This week’s blog is written by our US colleague, Steve Burrill, who is the vice chairman and national sector leader for Deloitte’s Health Care Providers practice in the US. This article first appeared in My Take, part of Deloitte's Health Care Current platform.1 The article highlights some of the challenges of providing post-acute care and suggests a number of solutions, some of which may be pertinent to other healthcare systems, including ours here in the UK.
No one is an island
A physician executive recently said that post-acute care has long been an archipelago of small islands, with no bridges, poor transportation, and limited communication options to the rest of the health care system.2 When someone needs rehabilitation or additional services after a hospital stay, there currently is little rhyme or reason as to why a patient is discharged to a skilled nursing facility (SNF), home health agency, inpatient rehabilitation facility, or long-term acute care hospital. It may be a choice based on convenience to the patient’s home, what the patient is familiar with, or just the hospital discharge planner’s or other clinician’s preferences.
Post-acute care is often “fragmented and siloed” from the rest of the health care system, which can result in poor coordination of care, higher than normal readmission rates, and suboptimal patient outcomes. One-in-five patients are admitted to post-acute care after being discharged from the hospital (about 8 million patients annually).3 On average, 22.8 percent of SNF patients end up back at the hospital within 30 days.4 Moreover, variation in post-acute care services accounts for 73 percent of Medicare spending variation – the single greatest contributing factor.5
For years, there was often no real incentive for hospitals to direct patients to the highest quality, most appropriate post-acute care facility, coordinate care, or continue to track the patient. Like Ed Murrow, the broadcast journalist, many hospitals would say “good night, and good luck” to their patients as they left the hospital. They had no accountability for what happened to patients afterward. Now, under the Hospital Readmissions Reduction Program, the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA), and the Medicare Bundled Payments for Care Improvement Initiative (BPCI), hospitals are penalized if their patients are readmitted or have poor outcomes. Hospitals have a financial reason to care about what happens to their patients after leaving the hospital and should be paying close attention to post-acute care.
Despite hurdles, like the fact that post-acute care was not included in a number of Centers for Medicare and Medicaide Services (CMS) programs to adopt and modernize electronic health records (EHRs), hospitals can make some smart next steps and think strategically about post-acute care. Limited data about what happens at facilities can make it hard to compare quality across facilities. In the face of these barriers, some forward-looking health systems are working with post-acute care facilities to create their own quality metrics, share data, and steer patients to certain facilities based on clinical need, quality, and outcomes. We saw this in our recent paper, “Viewing post-acute care in a new light: Strategies to drive value.”
Our conversations with key post-acute care stakeholders revealed that there is great potential for innovation in post-acute care. Directing patients to receive care at home with an aide or to a high-quality post-acute care facility, for either a short, intentional visit at a lower cost setting than the hospital or for a longer-term rehabilitation stay, could improve patient outcomes and reduce costs. The key is figuring out how a health system responsible for the outcomes of a patient can steer that patient to the best option for them. We explored two different ways health systems can work with post-acute care providers:
- Own: One option for health systems is to buy or build post-acute care services. By owning post-acute care, health systems can control the type and quality of care their patients receive, integrate the information into their EHR systems, and better manage care from a population health perspective. This, however, may not make sense for many health systems. There are scale, expertise, and capital requirement considerations to be made. Additionally, many post-acute care facilities have very narrow margins or are not performing well. This may pose a risk to well-established, large health systems.
- Partner: The preferred option from our research was for health systems to partner with post-acute care providers. Relationships can take different forms, such as joint ventures, leasing beds, and/or preferred referral networks. This could mean identifying the high performers with quality care, patient satisfaction, and low readmissions and developing relationships with them that encourage accountability and high-quality outcomes. Many established partnerships use their relationship as a platform to focus on quality initiatives for post-acute care. These efforts often focus on care transitions, augmenting clinical staffing, broadening the medical director role, reducing readmissions, developing patient-centered models, and enhancing clinical staff education.
While building the systems to capture this data may take time and the industry is just in the first stage of reconfiguring post-acute care, some of the interviewees said that even small, simple changes – such as getting the health systems on the phone with the admitting post-acute care facility to discuss what the patient needs in the next two to 12 hours – have huge potential for improving quality and keeping patients from being readmitted to the hospital. Additionally, more strategic use of post-acute care – not everyone should be discharged to a facility, because being at home could be helpful for recovery – could reduce costs and improve outcomes. As post-acute care evolves, post-acute care 2.0 could include greater integration with acute care, risk-based contracting, and more automation for referrals and patient care.
In the current environment, financial incentives often are misaligned, cost controls can be inadequate, and outcomes and patient experience can suffer. But we are moving to a new world of value-based care, and under new payment models health systems may need to take a hard look at their post-acute care strategies. That’s a challenge before all stakeholders – how to construct the necessary bridges and communication networks from the disparate health care islands. Patients depend on guidance from their doctors, hospitals, and health plans to make the right choices in a process that can be lengthy and frustrating. Health systems may need to be better at drafting horizontal networks that don’t leave patients – and each other – stranded on their own island.
2 Deloitte Center for Health Solutions, Viewing post-acute care in a new light: Strategies to drive value
3 Wen Tian, An all-payer view of hospital discharge to post-acute care, 2013
4 Robert E. Burke, Emily A. Whitfield, David Hittle, Sung-joon Min, Cari Levy, Allan V. Prochazka, Eric A. Coleman, Robert Schwartz, and Adit A. Ginde, “Hospital readmission from post-acute care facilities: risk factors, timing, and outcomes,” JAMDA: The Journal of post-acute and long-term care medicine 17, no. 3 (March 2016), p. 249-255, DOI: 10.1016/j.jamda.2015.11.005
5 Robert Mechanic, “Post-acute care—the next frontier for controlling Medicare spending.” New England Journal of Medicine (2014).