PCC Referral/Admission Integration Underway

The facility-based and community liaisons who screen for Spaulding Rehabilitation and Partners Healthcare at Home (PHH) are integrating processes to provide one point of contact for all PCC services. This integrated referral and admission model will provide a one-stop shop for customers in acute care hospitals, skilled nursing facilities, physician offices and community settings who want to access rehabilitation or home care services.

By combining the teams of Spaulding Rehabilitation and PHH liaisons, PCC is able to expand resources and geography, provide one point of contact for many customers, and most importantly, improve the transition of patient care.

This integration comes at a significant time when bundled payments and other models of care require moving patients through the healthcare continuum efficiently, without compromising patient care. This customer-focused process will safely and seamlessly transition patients from one care provider to the next, and deliver a complete, accurate referral and admission for Spaulding Rehabilitation and PHH.

The new model of care has been rolling out one region at a time, starting with the North, followed by the South in February, Urban I region in March, Urban II and the West regions in April. All PCC liaisons, situated in hospitals, nursing homes, physician offices and community settings throughout Eastern Massachusetts, have undergone cross-training in a rigorous month-long curriculum that has equipped them to assess needs and understand each level of care and their unique requirements.

The new model of integrated care has already begun in the North region. Penny Maylor, Regional Director of Continuing Care for the North, states, “This new model is much more team-focused, allows for better communication between caregivers, and promotes warm hand-offs. Having one liaison as the point of contact significantly improves the patient and caregiver experience.”

This model has been extensively studied, and planning has been underway for over two years. It has been a collaborative effort between executive teams, clinical teams, support teams and referral sources, who have thoroughly prepared to ensure that all customer needs are met during the transition. Lee Ann Baldini, Director of Case Management at NSMC, states, “The model benefits case managers in the acute setting because it facilitates teamwork. Having one liaison assigned to a service area allows better integration of services, and overall coordination of care.”

Lee Ann also adds, “In the acute setting, the model also streamlines workflow and processes, and truly builds a team spirit.”

For more information about the PCC Liaison Integration Model, please contact Nancy Schmidt at (617) 573-2251 or nschmidt@partners.org.