The flow of patients between inpatient hospital-based care and outpatient skilled nursing is well established. Frequent flyers move back and forth between the two settings, creating an environment where errors may occur during hand-offs, costs continue to escalate, and paperwork piles up.

While this is an ongoing issue for patient outcomes and satisfaction, it is also a priority for healthcare systems themselves that seek to:

• Reduce readmission and mortality rates,
• Serve patients with complicated health needs and comorbidities, and
• Provide long term and/or end-of-life care to their patients.

There are many contributing factors to readmissions and other clinical outcomes, some of which are out of a hospital’s control, such as social and economic factors. However, there are some that are within a healthcare system’s influence, such as:

• Inpatient Length of Stay (LOS),
• Access to rehabilitation and therapy (PT and OT) services,
• Duration between discharge and the first follow-up physician appointment,
• Availability of placement with the appropriate level of nursing care.

With all of the various clinical settings and resources that may be required in order to provide care (beds, PT, OT, physician, social worker, payer), coordinating effective post-acute nursing care is a complicated affair.

So how do you provide both cost-effective and clinically appropriate post-acute services without unreasonable delays for the patient? How do you optimize the system?

To really address the “rotating door” between inpatient and post-acute skilled nursing services, you need to utilize a variety of toolsets:

1. CHANGE MANAGEMENT – Use tools for engagement such as the elevator pitch, stakeholder assessment, and many others. Identify leaders from each important group of stakeholders to include in any discussion of potential changes.
2. LEAN – Visually map out the patient flow, communication lines, and delays in care. This will allow you to immediately identify waste in the system and opportunities for error.
3. SIMULATION – Once the process has been “leaned”, develop a simulation to identify and communicate additional opportunities for improvement.

Using simulation to model this complex environment achieves a few key benefits:

• Visualize feedback loops that reinforce certain outcomes.
• Evaluate the effectiveness of improvement ideas.
• Understand how each component of the system interacts with the others.
• Communicate complexity in a visual way.
• Inform system-wide dashboards and how performance targets are set.