Great Plains Family Medicine has successfully launched an effort to improve the experiences of nursing home patients by taking medical providers and nursing staff directly to the facilities.

The pilot project, which ran from April 16-May 31, aimed to enhance patient care, reduce hospital readmissions, and foster stronger relationships between healthcare providers and nursing homes.

The initiative began with provider meetings to set clear goals and vision for the project. After reaching out to local nursing homes, the response was overwhelmingly positive.

“We were welcomed with open arms,” Clinic Manager Megan Moore said. “The enthusiasm from the nursing homes was incredible, and it set a positive tone for the entire project.”

Key actions included creating and sharing SBAR (Situation, Background, Assessment, Recommendation) forms with nursing home staff to ensure timely provider communication, training Patient Access Technicians on appropriate scheduling, and coordinating with the hospitalist group on discharge procedures.

“We aimed to provide timely patient visits in their own environment, which not only improved the quality of care but also reduced the need for patient transportation, by the nursing homes.” Moore explained. “The real-time communication and updates significantly enhanced the continuity of care.”

Daily visits, achievements

Patients at Centennial Park, North Platte Care Center (NPCC), Linden Court, Linden Estates, Sutherland, and Premier Estates benefited from daily visits by Amanda Kramer, PA-C, and Medical Assistant Keri Allen, with coverage extending across the week.

Notable achievements of the six-week pilot program include:

• Only one hospital readmission during the six-week pilot, which was recommended by a provider during a patient visit.
• Prevention of two ER transfers/potential admissions.
• Reduction in overnight and weekend calls from nursing homes.
• Enhanced satisfaction among providers and nursing homes due to streamlined administrative processes.
• Improved communication with primary care physicians (PCPs) during each visit, enhancing care quality and continuity.
• Strengthening of the relationship between Great Plains Family Medicine and local nursing homes.

“We are thrilled with the outcomes of this pilot,” said Misti Hutchinson, Chief Provider Network Officer. “The decrease in hospital readmissions and ER transfers is a testament to the effectiveness of our approach. Providers also appreciated the reduced administrative burden, allowing them to focus more on patient care.”

Future goals

Building on the success of the pilot project, Great Plains Family Medicine has ambitious plans for the future.

“Our goal is to hire a full-time nursing home team to continue this important work,” Moore shared. “We also plan to expand the project and implement it on a wider scale.”

“This initiative has demonstrated the significant benefits of delivering healthcare directly to patients in nursing homes,” said Hutchinson. “We are excited to continue this partnership, further addressing the unique healthcare needs of these patients and ensuring they receive the best possible care right where they live.”

For more information about Great Plains Family Medicine and its initiatives, visit gphealth.org.

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