(l-r) Mary Van de Kamp, Tony Disser, Kathy Owens, Matt Sivret and Susan Sender (l-r) Mary Van de Kamp, Tony Disser, Kathy Owens, Matt Sivret and Susan Sender

Representatives from each of Kindred’s divisions – the Hospital Division, the Nursing Center Division, Kindred at Home, RehabCare and the Care Management Division – demonstrated ways in which Kindred clinicians and staff across the enterprise can collaborate to improve care transitions throughout the country during a presentation at the Fifth Annual Clinical Impact Symposium.

Tony Disser, Senior Vice President, Clinical Operations for the Hospital Division, noted that Kindred’s Transitional Care Hospitals – which take care of sick and medically-complex patients requiring high-level acute care over an extended recovery period – transition many patients to long-term care of various types. With that in mind, Disser challenged Hospital Division clinicians and staff to pay close attention to those care transitions and work with partners at other care levels to ensure that patients go to the right place at the right time with an eye toward reducing rehospitalization rates.

For the Nursing Center Division, as it experiences a metamorphosis, care transitions go in both directions.

“We will see length of stay reduced and we expect more than half of patients to be discharged home,” said Kathy Owens, Senior Vice President, Clinical and Residential Services for the Nursing Center Division, imploring colleagues to see the Nursing Center Division as a solution.

“It’s helpful to you to know what we provide to you – a cost-effective solution in this healthcare environment,” she said.

RehabCare, a common thread providing physical, occupational and speech therapy and wellness services across multiple settings, is uniquely positioned to play a prominent role in effective care transitions.

Even as systems and technology catch up, care transitions communications can be simple, said Matt Sivret, Divisional Vice President, Clinical Operations for RehabCare. “A therapist can simply pick up the phone and call the therapist in the receiving setting and communicate the patient’s three most important goals. We have a real opportunity to take advantage of the Kindred family.”

Kindred at Home currently goes by many different names and is struggling with easy identification, but this should not be a deterrent to the important role it can and should play in great care transitions, according to Kindred at Home’s new Vice President and Chief Clinical Officer, Susan Sender.

“I challenge you to reach out to one another,” Sender told symposium participants. “Reach out to your counterparts, have dinner, figure out how we can work together.”

As an example of how things can work well in a pilot project, Mary Van de Kamp, Senior Vice President, Quality and Integrated Care for Kindred Healthcare, described the work being done in the Boston, Indianapolis, and Cleveland integrated care markets through the Care Transitions Management program.

The care transitions manager addresses the patient’s physical and emotional needs, as well as the family’s needs to ensure that patients can successfully transition between varying levels of care. If needed, a transitional care pharmacist can be brought in to address issues of medication adherence or polypharmacy.

The day the patient transitions home, the care transitions manager collaborates with the home health nurse to be sure the patient has the right treatment plan.

Christine Plante, RN who is a care transitions manager in Boston was interviewed for a video about the program and said: “Having patients hug you and cry for the difference that you’ve made is so rewarding.”

http://www.youtube.com/watch?v=M8jSwZU3VXM

(l-r) Mary Van de Kamp, Tony Disser, Kathy Owens, Matt Sivret and Susan Sender