Posts Tagged ‘Post-Acute Care’

Infographic: The Post-Acute Care Landscape

May 8th, 2017 by Melanie Matthews

Hospitals can’t just leave patient care to chance after patients leave the hospital. They must be more actively involved in managing their patients to ensure that they will receive the most appropriate post-acute care and avoid readmissions, according to a new infographic by eviCore healthcare.

The infographic examines the components of the post-acute healthcare market, guidelines for avoiding unnecessary readmissions and strategies for modernizing post-acute care.

Reducing SNF Readmissions: Quality Reporting Metrics Drive ImprovementsA tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John’s Providence, along with the state’s Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization’s readmission rates along with the inside details on new readmission reduction target areas born from the program’s data analysis.

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Infographic: Top 5 Strategies for Managing Post-Acute Care

April 14th, 2017 by Melanie Matthews

As post-acute care costs increase, now accounting for $1 out of every $4 spent by Medicare Advantage plans, health plans are focusing on post-acute care management, according to a new infographic by CareCentrix.

The infographic examines the top five strategies healthcare organizations are using to manage post-acute care.

Medicare’s proposed payment rates and quality programs for skilled nursing facilities (SNFs) for 2017 and beyond solidify post-acute care’s (PAC) partnership in the transformation of healthcare delivery. Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient care—not just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient’s journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

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Infographic: Optimizing Post-Acute Care

October 17th, 2016 by Melanie Matthews

Seventy-five percent of hospital readmissions are preventable—more than $17 billion annually is wasted due to readmissions within 30 days, according to a new infographic by CareCentrix.

The infographic lists four keys to success in improving post-acute care and reducing readmissions.

Medicare’s proposed payment rates and quality programs for skilled nursing facilities (SNFs) for 2017 and beyond solidify post-acute care’s (PAC) partnership in the transformation of healthcare delivery. Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient care—not just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient’s journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

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Infographic: A Journey Through Post-Acute Care

March 7th, 2016 by Melanie Matthews

With steeper penalties from the Centers for Medicare and Medicaid Services for hospital readmissions, healthcare organizations are not only looking at internal factors that impact readmissions, but are also partnering with post-acute care providers to shore up issues across the post-acute continuum that could lead to a readmission.

A new infographic by ECG Management Consultants looks at the expected path through the continuum for a high-risk, congestive heart failure patient and how this patient might be better supported in a high-functioning post-acute care model.

2015 Healthcare Benchmarks: Post-Acute Care TrendsHealthcare is exploring new post-acute care (PAC) delivery and payment models to support high-quality, coordinated and cost-effective care across the continuum—a direction that ultimately will hold PAC organizations more accountable for the care they provide. For example: two of four CMS Bundled Payments for Care Improvement (BPCI) models include PAC services; and beginning in 2018, skilled nursing facilities (SNFs) will be subject to Medicare readmissions penalties.

2015 Healthcare Benchmarks: Post-Acute Care Trends captures efforts by 92 healthcare organizations to enhance care coordination for individuals receiving post-acute services following a hospitalization—initiatives like the creation of a preferred PAC network or collaborative. Click here for more information.

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HINfographic: 2015 Post-Acute Care Challenge: How to Foster Warm Handoffs

September 16th, 2015 by Melanie Matthews

With patient transitions between care sites a top post-acute care (PAC) challenge for 25 percent of healthcare organizations, discharge planning, hiring of care transition navigators and data exchange are helping to facilitate ‘warm handoffs’—full-circle communication between hospital and post-acute care clinicians regarding a patient’s care—according to 2015 Healthcare Intelligence Network metrics.

A new infographic by HIN examines the top strategies to improve post-acute care and reduce costs and the percentage of healthcare organizations that include post-acute care in value-based reimbursement methodologies.

2015 Healthcare Benchmarks: Post-Acute Care TrendsHealthcare is exploring new post-acute care (PAC) delivery and payment models to support high-quality, coordinated and cost-effective care across the continuum—a direction that ultimately will hold PAC organizations more accountable for the care they provide. For example: two of four CMS Bundled Payments for Care Improvement (BPCI) models include PAC services; and beginning in 2018, skilled nursing facilities (SNFs) will be subject to Medicare readmissions penalties.

2015 Healthcare Benchmarks: Post-Acute Care Trends captures efforts by 92 healthcare organizations to enhance care coordination for individuals receiving post-acute services following a hospitalization—initiatives like the creation of a preferred PAC network or collaborative. Click here for more information.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Post-Acute Care Payment Bundles: Catalyst for Clinical Redesign, Improved Care Transitions

July 30th, 2015 by Melanie Matthews

Brooks Rehabilitation jumped at the opportunity to participate in CMS’ Bundled Payments for Care Improvement (BPCI) program to be at the forefront of learning more about healthcare payment reform, said Debbie Reber, MHS, OTR, vice president of clinical services, Brooks Rehabilitation.

We saw it as an opportunity for post-acute care providers to help make some of the healthcare policy changes related to the future of healthcare reimbursement. We also really want it to serve as a catalyst for our business to begin working better as a system of care, Ms. Reber explained during last month’s webinar, Bundled Payments for Post-Acute Care: Four Critical Paths To Success, a Healthcare Intelligence Network webinar now available for replay.

Post-Acute Care Payment Bundles: Catalyst for Clinical Redesign, Improved Care Transitions

Brooks Rehabilitation achieves 19 percent savings over historic spend and reduces readmission rates to 15 percent through Bundled Payments for Care Improvement Program.

“Our move toward bundled payments was a great opportunity to improve our care transitions, our continuum,” said Reber. “The other huge opportunity is to experiment with clinical redesign. As we approached bundle pay, we approached it with ‘we have a blank slate. We can redesign the care to look and feel however we want it to be. If we were doing things all over again, what are the things or the gaps or cracks to the clinical care that we could really improve upon?'”

“We knew that we wanted to have a strong voice regarding future policy and payment reform changes. We really wanted to show that we were sophisticated enough to take risk and play a primary role with that continuum of care,” she added.

Brooks is serving under CMS’ Model 3, in which it selects from a list of DRGs. It started in October 2013 with fractures, hip and knee replacements as well as hip and knee revisions.

Brooks added congestive heart failure, non-cervical and cervical fusions and back and neck surgery bundles this past April.

“All of our bundles are for an episode length of 60 days with the only exception to that being congestive heart failure. We did heart failure for 30 days just due to the tremendous risk of managing those cases and to decrease our risk overall with that population,” Reber explained.

Brooks begins its process when the patient leaves the acute care facility.

“We are then responsible for all non-hospice Part A and B services, including physician visits, DME, medications, post-acute therapy or rehab services, as well as any readmission,” she said. Of particular note is that the readmissions are not just related to the acute episodes that we are seeing them for…it’s for any reason that the patient would be readmitted.

Understanding what those readmission reasons are is huge to our success, Reber explained. For example, on the orthopedic side, even though the patients have just been seen for an orthopedic surgery, the primary reason for readmission is predominantly around cardiac issues or pulmonary issues that are more likely due to prior comorbidities. It’s really just managing those issues more.

Brooks has achieved an overall savings of about 19 percent over its historic spend and has decreased its readmission rate to about 15 percent across the 60-day time frame within this program. And, has also seen increases in patient functional improvement and patient satisfaction rates.

During the webinar, Reber walked participants through the four domains that have been critical to its success in the BPCI program, including: using standardized assessments across care settings; patient and caregiver engagement; the in-house developed Care Compass Tool, which includes a longitudinal care plan; and enhancing the role of the care navigator.

10 Healthcare Trends Measured in 2014: Medical Neighborhoods, Data Analytics Flourish

January 13th, 2015 by Patricia Donovan

2014's HINtelligence Reports captured trends in healthcare delivery, technology and utilization management.


Each year, the Healthcare Intelligence Network’s series of HINtelligence Reports pinpoint trends shaping the industry, from cutting-edge care collaborations to remote patient management connections to tactics to reduce avoidable utilization.

HINtelligence Report benchmarks are derived from data provided by more than one thousand healthcare companies.

Here are 10 highlights from 2014 HINtelligence Reports that support Triple Aim goals of improving population health and the patient experience while reducing the per capita cost of healthcare.

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  • Readmissions: More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, said respondents to the fourth annual Reducing Hospital Readmissions Survey.
  • Palliative Care: While the majority of respondents (68 percent) administer palliative care on an inpatient basis, more than half (54 percent) say care is conducted on home visits and just under a third offer palliative care at extended care facilities.
  • Patient-Centered Medical Home: Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransformMed℠ as “a strong foundation of transformed primary care practices aligned with health systems and specialists to insure that care is maximally coordinated and managed.
  • Remote Patient Monitoring: More than half of 2014 respondents—54 percent—have instituted remote monitoring programs, the survey found, which was most often employed for patients or health plan members with multiple chronic conditions (83 percent). Other targets of a remote monitoring strategy included frequent utilizers of hospitals and ERs (62 percent) and the recently discharged (52 percent).
  • Telephonic Case Management: More than 84 percent of respondents utilize telephonic case managers. „One-fifth of telephonic case managers work within the office of a primary care practice.
  • Population Health Management: The last two years reflects a dramatic surge in the use of data analytics tools barely on population health management’s radar in 2012: the use of health risk assessments (HRAs), registries and biometric screenings more than tripled in the last 24 months, while electronic health record (EHR) applications for population health increased five-fold for the same period.
  • Emergency Room Utilization: Among populations generating the majority of avoidable ED visits, dual eligibles jumped nearly 10 percent in the last four years, from 2 to 11 percent, while other populations—high utilizers, Medicare and Medicaid—remained roughly the same. „„Chronic disease replaced pain management as the most frequently presented problem in the ER, at 54 percent.
  • Stratification of High-Risk, High-Cost Patients: The „LACE readmission risk tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Embedded Case Management: Fifty-seven percent of respondents embed or co-locate case managers in primary care practices, where their chief duties are care and transition management, reducing hospital readmissions and patient education and coaching.
  • 2015 Healthcare Forecast: Almost 92 percent of 2015 respondents said the impact of value-based healthcare on their business has been positive, with more than one quarter identifying healthcare’s value-based shift as the trend most likely to impact them in the year to come.

Make your healthcare voice count in 2015 by answering 10 Questions on Chronic Care Management by January 31, 2015. You’ll receive a complimentary HINtelligence Report summarizing survey results.

4 Trends for Healthcare Providers in 2014

January 30th, 2014 by Jessica Fornarotto

Dual-track medical homes, e-visits, retooled patient handoffs and more post-acute care are predicted provider trends for 2014, according to Steven Valentine, president of The Camden Group. HIN interviewed Valentine prior to his presentation during an October webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: What is the physician practice going to look like in 2014? How has the primary care team evolved to meet the Triple Aim values inherent in the PCMH and accountable care models?

(Steven Valentine): We should expect to continue to see consolidation amongst the medical groups. The independent practice associations will begin to assimilate together because they need to put more money into their infrastructure. And many of the organizations have underperformed, in all honesty.

The primary care team is still critical. We’ve benefitted by keeping many primary care doctors around because they were negatively hurt with their net worth in the recession in 2008-2010. But it’s slowly coming back and we’re starting to see those physicians thinking about retirement again. The reality is, we’re never going to replace all of these primary care doctors as they wind down their practice. We need to do a better job of getting telehealth going and utilizing e-visits. We’re seeing the health plans starting to pay for those e-visits, as well as having the consumer who uses them use a credit card and pay at that time, just like a visit.

We’re going to have to look at different models. Obviously, the nurse practitioner is getting more involved with the primary care. And yes, they’re still pursuing the Triple Aim. We know that quality scores, satisfaction scores and trying to manage cost per unit is still a critical focus of the triple aim moving forward with population health.

Lastly, with a PCMH in accountable care, while some of the pioneer accountable care organizations (ACOs) reduce themselves out of pioneer into the Medicare Shared Savings Program (MSSP), we still have a number of organizations and it’s growing. The commercial ACOs have been very successful in California.

We fully expect accountable care to continue. We think the PCMH will evolve into two tracks. The first track is a primary care PCMH. The spinoff is a chronic care medical home that has the multidisciplinary team organized around a chronic disease. This is a model developed by CareMore years ago in Southern California and it’s been expanded across the country. As I travel the country, I run into organizations that have set up these chronic care centers around the chronic disease.

HIN: Regarding the Pioneer ACO program, one of the top performers in the CMS pioneer program, Monarch HealthCare, told us that it’s going to be working to engage specialists in care coordination roles in year two and year three. What’s ahead for specialists in terms of quality and performance improvement as well as shouldering perhaps more care coordination duties, especially for Medicare patients?

(Steven Valentine): The specialists are going to be a critical piece to this whole solution. They have been a tremendous asset in the area of bundled payments, where you have the facility fee and physician fee combined into one payment. That works for both the Medicare as well as the commercial side. You’re beginning to see more of the bundled payments within an ACO.

The ACO manages what we call ‘frequency’ — in other words, the number of procedures to be done. Specialists are involved in satisfaction, quality scores, and resource consumption once the decision is made that the procedure needs to be done.

We expect the specialists to be involved with quality and performance. Everybody is putting in incentive programs to help drive higher quality, better performance, and a lower cost.

HIN: Hospitals have tightened the patient discharge process as a means of shoring up care transitions. But what other work needs to be done in terms of collaborations, perhaps with skilled nursing facilities (SNFs), long-term care and home health, for example, to improve patient handoffs and reduce hospital readmissions?

(Steven Valentine): Handoffs have probably been one of the areas where we’ve seen the most disappointment or underperformance within many ACOs. They have not effectively involved the hospitalists and the care/case managers who are typically embedded within the medical group that would oversee the patient throughout the care continuum. Or if it’s a health system, emanate centralized care/case management function where they manage all of the transitions from pre-acute, acute to post-acute. We think this will get better. As the doctors are more at risk, they will get more engaged with the care/case managers to manage these transitions and handoffs.

We also know that, while not in 2014 but the trend will start, we’ll see lower acute care utilization, pushing more patients to post-acute care. This means, in any given area, acute care hospitals will begin to convert excess capacity to post-acute care services like skilled nursing, long-term care, palliative care, hospice care, home care and rehab care. You will begin to see a closer proximity. The care managers will be able to work more effectively with the doctors and hospitals to manage the patient through the continuum, smooth out these transitions and have a better patient experience with better satisfaction scores at a lower cost.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

5 Barriers to Optimal Care in the Post-Acute Setting

January 22nd, 2014 by Jessica Fornarotto

Summa Health System’s care coordination network of skilled nursing facilities (SNFs) is working to decrease fragmentation, length of stay and unnecessary readmissions while improving outcomes of care. Mike Demagall, administrator of Bath Manor & Windsong Care Center, a participant in this network, identified five barriers to patient care that originated in the acute care setting.

First, we found a lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.

We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.

The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, ‘Is this going to send a lot of our patients — our referrals — to home healthcare and decrease our referrals by participating in this?’ That happened to not be the case at all.

There was still a lack of knowledge and respect toward long-term care (LTC). All the discharge planning individuals, which were the case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.

There was also a lack of quality information received from the nursing facilities on the transfer to an emergency department (ED). That was information that we needed to get back, just as we were asking for information as those residents were coming in.

Excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement

3 Key Post-Acute Partnerships that Reduce Readmissions

January 22nd, 2014 by Cheryl Miller


Developing post-acute partnerships with home health organizations is one of the three top ways healthcare professionals are seeking to reduce readmissions, according to more than half of the respondents to the Healthcare Intelligence Network’s fourth comprehensive Reducing Hospital Readmissions Benchmark Survey.

Almost three-fourths (67 percent) cited skilled nursing facilities (SNFs) as their preferred post-acute partner, and 50 percent said they were partnering with hospices to reduce readmissions.

Other partnerships cited included telemedicine, free/low cost clinics, physician networks, and transitional care programs.

Among other key facts:

  • Nearly all of the respondents said that partnering with post acute providers helped them to streamline processes, educate their staff, and implement effective changes of value to the patient.
  • Among respondents from hospital systems (42 percent) that partnered with home health organizations, identifying high risk individuals most likely to be readmitted post-discharge and communicating this information to providers was key to successfully averting readmissions. Involving the patient’s designated caregivers in follow-up dialogues and transactions also improved the odds of prevention.
  • In addition to post-acute correspondence with their home health organization within 24 hours of discharge, one hospital system also practiced medication reconciliation and education and physician scheduling.
  • Follow-up appointments for patients with their home health and/or SNF provider within seven days for Medicare and Medicaid patients with no primary care doctor factored into one hospital system’s readmissions prevention plan. Assuring that medication reconciliation information was made available to their post discharge providers, particularly for high risk utilizers, was also critical to prevention.
  • A hospital system that partnered with low-cost clinics in addition to home health organizations maintained daily and weekly telephonic education meetings with patients, coordinated by its diabetes disease management nurse, diabetes educator and clinical pharmacist.

The ultimate goal in partnering with post-acute providers was to engage with patients while in their facility and continue to follow up with them upon discharge, with continued education and teach back as well as monitoring and overseeing their patients’ progress.