Bridging the Gap: Continuing Care Services at WellSpan Health

By Allison Gorman
Monday, December 9, 2019
Category: 

A flourishing collaboration between WellSpan Health hospitals and skilled nursing facilities is reducing hospital readmissions and improving the patient experience.


Christie Magsino (left), Regional Clinical Quality Specialist with WellSpan’s Continuing Care Services, consults with Vonda Lenker, RN, Director of Nursing at HCR ManorCare – North, about a streamlined transition for patients between hospital and skilled nursing facility.

The transition from hospital to skilled nursing facility (SNF) is like a highway intersection — “It’s one of the most dangerous places for an accident, because so much is happening,” says Melissa Pierce, MPT, MHA, Administrative Director of Continuing Care Services at WellSpan. “The patient is leaving one unfamiliar environment for another, and the regulatory bodies that manage those facilities are different. Information has to be exchanged, orders have to be written, and the transition has to be timely and efficient.”

Now in its third year, WellSpan Health’s Continuing Care Services creates a safe, streamlined transition from WellSpan York Hospital and WellSpan Surgery & Rehabilitation Hospital to six SNFs — soon to grow to nine — and from SNFs to home or home health care. By coordinating communication and clinical protocols with preferred providers, WellSpan hospitals have seen positive improvement in readmission rates.

“Most of our skilled nursing facilities have readmissions way below the national average,” says Vipul Bhatia, MD, MBA, Medical Director of Continuing Care Services at WellSpan. “We now have 16 providers, and the original five who joined us three years ago are where we’ve seen the most improvement in readmissions.”

A major reason for the program’s success — and what makes the program unique in York and surrounding counties — is WellSpan’s collaborative, rather than top-down, relationship with partner facilities.

“The culture we’re fostering through this collaboration is one of mutual respect,” Dr. Bhatia says. “We know that when we’re both successful, we attain the best outcome for our patients.”

Promoting Clinical Integration

Continuing Care Services promotes clinical integration between hospital and SNF by removing the “artificial walls” between them, Dr. Bhatia says.

For certain complex conditions, such as sepsis and congestive heart failure, WellSpan has established cross-continuum care pathways based on evidence-based protocols. It also trains and educates SNF staff.

“Ultimately, these SNF team members are taking care of our common patients,” Dr. Bhatia says. “So we take the responsibility of bringing our knowledge to their staffs as a means of contributing to the better health of our patients.”

All partner SNFs now have WellSpan-employed, board-certified geriatricians or physicians with decades of experience working with elderly patients — a population that is especially vulnerable during transition. That is why WellSpan remains dedicated to bolstering communication between the acute and post-acute teams well before transition occurs. Nurses and rehabilitation specialists from both sides meet to ensure a warm handoff, giving the receiving facility all the information it needs to make the patient comfortable.

During and after transition, SNF physicians and clinical staff can use a shared EHR platform to view WellSpan’s hospitalization records for an incoming patient. As a result, referring providers can equip primary care providers or home healthcare workers with more complete medical records upon the patient’s discharge.

Continuing Care Services also reflects WellSpan’s focus on patient safety. Its process for anonymously reporting safety events now extends to partner SNFs so that problems can be addressed together in a constructive way.

“That’s something we’re really proud of,” Pierce says. “We’re getting bidirectional safety learning across our network.”


To learn more about Continuing Care Services available at WellSpan Health, call 717-812-6290 or email MPierce2@WellSpan.org.