’t go home but can’t stay here• Financial benefit to facility• For CAHs, the swing bed option helps to comply with the annual 96-hour
length of stay• Improved quality of life due to returning to their own community• Easier for family and friends to be involved and visit (decreased burden
of travel)• Patients may find a swing bed stay less disturbing than being transferred
to a nursing home• Swing beds may provide higher quality of care than nursing home given
skill mix of staff• Providers are less reluctant to discharge patients to a skilled level when
in-house• Provides extra time to craft a more comprehensive post-acute discharge
plan• Can prevent readmissions and avoidable ED visits
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Overview
• With uncertainty around a majority of significant provisions, such as payment, insurance, and delivery-system reforms, the healthcare industry must address future market changes
• Swing-bed services provide an important care resource for rural patients and a volume growth opportunity for the hospital
• Best practice peer rural hospitals target swing-bed ADC at a minimum of 4.0
• An effective swing bed strategy and process will have a significant impact on the number of patients in your swing bed program
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6Overview QuestionsDefinitions / Regulations
Swing Bed Volume Growth
7Swing Bed Volume Growth
Active Solicitation
• With a limited number of swing bed patients, hospitals need to actively pursue patients to increase volumes
• Best-practice rural hospitals will establish relationships with larger hospitals and actively pursue swing bed patients whenever beds are available
• One of the primary concerns of an acute care PPS hospital looking for swing bed placement is to free up the bed for future acute admissions
• The goal of the swing bed program is to establish a relationship with the other hospital so that you are the first hospital they consider when swing bed services are needed (Pull not Push)
• Best-practice rural hospitals will ensure patients who are transferred for acute services elsewhere return when needing swing bed services
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Admission Process
• Hospitals should implement a defined process to pursue swing bed patients and increase overall inpatient volumes
• The following is a best-practice process for swing bed volume growth:
• Pending Discharge Review• Pharmacy Review• Business Office Review• Rehabilitation Review• Central Supply / DME Review• Physician Review• Patient Pursuit
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Care Scale
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Nursing
Pharmacy
Provider
Business Office
Rehab
Supplies/Equipment
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Determine the number of available beds at the hospital
Reach out to all possible PPS hospitals daily to see which patients require placement• This can be done electronically through an EHR or by contacting a
Case Manager
Evaluate all patients needing placement and determine which patients could receive care at your facility• This should be done by a nurse or other individual who understands
the care abilities and the agreed upon “care scale”
Pending Discharge Review
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• The Pharmacy Review includes the following steps: • Determine the drugs necessary for each patient who could
possibly receive swing bed services• Determine the cost of the drugs necessary• Determine if the Pharmacy has the drugs necessary to provide care
• If the pharmacy does not have the drugs, how long until they could receive the drugs?
• Is acute care facility willing to send until available?
Pharmacy Review
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Business Office Review
• The Business Office Review includes the following steps:
• Determine the insurance type of each patient needing placement
• Insurance verification for each patient can include the following:
• Receiving prior authorizations when necessary
• Confirming the patient has enough eligible Medicare days
• Confirmation, if possible, with insurance company that patient had a qualifying admission justifying swing bed service need
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Rehabilitation Review
• The Rehabilitation Review includes the following:
• Evaluation of the rehabilitation services needed by the patient
• Determining if the rehabilitation service meets the skill requirement for swing bed services
• Determining if the hospital has the available staff to provide the skilled services
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Central Supply / DME Review
• The Central Supply / DME Review includes the following:• Evaluation of the supplies and/or equipment needed by the
patient• Examples: Wound care, bariatric equipment such as
beds, lifts, wheelchairs, bedside commodes• If ordering, when can the supplies/equipment be onsite• If acute care has the equipment needed, can it be sent
with the patient?
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Physician Review
Provide physician with discharge information about each patient facility plans to pursue• The physician should be the last person approached and
possible patients should only include those patients that passed all prior steps
Work with physician to determine which patients they are willing to accept into the swing bed program• This should be done by a nurse or other individual who
understands the care abilities and the agreed upon “care scale”
Physician should also confirm medical necessity for swing bed services
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Patient Pursuit
• After you complete all the prior steps and determine a patient is appropriate for swing bed admission, contact appropriate hospitals and pursue those patients for swing bed admission
• You will most likely not receive all the patients pursued while establishing a relationship with other hospitals
• The earlier you reach out to other hospitals, the more likely you are to receive patients
• Regardless of whether you receive a patient, continue to build relationships with Case Managers as this is a critical component for swing bed admissions
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17Overview QuestionsDefinitions / Regulations
Swing Bed Program Design
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Swing Bed Program Checklist
PROGRAM DEVELOPMENT
Dedicated swing bed coordinator Dedicated contact number, email and fax Create pre-admissions screening form and admission
checklist including DME needs, discharge plan and insurance verification process
Create basic admission order sets Education on teach back and Ask Me 3 Develop activities program Education on Effective Coding and Documentation
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Swing Bed Admission Checklist
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Swing Bed Admission Orders
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Swing Bed Order Set
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Discharge Plan of Care
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Discharge Prep Checklist
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The Teach-Back Method
See websites for a training program
• http://healthliteracymn.org/sites/default/files/images/files/Teach-Back%20program%20guide_updated%20060412.pdf
• http://www.nchealthliteracy.org/toolkit/tool5.pdf
See website for YouTube (video) training
• http://www.youtube.com/watch?v=90UYktrxClg
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Ask Me 3®
• What is Ask Me 3?
• Why is it important?
https://youtu.be/B3EB-icaNKQ
Ask Me 3® is an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stayhealthy.
Designed by health literacy experts, Ask Me 3 is intended to help patients become more active members of their health care team, and provide a critical platform to improve communications between patients, families, and health care professionals.
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ERH Swing Bed Weekly Schedule
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PMH Swing Bed Activities Guide
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PMH Swing Bed Activities Guide
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Swing Bed Program Checklist
MARKETING and PROMOTION
Referral source data collection Develop brochure, advertise open house, in-person visits Track all transfers from IP and ED for potential SB
admission Ensure employed and/or local PCPs understand the value
of the swing bed program Transitional Care Management coding for swing bed
discharges Relationship with local tertiary facility for daily lists of
patients ready for discharge (BAA)
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Swing Bed Case Manager Letter
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Initial Swing Bed Referral
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Swing Bed Referral
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Swing Bed Letter
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Swing Bed Brochure
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Swing Bed Brochure
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Swing Bed Brochure
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Swing Bed Program Information
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Swing Bed Program Checklist
CLINICAL PROCESSES and OUTCOMES
Interdisciplinary team review Interdisciplinary huddles at least twice a week and at
discharge Pharmacist at bedside for med teaching Meds to Bed Follow-up appointments made at discharge Discharge follow-up calls 24-48 hours after discharge Family and patient part of discharge planning
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https://www.stepsforward.org/modules/team-huddles40
https://medcitynews.com/2017/05/meds-beds-programs-aim-improve-patient-engagement-tackle-readmission-problem/?rf=1
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Swing Bed Program Checklist
PERFORMANCE MONITORING
Swing bed metricsUtilize readmission risk assessmentDevelop dashboard to include at a
minimum: ALOS, ADC, cost per episode, readmissions within 30 days
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Patient Risk Assessment
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Patient Risk Assessment
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Swing Bed Program Checklist
LEADERSHIP DEVELOPMENT and ACCOUNTABILITY
Hospital management has explicitly established swing beds as a strategic priority
Establish swing beds as a formal department for performance measurement and accountability
Provide ongoing leadership development training to swing bed manager
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47Overview QuestionsDefinitions / Regulations
CASE STUDY 1
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Case Study - Kohala Hospital
Kohala Hospital’s admission process can be lengthy and confusing. Currently, admission process can average 5 hours, vital information may be missing and the lengthy process creates the potential for losing the admission.
IMPACTED: Patient/family satisfaction, external referral source satisfaction, and employee satisfaction
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Current State
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Target State
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Gaps and Solutions
• Gaps• Fax lines in Business Office
and ED• Missing documentation• Reviews of documentation
caused wait times• Prior
authorization/notification not done
• Dietary restrictions and meds needed not communicated on the front end
• Solutions• Add one line in SB coordinator
office• Create a template for referral
source• Visit each referral source and
educate• Review by Provider/
Rehab/Nursing done simultaneously
• Prior auth/notification prior to acceptance
• Email sent on acceptance to dietary and pharmacy
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Gaps and Solutions
• Gaps• Isolation precautions
not communicated on the front end
• Unclear back-up plan for SB coordinator
• Solutions• Isolation precautions
communicated by email/team huddle at acceptance
• Create standard work for SB coordinator back-up plan
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Kohala Admissions Checklist
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54Overview QuestionsDefinitions / Regulations
CASE STUDY 2
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Identification of Barriers
• Have not established relationships with tertiary / referring facilities
• Providers refusal to accept patients not in their panel• Relationship with providers has been damaged due to
acuity of patients accepted• Hours for accepting patients are limited• Currently there is no agreement on the types of
patients the SB program should accept (care scale)• Have not evaluated the possibility of a niche market• Do not have a dedicated swing bed coordinator• Have not marketed services in the community
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Action Planning
Have not established relationships with tertiary / referring facilities
• Identify all hospitals with which to pursue relationship • Identify people to reach out to at the hospital • Two-pronged (CM to CM / CEO to CEO)• Pursue interface (BAA) with tertiary facilities to pull patient data• Advertise full complement of services when partnering with new
facilities• Continue to reach out to specialty providers (ortho, etc.) to drive
business to facility• Use data to show low readmissions that could potentially impact
PPS hospitals due to readmission penalty (also HACs)
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Action Planning
Providers’ refusal to accept patients not in their panel
• Discuss importance of inpatient services at facility • Find out what is preventing providers from seeing
patients not in their panel• Ask for specific reasons, not general statements• Look at hospitalist model (MD/APP)• Engage providers around hospital-specific care scale• Find out which patients have been rejected for care
at facility
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Action Planning
Relationship with providers has been damaged due to acuity of patients accepted
• Leverage EPIC to increase information available to providers to make informed decision
• Create interfaces with larger facilities so providers get more information
• Find out if specific hospitals are the ones that led to poor outcomes
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Action Planning
Hours for accepting patients are limited… providers want patients no later than 2pm
• Evaluate hospitalist model• Pursue patient(s) earlier in the day• Look at $$ tiering model for on-call
schedule based on volume• Reach out to tertiary facilities to
determine discharge schedules
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Action Planning
Currently there is no agreement on the types of patients the SB program should accept (care scale)
• Engage providers around what patients could receive care at facility
• Engage Rehab around the services provided• Engage Pharmacy around carried medications and
ability to get additional meds• Engage Nursing around competencies and what level
of care can be provided • Engage central supply - DME regarding
supplies/equipment that may not be readily available
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Action Planning
Have not evaluated the possibility of a niche market
• Assess needs within the community for swing bed services
• Reach out to System to find out discharge information about patients that need skilled placement
• Assess potential downstream revenue based on selected swing bed services
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Action Planning
Do not have a dedicated swing bed coordinator responsible for
soliciting patients
• Evaluate dedicated individual to solicit patients daily
• Find out who to reach out to at tertiary facilities
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Action Planning
Have not marketed services in the community
•Develop marketing campaign around swing bed services
•Get Medical Director to promote swing bed services to all providers
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Questions and Discussion
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