Massachusetts a Model Market for Successful Integrated Care

By Kindred Healthcare

The success of Kindred’s Massachusetts Integrated Care Market, which makes it a model for other integrated care markets and those moving toward becoming integrated care markets, is largely based on receptiveness toward evolution: the evolution from case to care management, and the evolution from “discharging” toward “transitioning” a patient across sites of care.

 Joe Hugar, Division Vice President of Operations for the Boston Integrated Market, Kindred Healthcare
Joe Hugar
Division Vice President of Operations for the Boston Integrated Market
Kindred Healthcare

Representatives from the Massachusetts market Joe Hugar, Division Vice President of Operations for the Boston Integrated Market, and Stacey Hodgman, Senior Director of Care Management for the Boston Integrated Market, explained the growth and development in Massachusetts and its plans for the future at the Kindred Clinical Impact Symposium – Care Across the Continuum.

Massachusetts is one of Kindred’s richest resources, with six Transitional Care Hospitals, 41 Skilled Nursing Facilities, one sub-acute unit, two home health locations, two hospice locations and two assisted living facilities. Prior to Kindred’s recent acquisition of IntegraCare, it was the only market to feature the full continuum of services, and it has seen a 200 percent growth rate in referrals across the continuum to PeopleFirst.

Massachusetts’ move from case to care management largely comes down to semantics: the dictionary definition of the word “discharge” stresses “relief of a burden,” while transition is a kinder, gentler word, said Hodgman.

As it has moved from case to care management, market leaders have paid close attention to the proximity of nursing centers to a Transitional Care Hospital location and the creation of pods, groups of Kindred care settings within a defined geography with the potential to perform better collectively than independently.

Also given heavy consideration have been cross-referral admission patterns from one site of care to another. A strategic workgroup was formed in Massachusetts with representatives from across the continuum of care, and it has looked at the building of relationships between the facilities, and cross-divisional education.

“Our goal is to develop and implement a model focused on care transitions to promote seamless navigation of patients through the post-acute continuum and improve patient satisfaction and outcomes,” said Hodgman.

Under the new model, transitional care nurses will be hired to follow patients through Kindred’s post-acute continuum, and staff and physicians will be educated about the role of the transitional care nurse.

Collaboration with primary care physicians is a big part of the transition from case to care management, said Hodgman. Transitional care nurses will be charged with calling the primary care provider with each transition of care.

“The PCP will be involved every step of the way,” she said.

 Stacey Hodgman, Senior Director of Care Management for the Boston Integrated Market
Stacey Hodgman
Senior Director of Care Management for the Boston Integrated Market


Transitional care nurses will also be charged with improving patients’ self-management skills and enhancing communication between the patient, healthcare delivery teams and the patient’s primary care physician. The nurse will physically and telephonically follow the patient through the entire post-acute episode of care.

With these new processes in place, the Massachusetts market will be launching a pilot program designed to reduce readmissions to acute care hospitals.

The intervention group will receive current discharge planning processes with the addition of structured patient encounter follow-ups and transition coaching throughout the entire episode of care. The transitional care nurse will be responsible for the completion of a patient satisfaction survey following each transition of care as well as upon transition from the lowest Kindred level of care.

During the survey process, the patient will be asked about readmission, trips to the emergency room and filled prescriptions.

The control group will receive discharge planning using current models with the addition of a patient satisfaction survey.

Transitional care nurses will meet with the intervention group patients on day of admission, weekly or more often after that, and within 24 hours of transition to home or home health care, within 48 hours of transition to hospice and on day 35 after transition from the lowest level of Kindred care. Patients who transition to a non-Kindred provider will receive phone calls 24 to 48 hours post-discharge to evaluate their Kindred experience.

“We hope we will be able to see a decrease in readmissions,” said Hodgman, and those results are likely to be shared within the coming year.

Below is the story of Vivian who started at Kindred Hospital Park View-Central Massachusetts, transitioned to Kindred Transitional Care and Rehabilitation - The Meadows, and then home.