Inadequate communications, minimal patient information-sharing, and misaligned incentives create a major disconnect that fuels hospital readmissions, unnecessary trips to the emergency room, and increased spending. Instead of viewing post-acute care as an extension of their own care team, many hospital leaders regard these settings as way stations that don’t deliver significant value for their patients.

Fortunately, a growing number of policymakers and providers recognize that extending clinical coordination downstream to the post-acute setting is just as important as reaching upstream to improve cooperation with primary care clinicians and specialists.

As the momentum for greater acute/post-acute integration builds, here are 4 key factors hospitals must understand when developing a post-acute care strategy:

• Post-acute providers are a major untapped resource — Long-term care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies possess a vast reservoir of information about a hospital’s patients. This includes clinical data accumulated over the course of long-term stays and details about patients’ home environments and relevant social determinants of health that can inform treatment decisions. What’s more, post-acute providers bring critical clinical skills and time-tested protocols for addressing challenging clinical conditions and comorbidities. Properly harnessed, patient information and clinical knowledge from post-acute providers can substantially strengthen comprehensive, end-to-end care.
• Effective integration requires genuine partnerships — Too often, communications between acute and post-acute care facilities are characterized by mandates and requirements imposed on the post-acute provider by policymakers, acute-care hospitals, and accountable care organizations. Clinical coordination requires a much more collaborative, two-way approach. By working together as equals, hospitals and post-acute providers can build a sustainable infrastructure to support tighter clinical cooperation. Critical elements should include integrated information systems, evidence-based clinical pathways, and standardized care plans. Partnerships should be measured based on clinically relevant performance measures that align incentives across the continuum.
• Medicare payment changes will fundamentally alter how your patients are treated in post-acute settings — On October 1, 2019, a new era in Medicare reimbursement for skilled nursing facilities (SNFs) began with the implementation of the Patient-Driven Payment Model (PDPM). The new Centers for Medicare and Medicaid Services’ payment system shifts reimbursement for SNFs from one based primarily on the volume of therapy provided to a system based on the patient’s clinical condition, needs, and characteristics. The approach is designed to more accurately reflect the level of care delivered in the SNF. These changes are expected to better align reimbursement with patients’ clinical needs and increase reimbursement for more medically complex patients. Already, PDPM is leading many SNFs to experiment with less therapy-intensive care models. A similar reimbursement approach—the Patient-Driven Grouping Model—will take effect for home health providers on January 1, 2020.
• Post-acute care providers can be highly effective risk partners with hospitals and ACOs — Many post-acute providers have experience with risk-based payment models through programs such as the Bundled Payments for Care Improvement. From these initiatives, post-acute providers have gained critical skills in managing complex patients. As risk partners, hospitals and post-acute providers can align incentives and work together to ensure an efficient hospital discharge and a well-managed post-acute experience.

Improving collaboration between acute and post-acute providers presents a significant, largely untapped opportunity for strengthening care across the continuum to improve outcomes, reduce adverse events, and enhance the patient experience.

Fred Bentley will participate in a panel discussion entitled “Focus on Post-Acute Care: Lower Costs, Fewer Readmissions, Happier Patients,” at the U.S. News & World Report-Best Hospitals Healthcare of Tomorrow summit. The event—scheduled for November 17–19, 2019, at the Marriott Wardman Park Hotel in Washington, DC—will bring together many of the nation’s top healthcare leaders to tackle today’s most pressing healthcare issues.

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