This article is sponsored by TeamHealth. In this Voices interview, Skilled Nursing News sits down with Jon Raffesberger, Director of Clinical Operations, Specialty Services, Post-Acute Care at TeamHealth, to discuss the StayPut program and its role in improving patient care and outcomes. Raffesberger highlights how collaboration between StayPut clinicians and facility staff enhances continuity of care and operational efficiency. He also shares a real-world example of how StayPut helps prevent unnecessary hospital transfers in the post-acute setting.
Skilled Nursing News: What is your background, and how did it lead to your role today?
Jon Raffesberger: My transition to a career in health care followed a personal injury that opened my eyes to the difficulty of navigating the health care system. This led to training as a nurse practitioner in adult geriatric primary care and the completion of a Doctor of Nursing Practice degree. That geriatric focus in school sparked a passion for working with vulnerable populations in skilled nursing facilities—patients who often lack the resources we typically consider in health care.
Starting at the bedside as both an RN and a nurse practitioner, I gradually transitioned into roles that allowed me to make a broader impact. This led to initiatives like TeamHealth’s Call Solution and StayPut quality improvement programs, where I have the opportunity to support clinicians in improving care for a larger patient population.
What are the most common care challenges for post-acute patients, and how does StayPut help address them?
Post-acute care patients face significant challenges, especially when managing complex conditions like heart failure, sepsis, and respiratory issues. These challenges are compounded by limited resources, high caregiver turnover, and the difficulty of ensuring timely interventions and effective communication among care providers. The risk of unnecessary hospital readmissions is both costly and detrimental to patient outcomes, and it is particularly high during overnight shifts when physicians and advanced practice clinicians are not physically present in skilled nursing facilities.
TeamHealth’s StayPut program helps address these challenges by providing real-time, after-hours telephonic support from a team of advanced practice clinicians experienced in post-acute care. By proactively intervening and offering clinical guidance, StayPut helps reduce unnecessary emergency department transfers and hospital readmissions. But it’s more than just expert clinicians—our data-driven approach identifies patterns and opportunities for improvement, while continuous education and quality initiatives strengthen staff capabilities and enhance the overall quality of care in the skilled nursing facilities with whom we partner.
How does StayPut enhance patient care in post-acute settings? What impact have you seen firsthand on patient outcomes?
StayPut enhances patient care by providing after-hours telephonic support from advanced practice clinicians who assess and manage acute issues before they escalate. This early intervention not only eases the burden on nursing staff, but also provides patients with the right level of care at the right time.
One of the most significant impacts we’ve seen is a reduction in emergency department transfers. In the first six months of our StayPut pilot program, transfers dropped by 17%, which really highlighted our success in preventing unnecessary hospitalizations. Additionally, addressing conditions like sepsis and heart failure earlier helped pilot participants improve patient outcomes by reducing complications, speeding up recovery, and minimizing disruptive hospital visits.
Can you share a specific instance where you’ve seen StayPut help prevent an unnecessary hospital transfer?
One example that comes to mind is a challenge our clinicians navigate almost daily. A TeamHealth medical director reviewing StayPut data identified a high number of transfers related to infections or early signs of sepsis at a partner facility. Using this data, we conducted a root cause analysis, which led to targeted quality improvement initiatives.
As a result, the facility implemented an antibiotic timeout program and provided additional education on early sepsis recognition and management for both the nursing team and StayPut advanced practice clinicians. These interventions significantly reduced infection-related emergency department transfers, lowering the facility’s return-to-hospital rates. This is exactly the kind of proactive care and continuous quality improvement that StayPut is designed to support.
How does collaboration between StayPut clinicians and facility staff improve continuity of care and overall efficiency?
Collaboration between StayPut clinicians and facility staff is the cornerstone of a seamless care experience for patients. By working closely with nursing teams, StayPut clinicians can maintain a steady flow of information and a more unified approach to patient management. Their clinical expertise helps staff make informed decisions, leading to quicker interventions and improved care coordination.
This partnership approach also strengthens the facility’s overall efficiency by reducing redundancies, such as unnecessary hospital transfers or prolonged hospital stays, which can put a massive strain on their resources. StayPut doesn’t replace existing care teams—it supports them with data-driven insights and clinical expertise, ultimately making the entire care process more streamlined and effective.
What sets StayPut apart from other care solutions, and how do you see it evolving in the future?
What sets StayPut apart from other care solutions is its combination of advanced practice clinician expertise, real-time telephonic intervention, and a data-driven approach to improving patient outcomes. Many solutions are reactive and only address issues after they arise. StayPut is proactive, using continuous monitoring and support to prevent complications before they escalate into emergencies. This model empowers care teams to make early interventions with conditions like sepsis and heart failure, leading to better outcomes and fewer unnecessary hospital transfers.
A recent New England Journal of Medicine article highlighted how real-time data and early intervention can significantly reduce preventable hospitalizations and improve care for complex patients, which is the foundation of StayPut. By combining clinical expertise with real-time data analysis, StayPut helps facilities address these issues before they turn into severe health crises that require hospitalization.
Looking ahead, StayPut will align more closely with the care continuum as value-based care continues to evolve. Programs that reduce hospitalizations and enhance patient outcomes will be key to success in the changing reimbursement landscape, and StayPut’s data-driven approach complements this transition. As health care increasingly prioritizes outcomes over volume, StayPut is positioned to play a significant role in providing post-acute patients with the right care, in the right place, at the right time—especially during critical after-hours, weekend, and evening periods.
Finish this sentence: “In 2025, the skilled nursing industry will be defined by…”
…advancements in quality initiatives like StayPut.
Editor’s note: This interview has been edited for length and clarity.
TeamHealth offers clinical and medical directorship services to partners nationwide. Our clinical and operational practice models can be tailored to our partners’ unique needs, making it the optimal solution for post-acute facilities. To learn more, visit teamhealth.com/post-acute.
The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact [email protected].
