Kindred Hospitals: Helping Medically Complex Patients Return Home

Saleem Alinur, Sharon Lee, and Lorene Perona from ScionHealth's Kindred Hospitals discuss the importance of helping medically complex patients discharge to home after a hospital stay, and how Kindred is achieving this goal.

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more. 

Today, we are going to be talking about the importance of helping medically complex patients return home after a hospital stay. Today, we're joined by 3 guests from ScionHealth's Kindred Hospitals. Would you please introduce yourselves?

Saleem Alinur: I'm Saleem Alinur, Vice President of Managed Care at ScionHealth, which includes Kindred Hospitals.

Lorene Perona: Hi, I'm Lorene Perona, Vice President of Clinical Operations at ScionHealth.

Sharon Lee: I am Sharon Lee, Vice President, Managed Care for the West Region for ScionHealth.

Thank you all for joining. So first off, Saleem, can you tell us why facilitating patients' return home is so important to the managed care community?

Mr Alinur: Sure. Helping patients return home and remain home is very important, mostly because of the patient's wellbeing, as well as the overall cost mitigation. 

First off, studies have shown that patient outcomes improve faster in a home setting. Some of the reasons have to do with supportive family and friends in the home setting, not to mention the reduction of further risk of contamination you would normally find with prolonged exposure to a clinical setting. 

Secondly, by getting the patient home, it avoids the cost of further lower levels of care. Also, reducing readmissions to acute levels of care is very instrumental in reducing overall cost of care.

So, patient wellbeing and cost reduction—those are the 2 key priorities. Sharon, how is Kindred Hospitals tuned into this focus on getting patients home?

Ms Lee: Over the past several years, Kindred Specialty Hospitals has worked more and more with managed care patients. Because we see the importance of discharging patients to the home, we work closely with payers to expedite the journey home and reduce the risk of readmissions. 

Some of the initiatives include care coordination meetings, which are meetings we have set up with key payers to discuss barriers to moving challenging patients through the continuum. We also invite our payers to sit on interdisciplinary care team meetings, which are meetings that leverage the expertise of each discipline to advance the patient's plan of care, and we have a number of clinical initiatives that start on the day of admission, which Lorene can explain in more detail.

Great. Lorene, can you tell us more about these clinical initiatives at Kindred?

Ms Perona: Sure. First of all, it's really important to get an early assessment for discharge planning. It starts prior to the admission, with getting information from our referral hospitals. The goal is always a home discharge, so we work towards that. 

We assess with the patient and family what we need to do to get them successful home discharge, and we involve the interdisciplinary team with the patient, and the family if the patient desires, within 24 to 72 hours. Case managers also assess social determinants of health to identify issues such as food insecurities, housing or financial issues, medication compliance, anything that's going to be a barrier to help them be successful getting home.

So discharge planning starts day 1, but how are patients supported throughout their stay at Kindred?

Ms Perona: While they're in house, again, we use that assessment as the foundation for planning from day 1. We involve the patient, the families, and others as needed or desired in our interdisciplinary care team meetings. We use a Move Early program, which helps patients ambulate early, even when they're on a ventilator, if possible, to strengthen the muscles that help patients wean from the ventilator and strengthen limbs for early ambulation to ensure stability by the time the patient is able to discharge. 

Patient education is also very important to ensure patients understand their disease process and how they can manage it at home. We work with the patient to help prepare for and understand the importance of follow-up care, signs and symptoms to report early to their caregivers so that we can hopefully prevent readmissions, and why it is important to take medications as prescribed. Generally, we are trying to help them get control of their own narrative and feel safe being at home.

Does Kindred's involvement end when the patient is discharged?

Ms Perona: No, not at all. Actually, we have an aftercare program where we contact the patients within 24 to 48 hours postdischarge, and then at 1 week, and then at 14 days, and then at 31 days. These are all check-ins to make sure the patient has everything they need to feel comfortable with their discharge and prevent readmission to an acute care facility. These calls and texts also ensure compliance with the discharge plan and identify any additional support the patient may need once they discharge. 

This aftercare program helps us understand if there are certain things in a community or market that prevent consistent discharging such as food insecurities or lack of resources for medication management. We look to see what the patients are experiencing and if we can help connect them with resources. Each hospital is currently developing a health equities committee for their hospital to ensure community resources are available or needed for the patient population.

Thank you, Lorene, Sharon, and Saleem for joining us today for this important discussion.

Ms Perona: It's our pleasure. Thank you for the opportunity.

Mr Alinur: Yes, thank you for having us.

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This transcript has been edited for clarity.