Post Acute Partnerships Flourishing

Most health systems and hospitals do not own post-acute facilities (PAC), and so must develop alliances. The emerging trend is for acute care providers to establish a PAC strategy and form a narrow preferred provider network of appropriate PACs, often including an inpatient rehabilitation facility, one or more skilled nursing facilities (for adequate bed capacity), one or more home health agencies (for effective geographic coverage) and a hospice. The choice of partners should be driven by a focus on optimizing care coordination and management, rather than on minimizing the number of separate relationships.

The days when financial success was tied to a hospital's inpatient census are coming to a rapid close. Payers are committed to value-based care, which means patients must be treated in the least-expensive appropriate setting. New payment models, such as global payments and bundled payments incentivize the organizations to keep patients out of inpatient beds whever possible. 

That new perspective is prompting hospital care coordination leaders to seek innovative ways to work with skilled-nursng facilities, rehab facilities and other post-acute care providers.  But like any new marriage, developing a partnership can be tricky.  While both share the goal of avoiding unnecessary inpatient stays, a hospital's facilities, policies, and standards are very different from those of an SNF and the communication gap between the hospital and the SNF is greater than previously realized.  

Of course, Medicare patients can choose any nursing facility they want, regardless of whether it is on a hospital's preferred provider team.  But hospital care coordinators and patient nurses' have learned that it's OK to tell the patient and family that "these are the facilities that we work with to avoid unecessary rehositalizations and who support our goals for high quality care."  And patients with commercial insurance know that their choices are limited by the preferred networks created by their insurance company 

Hospitals are looking for post acute provider partners who are willing to share data, agree to meet quality standards, provide certain services that may not have been available previously.  This new approach to communication between the partners often reveal the differences that can become barrers if not understood and/or remedied. For example, SNF frequently have limited formularies.  So while the acute care team may come up with a great post acute medication plan, the SNF may not be able to carry it out because it's too cost prohibitive or can't be initiated promptly.  Other barriers we've identified include loss of the clinical information that was efaxed to the SNF in advance of the transfer. Seems that the bulk of the information requested at the time the transfer was planned does not timely or consistently reach the professional nurse caring for the patient nor is there any follow up for pending tests (e.g. lab results) to be sent to the SNF. 

With incomplete information known to the SNF care team, there is often barriers on how to get any missing information.  When the SNF nurse calls the hospital, the nurse on duty more often than not, tells the SN F nurse that "I don't know that patient."  A method of communication to remedy this information gap must be addressed  by both parties as part of the partnership disussions.

One of the innovations we applaud is the 'warm hand-off' between the patient's nurse or care coordinator and their counterpart at the SNF or acute rehab facility.  Before actual transfer from the hospital to the new facility, the two coordinating resources (whatever the title) discuss the care plan and make sure that any changes in treatment are known between the two sides. And they verbally go over the post-acute medication list. Then the same pair connect again 24-48 hours after the patient arrives at the new facility. 

Another innovation relates to the ongoing quality of care meetings held between hospital coordinators and their post acute service provider partners. They agree to mutually support quality goals and provide assistance to ensure that the expectation of quality at the post acute facility becomes part of the facility's    

Starting Oct 1, 2018, CMS will be withholding 2% of Medicare payments to SNF to fund the SNF incentive payment plan. The very first metric of the new SNF value based paymnent program is the SNFRM - SNF 30-day all cause readmission measure. So now SNFs will have an incentive to work with the hospital team to reduce ED visits and readmissions.  That incentive means that the SNF and the hospital each agree to a set of expectations designed to improve care coordination and thereby decrease preventable readmissions.  For example, Hackensack (N.J.) University Medical Center recently completed an in-depth assessment of the SNF resources in their area and chose a provider with several facilities within 50 miles of the hospital.  The provider agreed to add nurse practitioners to their staff so that some conditions - for example, pneumonia - could be treated at the SNF instead of the hospital. Given the SNF economic model, high occupancy is of primary importance so a steady referral base from Hackensack is significant.  Subsequently, the SNF provider started their own 'care transitions' program and now their staff follow the patient for 30 days after discharge from the SNF to make sure the patient takes meds correctly, connects promptly with their PCP, and accesses holme health and other services that are needed - and avoid a hospital readmission.