Kimberly A. Bell, MD, MMM, SFHM, FACP, Facility Medical Director, Hospital Medicine
Tiffany S. Hanf, MD, FACP, Regional Medical Director, Post-Acute
Marcie Matthews, Vice President, Post-Acute
Suzanne Powell, MHA, Vice President, Performance Improvement, Hospital Medicine
Suj Sundararaj, MD, MBA, Performance Director, Performance Improvement, Hospital Medicine
Kelley Lilly, Vice President Operations, Hospital Medicine
Kevin M. Donohue, DO, FACP FHM, Regional Medical Director, Hospital Medicine
As patients move from acute to post-acute facilities, often with more medically complex cases, the transitions between these sites of care become increasingly important. The transition from the hospital to a post-acute facility is more than a touchpoint. Instead, these transitions provide valuable opportunities to focus on seamless and coordinated care that can improve clinical quality and patient safety. After hearing about the Acute-to-Post Acute (ATP) program at TeamHealth’s National Medical Leadership Council (NMLC), Dr. Kimberly Bell, facility medical director of Hospital Medicine, took the initiative to implement ATP at Trios Health Southridge Hospital in Kennewick, Washington.
Why care transitions matter
When transitions of care are not prioritized, patients may experience fragmented care, exacerbated by the siloed approach commonly seen between acute and post-acute settings. Fragmentation can lead to suboptimal care, negative patient experiences, clinician frustration, and higher costs. In a proactive step to enhance care delivery, Dr. Bell engaged TeamHealth’s Performance Improvement Consultants (PIC) team to implement ATP at Trios Health Southridge Hospital. Upon initial engagement, the PIC team conducted a site visit to the facility, meeting with about 30 stakeholders from the hospital and aligned skilled nursing facilities (SNF) at a town hall to create a coordinated action plan.
The group noted some immediate barriers to seamless transitions:
- Inpatient length of stay (LOS) to SNF
- Weekend discharges when PAC facilities can’t always accept weekend admissions
- Timely and accurate discharge summaries
- Concerns about prescriptions for patients discharged on weekends when PAC pharmacies are closed
The swift intervention from initial engagement in December to creation of the action plan in February is a credit to the vast and scalable resources TeamHealth offers. Within months, the cross-functional group had identified their biggest hurdles and created a plan to address and remedy them. As a result, the Hospital Medicine PIC team conducted a rapid process improvement workshop at Trios Health Southridge Hospital.
Building seamless transitions
One of the biggest goals from the action plan was to create an ongoing collaborative where the facility and SNFs actively solve problems together. The team met regularly and they have significantly reduced LOS and avoidable days. Moreover, they have sustained this success for more than six months.
”Anytime we can admit a patient to a Skilled Nursing Facility on the weekends is a win!
Charlie PearceExecutive Sponsor, Market Chief Financial Officer
The team achieved these results with several key strategies. First, they solidified a sustainable collaborative that continues to engage departmental leadership, SNF stakeholders, and facility executives to ensure processes remain consistent. In these collaboratives, there is bi-directional dialogue on what is working and what is not. Action Plans are
updated accordingly. Second, they aimed to increase communication and break down the silos that traditionally hinder improvements for transitions of care.
Finally, they addressed the specific barriers identified in the town hall by creating custom tactics:
- Hospital gives advance notice to the SNFs for weekend transfers and works from a checklist to ensure SNFs have what they need
- Hospital allows SNFs secure EMR access and Tiger Text for better flow of communication
- SNFs provide pharmacy hours for the weekends to ensure patients receive medications in a timely manner
- TeamHealth provides additional tailored education to further improve transitions of care
After 6 months, overall GMLOS variance dropped from 1.17 to 0.92, SNF variance fell from 2.68 to 1.8, without increasing readmissions, and overall readmissions fell from 7.1% to 6.0%, while avoidable days declined.
Enhancing key metrics
The collaborative has seen impressive results thus far. As noted, these results have been sustained for over six months to the credit of the strong partnership among all stakeholders. Specific results include:
- Reduced overall GMLOS Variance from 1.17 to .92 from January to July 2025
- Reduced GMLOS to SNF Variance, without increasing readmission, from 2.68 to 1.8 from January to July 2025
- Reduced overall readmissions from 7.1% to 6.0% from January to July 2025
Strengthening acute to post-acute transitions
An engaged and supportive partnership is the key to success. From the hospital executives and TeamHealth colleagues to the SNFs, everyone continues to work toward the same goal together, providing exceptional patient care. Our integrated leadership model helps us align with our partners to achieve excellent clinical quality, while maintaining focus on improving healthcare delivery. The PIC team provides customized, scalable solutions for partners across the country, backed by our resources and expertise in managing the full spectrum of care. To learn more and partner with us, please reach out to our team.
