Advancing Community Coordination - 5 New Courses for Swing Bed Professionals

Swing bed programs are increasingly important to the financial health of rural hospitals, but also a key component in the continuum of health care as many communities face aging populations, increasing comorbidities, and tightening of healthcare dollars. This program is designed to look externally at community needs before determining drivers of swing bed needs; but, equally important, it expands the network supporting health needs of your area’s population.

Course 1: Performing Baseline Evaluations

Hospitals having the right programs, staff, and equipment provides the opportunity for services closer to home; at the same closer to home is highly dependent on other health care and non-health care settings. Evaluating next steps means understanding all services available and building up a community team beyond hospital walls. Your “team” may include a civic group member or a school leader, a county health department official or a rural health clinic director, a driver or a community garden organizer. Community coordination is a name, an effort, and a determination for best results. The initial assessment, based on a team evaluation, will determine the baseline measures for your Swing Bed program planning. It begins a process of self-evaluation of steps already taken, next steps to be determined, and determination of focus areas – all specific to your program, your hospital, your service area.

LEARNING OUTCOMES:

Upon completion of this session, you should be able to:

• Identify health-related priority services for outreach and follow-up.
• Explain how to develop a baseline measure tool specific to your community.
• Discuss awareness of the swing bed program and supporting hospital services.

Course 2 - Community Services Needed for Viable Patient Care 

Community services have always worked hand-in-hand with healthcare in rural communities, but coordinated care has been hampered by funding, inability to set common goals, and not always understanding service gaps. It’s one thing to identify gaps, as an example, in transportation to/from physician visits and outpatient services, and another to formalize a program with funding. Explore what’s missing from your community potential in this next step toward advancing community coordination.

LEARNING OUTCOMES:

Upon completion of this session, you should be able to:

• Identify health-related and community services available.
• Explain what gaps exist in developing cooperating agency involvement.
• Discuss the need for coordinated care with community services to reduce unnecessary medical costs.

Course 3 - How to Track Swing Bed Discharges Through Community Services for 30 days

Rural hospitals who prioritize care coordination can provide stable patient support as staff follows the patient through a myriad of available services. Current Medicare standards (i.e., financial penalties for PPS hospitals, SNFs, SWBs) means tracking readmissions and avoidable ER visits within 30 days of discharge (from the last inpatient stay). This course moves programs into an action phase with suggestions for planning, prioritizing and developing communication with community entities through multiple site ideas and tools that can be adapted to each individual swing bed program.

LEARNING OUTCOMES:

Upon completion of this session, you should be able to:

• Identify health related and community services included in a localized coordination plan.
• Prioritize and plan tracking between services/agencies.
• Develop appropriate forms for interagency/facility involvement.

 Course 4 - Review of Patient Care Improvement Through the Coordinated Effort

In this session of the Advancing Community Coordination Series, Kerry Dunning covers the key essentials of coordinated care and the role it plays in rural health communities. The development of this approach is the basis for healthier populations while addressing Medicare concerns about unnecessary health costs. She shares approaches which have enabled communities to develop/improve patient discharge through the first 30-days after discharge. The importance of both clinical and financial measures, as well as successful tools/approaches will be explored.

LEARNING OUTCOMES:

Upon completion of this session, you should be able to:

• Define key elements of healthcare care coordination.
• Access tools to aid in the development of a coordinated approach to care as patients discharge.
• Establish measures for program success.

Course 5 - Most Valuable Services within the Community and Potential Development of Others

Rural hospitals who prioritize care coordination can provide stable patient support as staff follows the patient through a myriad of available services. Current Medicare standards (i.e., financial penalties for PPS hospitals, SNFs, SWBs) means tracking readmissions and avoidable ER visits within 30 days of discharge (from the last inpatient stay). This course moves programs into an action phase with suggestions for planning, prioritizing and developing communication with community entities through multiple site ideas and tools that can be adapted to each individual swing bed program.

LEARNING OUTCOMES: 

Upon completion of this session, you should be able to:

• Develop a plan for expanding community coordination of services needed post swing bed stays.
• Evaluate the value of service needs specific to your community.
• Address the potential need for post-COVID/Long Hauler services in your community.