Care Redesign

Survey Snapshot: How to Achieve Post-Acute Care Coordination

Insights Report · November 22, 2016

Edward Kersh, MD, FACC, Medical Director for Telehealth at Sutter Care at Home, says the future of care delivery must be firmly rooted in the relationship between hospitals and the post-acute care setting. Sutter Care at Home, a nonprofit home health care and hospice agency that serves 160,000 patients in 28 northern California counties, is an affiliate of Sutter Health, one of northern California’s largest hospital and health care systems.

“Post-acute care will improve when more attention is paid to its role in patient outcomes,” he says, adding that for years, quality leaders have hyper-focused on the hospital as a place to lower readmissions when they should have concentrated more on the post-acute setting.

Kersh was among 30% of respondents to NEJM Catalyst’s recent Care Redesign Survey who say their organization’s patient experience between the inpatient setting, post-acute setting, and home environment is “mostly coordinated.” Sutter Care at Home is working toward the “fully coordinated” status that 7% of council members claim, he says.

Care Experience Coordination Post-Acute Care

Care Redesign Insights Report. Click To Enlarge.

At Hoag Memorial Presbyterian, a nonprofit hospital in Newport Beach, California, the goal is to be fully coordinated and to have a preferred post-acute care network of formal arrangements, says Nathan Gilmore, MD, MBA, Assistant in Quality Improvement and a specialist in critical care and emergency medicine.

“I would argue that fully coordinated care means there are seamless care management structures and interventions, including seamless sharing of real-time, easily accessible information,” Gilmore says.

Hoag has made strides toward this goal by having its preferred skilled nursing facility providers create reliable access to the same EMR, lab, and radiology systems. But Gilmore says the biggest move toward being fully coordinated has been sending doctors to round at the skilled nursing facilities. “If the patient is identified as part of the Hoag health care delivery network, then someone from the hospital or private practice will go see them in post-acute care,” he says.

“By deploying our own resources through contractual and informal relationships, we’ve seen decreased bounce-backs to the hospital as well as improvements in acuity measures,” Gilmore says.

Benefits and Difficulties of Preferred Networks

Using a preferred post-acute network enables the health system to require usage of the same EMR system across facilities, and to establish consensual contracts to ensure coverage of post-acute treatment by payers, according to Kersh. Preferred networks also promote monitoring and measurement of key metrics such as falls, ER visits, and readmissions — a benefit of preferred post-acute networks listed by 38% of respondents.

Benefits of Preferred Post-Acute Care Network

Care Redesign Insights Report. Click To Enlarge.

Hoag Memorial Presbyterian has a preferred relationship with a long-term acute care [LTAC] facility, but it is 20 miles away, making distance a barrier to owning the process door to door.

“And that facility is not one in our network, so I can’t look at the labs or the vital signs of a patient I sent there a week ago [because of separate EMR systems],” Gilmore says.

“If I try to contact a nurse at that LTAC, she can’t consult with me because I am not that patient’s provider for that facility, so I would have to go through the necessary HIPAA-compliant steps.”

Value-Based Care Could Help Integration

Patrick Burke, MD, MHCDS, pediatric hospitalist at Valley Children’s Healthcare, a nonprofit 358-bed children’s hospital in Madera, California, says his organization is “somewhat coordinated” but is moving toward “fully coordinated,” including building out contractual agreements and its own service offerings.

“We had few, if any, options for home health care partners, both due to metro Fresno’s relative isolation from larger metropolitan areas as well as our 45,000-square-mile catchment area in the rural Central Valley,” Burke says. Therefore, to improve patient experience, Valley Children’s started up its own home health care service, Valley Children’s Home Care.

Burke believes value-based care will drive a stronger bond between hospitals and post-acute settings, as bundled payments and other forms of value-based purchasing become more widespread. “These changes link individual providers and services into a single episode of care,” he says.

He offers treatment of cystic fibrosis as an example. When a patient is discharged home, the care received, including administration of intravenous medications and central line management, becomes part of the complete scope of care. Therefore, hospitals have to be invested in how that home health care is delivered. “There is wider recognition that we can’t control quality unless we have this relationship,” he says.

Bundled payment programs such as Medicare’s Comprehensive Care for Joint Replacement Model will create strong incentives for improved quality, he says. “As outcomes measurements improve, future bundled payment programs may evolve to consider functional return to baseline or ambulation as quality metrics, creating more pressure to manage process and variation.”

Communication Is the Key to Preventing Readmissions

The top opportunity to improve transitions between settings, according to NEJM Catalyst survey respondents, is improved real-time communication between hospitals, post-acute facilities, and primary care/outpatient providers. To foster a closer relationship between the hospital and post-acute setting in his own health system, Sutter Care at Home’s Kersh meets with local hospital readmissions committees. He also speaks to cardiologists, hospitalists, discharge planners, primary care physicians, administrators, and other key players about what happens in home health care for heart failure patients.

Opportunities to Improve Transitions Between Acute & Post-Acute Care Settings

Care Redesign Insights Report. Click To Enlarge.

Making sure that all parties understand each other’s roles is a way to achieve a decrease in readmissions, Kersh says. For example, if home health staff understand the role of hospice agencies, they can work with them to avoid inappropriate ED visits and rehospitalization for patients with terminal conditions.

He also trains the Sutter Care at Home’s nurses on how to interact with specialists and what issues to elevate to them. “You don’t call up the cardiologist and say, ‘Your patient has gained five pounds, what should we do?’ You say, ‘Your patient gained five pounds, should we double the Lasix dose?’”

Presenting a solution, he says, captures the cardiologist’s attention and makes the physician more invested in the link with post-acute care. “We’re shifting the focus so the home health nurse is now being considered a trusted partner,” he says.

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Opioid Prescriptions Strength Conversion Table

Tackling the Opioid Crisis with Clear Prescription Guidelines, Accurate Monitoring, and Provider Education

How a large physician organization reduced the amount of opioids prescribed per patient while increasing referrals for pain management consultation.

David Waters Community Servings CEO

Food as Medicine: Meeting the Needs of Complex Medical Diets

How Community Servings evolved from an HIV nutrition program to one that feeds people with any illness.

HaH-Plus Program Reduces Patient Days Spent in Health Care Facilities in Final 180 Days of Life

Hospital at Home–Plus Reduces Days Spent in Hospitals and Other Inpatient Facilities

Patients enrolled in Mount Sinai Health System’s HaH-Plus program spend about one-third as many days in health care facilities as inpatients in the last 180 days of life.

SLUCare General Internal Medicine Interactive Voice Response - Patient Access

Creating a Holistic Approach to Patient Access

To get beyond simplistic measures such as increased patient appointments or decreased lag days, operations administrators and physician champions must develop effective partnerships.

Bridgeport Hospital Senior Staff Safety Rounds - Improving Serious Safety Event Rate

Senior Staff Safety Rounds: A Commitment to Ensure Safety Is the Top Priority

Bridgeport Hospital leaders find that face-to-face feedback from physicians and staff leads to real-time improvements that have positively impacted safety.

Responding to Opioids Epidemic - chronic pain, opioids epidemic data

The Physicians’ Quandary with Opioids: Pain versus Addiction

The national addiction crisis has led to a crackdown on physician prescribing abilities for opioids. Frontline physicians and clinical leaders are torn between wanting to prevent addiction and wanting to treat chronic pain.

2013 Jefferson Emergency Department Safe Opioid Prescribing Guidelines Poster

A Grassroots Effort Led by Emergency Physicians to Mitigate the Escalating Opioid Epidemic

Collaboration among Emergency Departments in addressing a public health crisis can have a broad-reaching impact that addresses the unique needs of an at-risk population.

Patient Outcomes Stratified by Low, Moderate, and High-Risk HEART Score

Improving Emergency Department Care for Low-Risk Chest Pain

How Kaiser Permanente Southern California improved ED standard of practice for possible acute coronary syndrome by adopting an evidence-based clinical decision tool.

Academic Innovations Collaborative Colorectal Cancer Driver Diagram - Leading Transformational Change in Primary Care Delivery

Five Keys to Leading Transformational Change in Primary Care

Lessons learned from a Harvard Medical School intervention to strengthen primary care delivery that emphasized teamwork, reflection, and leadership engagement.

Providing Free Food as a Treatment for Diabetes Yields Improved Outcomes for Patients While Reducing Cost of Care - Fresh Food Farmacy - Geisinger program for addressing food insecurity in patients with diabetes

Prescribing Food as a Specialty Drug

Geisinger’s program of providing free food as a treatment for diabetes yields improved outcomes for patients while reducing the cost of care.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Coordinated Care

112 Articles

The Health System Crisis: A Call…

To overcome current failures within our health systems, we need to improve interprofessional education and…

Care Integration

56 Articles

Survey Snapshot: Integrated Care Makes Sense…

NEJM Catalyst Insights Council members call for integration of mental and behavioral health services with…

Tackling the Opioid Crisis with Clear…

How a large physician organization reduced the amount of opioids prescribed per patient while increasing…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now