Creating Pathways to Post-Acute Care for Mass General Brigham Patients

Jan 27, 2025

7 minute read

woman pushing wheelchair in hospital hallway

There are many barriers that can prevent medically ready hospital patients from transitioning to the post-acute care that they require. For a patient recently at Brigham and Women’s Hospital (BWH), it was a piece of medical equipment — a thoracic walker that provides extra upper-body support. The skilled nursing facility set to accept the BWH patient didn’t have this specialized walker and said it would take them five to seven days to procure one, which would have prolonged the patient’s stay at BWH.

That’s when Mass General Brigham’s Post-Acute Capacity team helped find a solution. Working with colleagues at BWH, they arranged for BWH to lend the skilled nursing facility a thoracic walker to use until their own arrived. This collaboration expedited the patient’s transfer, enabling the patient to progress faster in their care and recovery at a facility closer to home, and created much needed capacity at BWH.

“Our goal is to facilitate bidirectional communication between Mass General Brigham and post-acute care providers and work together to better serve our patients with complex needs,” said Trancy Escobar, executive director of Complex Care and Care Continuum for Mass General Brigham and leader of the Post-Acute Capacity team. “We’re also a resource to support frontline care teams within our hospitals. Together we’re finding creative ways to overcome discharge barriers and provide our patients improved access to post-acute care.”

The Post-Acute Capacity team made sure the walker was returned to BWH, which ended up being 12 days after the patient transitioned to the skilled nursing facility. This example highlights the critical work underway to improve Patient Care Progression — our systemwide initiative to reduce inpatient length of stay. Launched in the spring of 2024, Patient Care Progression is focused on improving the timeliness of care delivery and transitions out of the hospital for our patients, expanding access to help alleviate capacity pressures within MGB and enhancing quality of care. For example, by transitioning patients to home or a post-acute facility sooner, we reduce their exposure to risks of hospitalization, such as delirium or hospital-acquired infections.

Two multidisciplinary teams with dedicated areas of focus — Clinical Progression and Care Transitions & Post-Acute Access — are leading Patient Care Progression. Colleagues from across Mass General Brigham are collaborating on best practices and new ideas within each of the 15 workstreams that these teams encompass. Led by Kim Barry, RN, MS, FACHE, the system’s first vice president of Enterprise Care Continuum, the six Care Transitions & Post-Acute Access workstreams are strengthening partnerships with Mass General Brigham and external post-acute care providers and creating pathways to connect medically ready patients to the next level of care that they require.

Central to this effort is the Post-Acute Capacity team, which is based in Mass General Brigham’s Assembly Row headquarters. Escobar and her team of six referral management and care transition specialists support MGB hospital care teams when they struggle finding a post-acute bed for a patient with complex needs. In the case of the BWH patient, it took case management referrals to more than 20 skilled nursing facilities before an appropriate placement could be secured. The Post-Acute Capacity team helped navigate and overcome a number of obstacles, including insurance limitations and the specialized equipment requirement.

We’re here to open doors for our patients and advance their care and we continue to support them after they are discharged from our hospitals.

Trancy Escobar

Executive director of Complex Care and Care Continuum

Alicia MacLellan, LCSW, a transitional care manager on the Post-Acute Capacity team, made weekly visits to check in on the BWH patient at the skilled nursing facility and helped coordinate follow-up care with BWH clinicians. When the patient was ready to go home, MacLellan assisted the skilled nursing facility staff in securing transportation that was covered by the patient’s insurance.

After the Post-Acute Capacity team recently helped a Massachusetts General Hospital patient transition to a skilled nursing facility, Transitional Care Manager Jason Figueiredo, DPT, CCM, was at the patient’s beside the following day, comforting the patient and her spouse in their native Portuguese. In addition to overcoming a language barrier, Figueiredo helped the patient access insurance coverage, working with family members to complete the necessary documentation, and successfully advocated for the patient’s subsequent transfer to another care facility closer to the patient’s home, making it easier for her husband to visit.

Building a reliable care continuum network

To support the Post-Acute Capacity and Mass General Brigham care teams, Barry is working with case managers and social workers across the system to forge closer connections and collaboration among internal partners, including Spaulding Rehabilitation, Behavioral Mental Health, Population Health, Home Care, Home Hospital and EMS/Transport Services. These partners, meanwhile, are evolving to meet our patients’ and system’s needs. This past fall, Spaulding Rehabilitation Hospital for Continuing Care (Cambridge) celebrated the opening of its new Acute Rehabilitation Unit. The new unit provides expert care to patients who require specialized levels of therapy along with complex medical and nursing care.

Mass General Brigham also is committed to strengthening partnerships with post-acute facilities outside our system to develop a reliable care continuum network. “We have a large portfolio of facilities that we collaborate with clinically and we need to work with them to build out their programs to support admissions from Mass General Brigham,” Barry said. “We have initiated a process to determine what their needs are.”

Within Mass General Brigham hospitals, care teams are taking a more proactive approach to discharge planning that begins at admission and continues as a patient progresses in a timely, appropriate and safe way through the hospital, Barry said. Work has begun to develop and implement daily multidisciplinary care coordination rounds to identify and quickly address issues that could delay care progression. Hospitals, including Cooley Dickinson Hospital and Newton-Wellesley Hospital, also have begun to institute “long-stay rounds,” a weekly multidisciplinary forum to review long length-of-stay patients and escalate challenging, complex cases to the Post-Acute Capacity team.

“We’re on the right track,” Barry said. “It’s energizing to see the dedication of our caregivers and their willingness to take on challenges to keep patients moving along a healthy care pathway.”