By Lou Woolf, President & CEO, Hebrew SeniorLife
Robin Hynds, MSN, RN, CPHM, Senior Vice President, Network & Strategic Operations, Chief Clinical Integration Officer, Lawrence General Hospital

For many patients, being discharged from the hospital doesn’t mean returning home or back to live as usual. That’s why we have providers that deliver care in “post-acute” settings, such as long-term acute care hospitals, inpatient rehabilitation facilities, assisted living residences, skilled nursing facilities, hospice, and home care.

Our post-acute providers have always played an invaluable role in our healthcare system, but their work has been especially crucial to Massachusetts’ COVID-19 response. It’s an effort that has required quick action, close collaboration, and heroic work from caregivers.

Addressing the Challenge Together 

As the initial COVID-19 surge approached here in Massachusetts, sustaining acute care hospital bed capacity was among the most urgent priorities for the healthcare system. Transitioning recovering patients to non-acute settings, once they were healthy enough to do so, was a necessary way of keeping hospital beds open for the sickest patients.

But with so many moving pieces within the system and a rapidly growing number of COVID-19 patients no longer in need of acute care, what were the most efficient ways to transition these recovering patients to post-acute facilities? And what were some of the safety standards that organizations should adopt for the protection of these patients, non-COVID-19 patients, and staff? These were unique problems that required speedy, collaborative solutions.

We brought together a Post-Acute Care Transitions Workgroup in late March, which included nearly 50 members representing every segment along the continuum of care and across the commonwealth. With support from the Massachusetts Health and Hospital Association (MHA), we met virtually every week to discuss our greatest challenges, needs, ideas, and solutions on how to streamline the way patients are transferred and admitted to post-acute settings after leaving the hospital.

This workgroup of hospitals and post-acute providers accomplished a great deal in a short amount of time. We developed recommendations on the transition process for assisted living, inpatient rehab, and long-term acute facilities – recommendations that are now in process of being applied across the state. We focused on safety recommendations, such as patient testing criteria and infection control in skilled nursing facilities and the use of personal protective equipment (PPE) coaches to ensure the effective and efficient use of PPE in post-acute settings. We also raised awareness of the importance of advance care planning conversations in all types of care settings during this pandemic.

At the heart of all this work is our shared mission to provide patients with the right care, in the right place, at the right time. This was a priority before COVID-19 arrived, but it became an absolute necessity once the pandemic, and its potential to overwhelm our healthcare system, required us to develop new ways to serve our communities most effectively.

We are thankful that many of these recommendations have been embraced by our partners at the state and are already making a difference in the way we deliver care and interact with one another during this unprecedented public health crisis. When we are coordinated and actively listening to those from other parts of the healthcare system, it’s our patients who benefit most.

The Heroics of our Caregivers

Planning means nothing without execution. Throughout this crisis, post-acute caregivers have done absolutely heroic work in making sure every patient in need of care – whether for COVID-19 or not – is treated in an effective, safe, and timely manner.

These healthcare professionals face the unknown on a daily basis, for both themselves and their families. Home care workers enter patient homes where the ability to mitigate their exposure to COVID-19 is much less within their control. Those working in assisted living, long-term acute care, and skilled nursing facilities feel the pressures of treating large volumes of at-risk individuals. And yet, they continue to show up, make their patients comfortable, and provide world-class care.

We owe these unsung heroes a huge debt of gratitude. We are fortunate that we can rely on their fortitude and commitment at a time when seemingly everything else is uncertain.  

The Path Forward

Our workgroup provided a voice and representation for those across the healthcare continuum. It’s critical that we continue to provide a platform for those voices in the long term.

With that aim in mind, the workgroup will become a subcommittee of the existing MHA council chaired by the two of us – the Continuum of Care Council (CCC). The CCC, comprised of representatives from hospitals and post-acute organizations, will keep its finger on the pulse of the issues and needs of the post-acute community, and will establish actionable solutions to improve our synergy with hospitals and the care we provide, thus improving care across the continuum. Many of the obstacles highlighted by the COVID-19 pandemic existed long before this crisis began, and we look forward to addressing those in collaboration with colleagues across the state.

Of course, this public health crisis is far from over. With a second wave anticipated this fall, our coordination will be more valuable than ever. We are proud to have created an infrastructure for the hospital and post-acute community to come together and confront any challenges this virus presents us in the months ahead.