How to align resources for post-acute care

Editor’s note: This is the first report in a two-part series on post-acute care strategies and tactics.

Every segment, every niche across the nation’s entire healthcare delivery system during the past several years has been inundated by an unprecedented wave of radical, disruptive transformation.

Fundamentals driving clinically integrated care networks

Clinically integrated care networks are rapidly spreading to enable seamless transitions between physicians, hospitals, rehab and skilled nursing providers, and community-based services. These risk-based, pay-for-performance reimbursement models have emerged:

  • Accountable care organizations. Typically pool 5,000 lives or more in a population health/wellness management model funded by an annual per capita fee that covers the costs of virtually all services across the care continuum.
  • Bundled payment. Providers bear risk under a flat rate structure that reimburses for entire episodes of care by dividing the fee among pertinent service providers across the care continuum.

With the emergence of risk-based, pay-for-performance reimbursement models such as accountable care organizations and bundled payment, clinically integrated care networks are rapidly spreading to answer the need for the seamless coordination of transitions between physicians, hospitals, rehab and skilled nursing providers, and community-based services. The fragmented delivery systems predicated on the economics of volume-driven, fee-for-service procedures are giving way to a broader, holistic approach that uses clinical care pathways to comprehensively, cost-effectively manage entire episodes of care throughout multiple care delivery sites.

So how does a post-acute care (PAC) operator take advantage of these seismic changes and get in the game?

Data-driven metrics

The key to forging partnerships is developing data-driven metrics that track outcomes to validate a PAC operator’s qualifications and measure its ongoing performance. At the same time, PAC organizations also must analyze Medicare-related trends at their referring hospitals to identify opportunities for performance improvement that their acute care counterparts may have overlooked. By drilling into the performance data from the PAC operator and the analysis of hospital Medicare trends, both groups can jointly move forward to develop partnership strategies to improve outcomes, increase efficiency, reduce costs and enhance throughput/access.

The ability to consistently track and analyze a wide range of outcome and performance metrics in post-acute care depends, in large part, on software and information technology capabilities. Ongoing data input from a multidisciplinary team is crucial.

Basic PAC quality indicators address pressure ulcers, urinary tract infections, weight loss, falls, fractures, decline in activities of daily living and restraints. The Medicare Nursing Home Compare five-star ratings also are a routine point of reference.

For short-term, post-acute rehab stays, each admission should be categorized according to payer source, admission and discharge dates, length of stay, diagnosis category and site of relocation following the rehab stay. Discharge data are required to gauge whether transitions from post-acute care back to the community have been successful.

Measuring rehab functional gains outcomes, along with rehab therapy performance, is critical. And members of the clinically integrated care networks will monitor the PAC clients’ satisfaction scores.

Keys to successful partnerships

Post-acute care organizations and hospitals should aim for success in the following:

  • Quality outcomes
  • Clinical care pathways
  • Length of stays
  • Readmissions performance
  • Electronic health records interfaces
  • Physician integration
  • Cost-tracking per episode
  • Post-discharge management
  • Patient/resident satisfaction

Timely length-of-stay transitions are a focal point under the pay-for-performance paradigm. To determine whether a provider is efficiently managing length of stays and following the clinical care pathway program, individuals should be classified according to diagnosis category to provide more specific medical profile breakouts. These categories may include:

  • Post-surgery recuperation,
  • Orthopedic recovery,
  • Fractures,
  • Stroke,
  • Cardiac rehabilitation,
  • Pulmonary rehabilitation,
  • Complex wound care,
  • Palliative care,
  • Oncology and
  • Medically complex.

Hospital utilization

Controlling hospital utilization is paramount to successfully participating in a partnership. Doing so requires a continuous evaluation of historic emergency department admission trends to identify condition/reason, date and shift, and length of PAC stay prior to hospital admission.

By following early intervention programs that identify individuals at risk for hospital admission, action plans can be implemented to head off transfers. Efforts can include the use of protocols such as the INTERACT (Interventions to Reduce Acute Care Transfers) tool, which is a framework for the early identification, assessment, intervention, documentation and communication of changes in a resident’s condition.

The Medicare Hospital Readmission Reduction Program, which penalizes hospitals for greater-than-expected 30-day readmission rates, has become an extremely high-profile concern. Hospitals and networks are closely tracking the ability of PAC operators to manage readmissions.

Conditions currently targeted for hospital readmission payment penalties are acute myocardial infarction, heart failure and pneumonia. This group of conditions will be expanded in fiscal year 2015 to include chronic obstructive pulmonary disease, coronary artery bypass, angioplasty and other vascular conditions.

Care coordination, PAC utilization and readmissions will draw more oversight next year, when Medicare’s value-based purchasing program incorporates a spending-per-beneficiary measure in its reimbursement formula for hospitals. Hospitals will be assigned efficiency scores for each major diagnosis category, considering costs for the three days before admission, the length of the inpatient stay and the 30 days following discharge.

This change will put the spotlight directly on the costs and efficiency of post-acute care, which when delivered in the same market often has significant payment variances within an episode of care while delivering services to people of similar health status.

Jim Bowe is principal of GlenAire HealthCare, LLC, in Bloomfield Hills, Mich. GlenAire works to realign the continuum of care with an emphasis on rewarding quality outcomes and cost efficient operations through developing, expanding and repositioning post-acute care and senior living operations. Contact him at (248) 904-6766 or

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