Analysis of the third NEJM Catalyst Insights Council Survey on the Care Redesign theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
Over the past five years, the post-acute care landscape has changed dramatically. A space once dominated by small, siloed businesses now is being entered by large health systems and hospitals, which are starting up, scooping up, or integrating with post-acute care facilities, including home care and hospice agencies, and acute rehabilitation, skilled nursing (SNF), and long-term acute care facilities.
These health systems, which in the past have focused largely on acute care, now see greater opportunities in post-acute care, given reform initiatives introduced by influential payers such as the Centers for Medicare & Medicaid Services.
Given how rapidly this market shift is unfolding, the latest NEJM Catalyst Care Redesign Survey of our Insights Council members shows that the post-acute sector needs more resources and attention to strengthen the hospital–post-acute connection, reduce inappropriate readmissions and length of stay, and boost reimbursements and incentives.
Currently, the three types of post-acute organizations most likely to be owned by, or contractually integrated with, traditional provider organizations are home care agencies (47%), acute rehabilitation facilities (46%), and hospice agencies (40%), according to our survey respondents. Health system ownership of post-acute facilities is most prevalent in the Midwest, where 45% of respondents say their organizations own acute rehab facilities and home care agencies.
Far from Coordinated Care
Despite this trend toward integration across the care continuum, only 7% of respondents call the care experience of their organizations’ patients “fully coordinated” between the inpatient, post-acute, and home settings. Less than a third say the experience is “mostly coordinated.” Even in the Northeast, the region where respondents were most bullish on care coordination, less than 50% of respondents say care across settings is fully or mostly coordinated.
In sum, the structural changes for post-acute organizations appear to be out ahead of care delivery redesign.
Patients need care to be fully coordinated, because when it isn’t they and their families suffer — as exemplified by the experience of one of the authors (ACP). Her mother-in-law was moved from a hospital to a rehabilitation facility after a lengthy inpatient stay for a fractured elbow. At the hospital, she contracted Clostridium difficile, or C. diff., but recovered with treatment. Later, in the rehabilitation facility, she began wheezing.
But because the care was not fully coordinated, the providers didn’t know about her recent C. diff., nor her lifelong history of asthma. They didn’t realize that she was not getting her inhalers, so they treated her empirically with antibiotics. The C. diff. returned and she died shortly thereafter. Because the caregivers had little insight into her complex stay in the hospital, they weren’t able to properly treat her condition based on her history, defaulting to treating probabilities rather than personalized care.
For many patients, the post-acute setting is a critical part of their care trajectory. As this market grows, we in health care must make sure it does so in a patient-centered manner, without exploding the total cost of care. To move from 7% to 70% of patients receiving fully coordinated care, we must align incentives among primary care, post-acute, and inpatient providers.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
If you could improve one aspect of the post-acute care your organization’s patients receive, what would it be?
“Coordination and communication between and among care providers.”
“Shared data. It is not logical that so much functional and other data exist in different silos.”
“Add warm handoffs.”
“Improved coordination and access to medical information regarding patient.”
“Better integration/rounding/communication/handoff during transitions of care.”
“Shared electronic medical records systems.”
“Aligning top management to foster cross-functional teamwork between acute and post-acute continuum.”
“Get on same EMR.”
“Better handoffs. Consistency of providers between acute and post acute.”
“Care along the continuum needs rebalancing of incentives.”
“Patient and family education in all matters regarding care. Include hygiene, medication, exercise, diet. Talk to patient as one would someone who knows nothing about the illness he or she has.”
CMS’s Hospital Readmissions Reduction Program, launched in 2012, is a good start, attempting to address the issues between the hospital and post-acute settings. CMS estimated it would penalize 2,588 hospitals in 2016 for excessive readmission rates. Commercial and federal bundled payments for cardiology, orthopedics, and other specialty areas also are putting pressure on hospitals and post-acute organizations such as SNFs, by tying 30-day outcomes to reimbursements, incentives, and profit margins.
And we are seeing the results. More than half (58%) of survey respondents say their organizations have contractual arrangements or informal relationships with a preferred post-acute network — agencies and facilities with aligned values and systems to provide seamless care across venues after a hospitalization. We see this as an indicator of organizations trying to do the right thing for patients, even if a formal agreement is not in place. In the long term, though, health systems/hospitals and post-acute providers may need formalized contracts that include shared risk models to improve outcomes and maintain margins.
Opportunities and Barriers to Improve Post-Acute Care
NEJM Council members had mixed responses on the benefits of preferred post-acute networks. More than half (55%) of respondents say preferred networks will lead to appropriately decreased readmissions to the emergency department or hospital. Others cite the ability to improve quality metrics outcomes and appropriately decreased inpatient length of stay. Just over a quarter (26%), however, point to an improved patient experience.
The survey identifies several opportunities to improve transitions among the inpatient, post-acute, and home care settings, starting with real-time communication (71%). In the example above, real-time communication to share details specific to the patient’s history and care, along with shared electronic medical records/data exchange (named by two-thirds of survey respondents), could have been a game-changer.
The post-acute care setting has considerable obstacles that cannot be overlooked, including respondents’ top-ranked challenge: fragmentation of care and poor integration with acute-care providers (chosen by nearly three-quarters of respondents). Ranking second, more so by executives than clinicians, is lack of standardized care among institutions. Patients want to know what to expect as they transition between settings of care. Respondents place inadequate incentive alignment or underpayment as the third-biggest challenge.
Although 53% of respondents call for embedded rounders (such as physicians, nurse practitioners, or case managers) to improve transitions between settings, smaller organizations will find them cost-prohibitive.
To realize better outcomes in post-acute care, change has to happen. But remember that change happens at the speed of trust. Trust comes from experience and, as it turns out, more than half of respondents (56%) have not personally visited nor observed at a post-acute care facility within the past five years. Just over a third (36%) have been to one within the past six months. Among executives, who lead change for their organizations, 13% have never personally visited or observed at a post-acute care facility. To move forward at the speed necessary, executives, clinical leaders, and clinicians, as a simple first step, should gain more firsthand familiarity with the post-acute setting.
METHODOLOGY AND RESPONDENTS
In September 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinician leaders, and clinicians at organizations directly involved in health care delivery. A total of 375 completed surveys are included in the analysis. The margin of error for a base of 375 is +/- 5.1% at the 95% confidence interval.
The majority of respondents were clinicians (45%), followed by clinician leaders (32%) and executives (24%). Most respondents described their organizations as hospitals (39%) or health systems (17%). These hospitals were predominantly midsized (37% had 200–499 beds) or larger (41% had 500 or more beds).
Only 6% of respondents indicated that their major affiliation was with a physician organization. Those physician organizations tended to be big — 74% had 100 or more physicians.
Nearly three-quarters of the organizations (73%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.