Every time we set foot on a plane, we take comfort in knowing the pilot and every member of the flight crew have gone through standardized checklists and processes to ensure we arrive home safely. Likewise, our healthcare teams, led by physicians, need to standardize their processes to come to the best decision for their patients so they can feel that same sense of comfort. Timing and input matters. An ad hoc collection of information simply does not work.

In a 2017 JAMDA study¹ titled “Transitions from SNF to Home: The Relationship of Early Outpatient Care to Hospital Readmission” the authors examined the relationship between early outpatient care and hospital readmissions. They concluded that a home health visit within a week of a patient’s discharge from a skilled nursing facility (SNF) was associated with a reduced risk of 30-day readmission. Though not the focus of their study, they also observed an alarming number of patients, almost half, who did not ultimately return home after their stay in a SNF. Shockingly, after a three-day hospital stay, our seniors have a mere 50/50 chance of returning home if they transition to a SNF. What can we do as clinicians to give our seniors the best chance of returning home?

The optimal next site of care decision is a standardized team approach to the transition of care to home. There are many routes, but only one ultimate destination. After what is for many patients a short trip to the hospital to stabilize medically, most will continue their recovery outside of its four walls. The question then is how we, as a health care team, can work with patients and families to select the best path to safely return a patient home? Does the most efficient and best route include a short stay at a skilled nursing facility? Or does the best choice involve simply receiving care as an outpatient? Perhaps the best level of care involves home health support or hospice care?

There are four crucial strategies care teams can employ to optimize this vitally important next site of care decision:

• The next site of care decision process must be standardized. As a frequent flyer I’m grateful that the flight crew responsible for delivering me to my next site of living have standardized processes and checklists to ensure my safe arrival. Creating and using a consistent structure (whether concurrent or asynchronous) for the NSOC decision ensures that patients will go to the optimal location to continue their care.
• The decision should be a team effort: A 2004 study ² concluded to stay current in their fields some specialists would need to read literature at a rate of 627.5 hours a month. Given the speed at which medical knowledge advances it is challenging for any one member of the healthcare team to stay current in their own discipline, let alone any others . The optimal NSOC decision is derived from a structured team process, led by a physician.
• A cultural shift from discharging a patient from the acute care hospital to transitioning a patient to their NSOC must take place.  With few exceptions, patients admitted to the acute care hospital will recover outside it’s four walls once medically stable. Reframing conversations about ‘discharging’, to where a patient will transition to safely and effectively continue their care is a vital decision. Standardizing the way the team comes together and contributes to this decision is best practice. The decision the team needs to make is where this recovery will continue, which brings us to the final crucial question care teams should ask…
• “Why not home?’ Ultimately, every next site of care decision should include this simple question. An optimal NSOC decision results in the patient transitioning to home, period. Patients who recover at home have lower risk of complications and better patient satisfaction. Even if they’re not able to recover, the vast majority of Americans still want to be in the comfort of their home when they die.

This reform is not out of the reach of any healthcare team—recent results from Remedy Partners’ partners have shown progress in discharging more patients to home. Interdisciplinary care teams at Edward-Elmhurst Healthcare recently looked into their NSOC decision making process with the support of Remedy Partners’ NSOC Gap Analysis. Marcie Lafido, MSN, CNS System Director Care Coordination at Edward-Elmhurst, shared promising results from Edward-Elmhurst Healthcare’s discharge patterns at Remedy Partners’ recent National Innovation Collaborative event.

The results clearly indicated how motivated interdisciplinary teams of clinicians can work together to achieve rapid progress on behalf of their patients. As clinicians, we owe it to our patients to put in the work and consideration to support a home recovery whenever it is medically appropriate.

1. Carnahan JL et al. “Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission.” J Am Med Dir Assoc. 2017 Oct 1;18(10):853-859. doi: 10.1016/j.jamda.2017.05.007

2. Alper BS et al. “How much effort is needed to keep up with the literature relevant for primary care?” J Med Libr Assoc. 2004 Oct; 92(4): 429–437