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The American Journal of Accountable Care September 2017
Population Health in Primary Care: Cost, Quality, and Experience Impact
Tracy L. Johnson, PhD, MA; Mary van der Heijde, FSA, MAAA; Stoddard Davenport, BA; Carlos Irwin Oronce, MD, MPH; Daniel Brewer, BA; Rachel Everhart, PhD, MS; Patricia Gabow, MD; Simon J. Hambidge, MD; Adam Atherly, PhD; and Holly Batal, MD, MBA
A Literature Review of Heart Failure Transitional Care Interventions
Clarinda Gutierrez Garcia, DNP-FNP-BC, NP-C, RN, CNL, PCCN
To Err is Avoidable: The Automation of Knowledge and the Clinical Decision Support Revolution
Ezra Mehlman, MBA
Building Partnerships Between a College of Pharmacy and ACOs: Development of the ACORN SEED
Stephanie A. Gernant, PharmD, MS; Genevieve M. Hale, PharmD, BCPS; Tina Joseph, PharmD, BCACP; Renee S. Jones, PharmD, CPh; Sarah Alameddine, PharmD; Stacey Maravent, PharmD; Sara M. Eltaki, PharmD, B
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Postacute Care Partnerships and Patient Progression
Penny Gilbert, MSN, MBA, RN, NE-BC, CPHQ; Nancy J. Maggard, MSN, RN, NE-BC; Cheryl Talbert, MSW, LCSW; and Donna Vela, MSN, RN, NE-BC, CPM

Postacute Care Partnerships and Patient Progression

Penny Gilbert, MSN, MBA, RN, NE-BC, CPHQ; Nancy J. Maggard, MSN, RN, NE-BC; Cheryl Talbert, MSW, LCSW; and Donna Vela, MSN, RN, NE-BC, CPM
Postacute care partners are required for successful patient transitions. Collaboration among multidisciplinary teams and community resources is critical for discharge planning and partnership alignment.
Due to substance abuse population volume, extended LOS, and the loss of transferred patients from across the state, an Opioid Use Disorder Taskforce was formed. The Taskforce proposed development of an addiction medicine consultative service within the Enterprise. The service, on track for approval, will assess and treat substance abuse during the inpatient stay and provide transitional management. A business plan for the service has been submitted and is currently under review for approval by senior leadership.


Thinking of poverty in third-world countries is often easier than thinking in the context of developed countries.12 “Most Americans would probably acknowledge there is poverty here, but it has not been seen as a serious problem since the 1970s.”13 Homelessness is another challenge being addressed through community partnerships. In Kentucky, the homeless population creates challenges for healthcare providers. UKHC has partnered internally and externally in an effort to guarantee care for the homeless population. 

Internally, the team is working with ED physicians to identify and create standard plans of care for high ED utilizers. This often includes incorporating KATS services to follow patients once they have been discharged. Financial services become involved if there is no payer source, and social services work to reconnect patients with estranged family or friends and needed resources. Social workers are positioned to provide a voice for homeless populations, thus ensuring better response to patients who are low income and/or experience SUD.6 A UKHC social work manager attends quarterly community health and homelessness coalition meetings within the community. One main goal for Lexington and UKHC, currently, is to create a medical program respite for homeless individuals who do not require skilled services, but are also not well enough to go back to the street.

Externally, the team is working with the city liaison in addition to other acute care providers in the region to assist with identifying the unique number of healthcare challenges experienced by the homeless, and potential locations for respite when facility care is no longer needed. The team further partners with the Area Agency on Aging, city health coalition, and the state quality improvement organization. The partnership allows for a diverse group of individuals/teams to problem-solve for homeless situations. 


It has been said, “In healthcare, the days of business as usual are over.”14 Preferred partnerships are a necessity rather than a luxury. Program implementation requires data analysis to identify focus areas, return on investment, and ultimate patient outcomes. It is important to set expectations of data sharing and transparency and to use the data to drive enhancement for all parties. Although partnerships may be similar, each will bring unique challenges and rewards.

Author Affiliations: University of Kentucky HealthCare (PG, NJM, CT, DV), Lexington, KY.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (PG, NJM, CT); acquisition of data (PG); analysis and interpretation of data (PG, DV); drafting of the manuscript (PG, NJM, CT); critical revision of the manuscript for important intellectual content (PG, NJM, CT); statistical analysis (DV); provision of study materials or patients (PG); administrative, technical, or logistic support (PG); and supervision (PG).

Send Correspondence to: Penny Gilbert, MSN, MBA, RN, NE-BC, CPHQ, University of Kentucky HealthCare, 800 Rose St, Office H-149, Lexington, KY 40536. E-mail: 

1. Gray CS, Berta W, Deber R, Lum J. Organizational responses to accountability requirements: do we get what we expect? Health Care Manage Rev. 2017;42(1):65-75.

2. Evans M. Hospitals select preferred SNFs to improve post-acute outcomes. Modern Healthcare website. Published May 9, 2015. Accessed August 2017.

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9. Community-based care transitions program fact sheet. CMS website. Published April 2011. Accessed December 11, 2016.

10. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549-555.

11. Naylor MD. Advancing high value transitional care: the central role of nursing and its leadership. Nurs Adm Q. 2012;36(2):115-126. doi: 10.1097/NAQ.0b013e31824a040b

12. Kilty KM. Hiding from poverty. J Poverty. 2008;11(3):85-88. doi: 10.1300/J134v11n03_08. 

13. Kentucky health care for the homeless planning report. National Health Care for the Homeless Council. 2015.

14. Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review. 2013;91(10):50-70. 
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