Orlando Health recognized nationally for patient discharge programs

Right out of the gate, Orlando Health was recognized nationwide for its successes in Transition Services, only a year after the healthcare system launched the program. VHA Inc., a national network of not-for-profit healthcare organizations, selected the organization’s model to serve as a roadmap to others.

“Transition Services, which manages the coordination of continued care after a patient’s hospital discharge, is being driven by changes in the new pay-for-performance environment, specifically concerning new guidelines for Medicare reimbursement,” said David Sylvester, vice president of Post Acute and Transition Services for Orlando Health.

“The new Medicare regulations will penalize hospitals for readmitting patients within a 30-day window of discharge for heart attacks, pneumonia or congestive heart failure. This readmission interest level has grown significantly nationally because it will greatly impact hospitals’ abilities to be reimbursed by Medicare in the future. It’s also a better quality and safety concern measure for patients. They generally do better at home than in the hospital.”

Formed in 1977, Texas-based VHA Inc. works with nearly 1,350 not-for-profit hospitals and more than 30,000 non-acute care providers through 16 regional offices to drive maximum savings in the supply chain arena, set new levels of clinical performance, and identify and implement best practices to improve operational efficiency and clinical outcomes. VHA’s Leading Practice Blueprints™ capture and explain leading healthcare practices in a visual format that includes clinical, engineering, social science and design components. VHA’s online clinical portal provides around-the-clock access to data analysis and benchmarking, and some 100 Leading Practice Blueprints based on best practices, placing Orlando Health squarely in the network’s leading 10 percent.

“An important component to the success of our program is that, as vice president for transition services, there’s one point of accountability in coordinating efforts across our healthcare service to the post-acute arena – and that’s me,” said Sylvester, who joined Orlando Health last July after 14 years as a senior vice president at Health Central. The hospital’s Transition Services program was established last September by his predecessor. “A single point of accountability is a big factor in our success.”

Orlando Health’s Transition Services include several programs to improve health outcomes and efficiency of care and to reduce the cost of healthcare services, preventable hospitalization and hospital-readmissions. Key components involve the Visiting Nurse Association, home health division, Orlando Health Housecalls, a home-based physician practice, and several other innovative programs. Clinicians, social workers and other committed team members and leaders staff Telemedicine Heart Failure Monitoring Technology, an in-home service that alerts nurses to changes in vital signs so appropriate steps may be taken; Medication at Bedside Pre-discharge Delivery Service; Spiritual Care Home Volunteers; and Social Work Field Unit.

“Several organizations around the state have visited us to see how we operate the program, and we have ongoing dialogue with them,” said Sylvester. “The sharing of ideas has added to our success. For example, Transition Clinics in Tallahassee has a very interesting approach: a freestanding building with a number of services provided to patients upon discharge from the hospital.

“One of my personal goals is to change the nomenclature from being ‘discharged’ to being ‘transitioned’ from the hospital because as we go forward and are paid by bundled payment methodology, the hospital will be responsible for providing care after patients move from the walls of the hospital to the next level of care, whether it’s their personal home, a skilled nursing home, or an assisted living facility. When you discharge a patient, it implies your responsibility has ceased. If you’re transitioning the person from an acute care setting to a post-acute care setting, it indicates you continue to have some responsibility and accountability for their health.”

Central Florida’s fifth largest employer, Orlando Health has a community-based network of hospitals and care centers that includes the region’s only Level One Trauma Centers for adults and pediatrics. Other healthcare system partners include Orlando Regional Medical Center; Arnold Palmer Hospital for Children; Winnie Palmer Hospital for Women & Babies; Dr. P. Phillips Hospital; South Seminole Hospital; South Lake Hospital; St. Cloud Regional Medical Center; and MD Anderson Center Orlando, the inaugural affiliate of The University of Texas MD Anderson Cancer Center in Houston. 

“Because healthcare is moving from a volume-based system where we’re paid for everything we do to a value-based system where we’re paid for outcomes, Transition Services represents a key component to moving us to a value-based system,” said Sylvester.

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