A health care organization's most vulnerable patients are often those that undergo a transition to and from multiple care sites. There are lots of opportunities for mistakes when transferring between venues of care, which can lead to adverse outcomes for the patient and the organization — including unnecessary rehospitalization. This is a mounting concern for hospitals and other acute care facilities, which are in the process of adjusting as the industry shifts from fee-based to value-based reimbursement models.
Given these pressures, the timing has never been better for hospitals and Long-Term and Post-Acute Care (LTPAC) providers to engage with each other to help improve care coordination, care delivery, patient outcomes and the patient experience. Most organizations will agree on these common goals — the challenge is in finding the right path there. With that in mind, here are five ways health care organizations can align for LTPAC success.
1. Evaluate referral patterns
Since the Hospital Readmissions Reduction Program (HRR) began in October 2012, hospitals with relatively high rates of Medicare readmissions have become financially penalized. The idea behind this program is that hospitals should be sure that they're taking care of patients completely and are not sending them to a post-acute environment prematurely. If a patient is discharged from the hospital too early — before they have healed properly or without being educated about maintaining their care — they're more likely to experience a recurrence or be readmitted.
With up to 3 percent of each Medicare case reimbursement currently at risk, more and more hospitals are beginning to pay close attention to what happens to their patients after they leave the four walls of the hospital. Are patients being referred to any skilled nursing facility available in the area, or are they going to specific nursing facilities that have an established relationship with the hospital? For many acute facilities, the HRR prompted a change in referral procedures. Before, a hospital might have referred a patient to any LTPAC organization in a geographic area. Today, savvy hospital leaders have whittled that list down a preferred network of just several organizations that they're recommending to patients.
2. Establish strategic relationships
It's unsurprising that after being hospitalized, most patients would want to go home. That's usually their first choice — and it that tends to be the most cost-effective option for the individual. However, not everyone is an appropriate candidate for home care. Increasingly, hospitals have to pay close attention to the characteristics of each patient to identify if he or she should go home, or if the patient would be better served by going to an inpatient rehab facility, where they can receive extensive rehab services, or to a skilled nursing facility, where they receive around-the-clock nursing care.
These decisions can be tough for hospitals, especially if there's insufficient information about the patient being discharged. That's where partnering with trusted LTPAC facilities becomes important. Those facilities have more experience dealing with patients who need rehabilitative services, and they can help recommend and guide patients toward the right venue of care.
Increasingly, we're going to see more and more LTPAC facilities that are not providing just one venue of care, but that have multiple offerings — home care, skilled nursing and so on — so that they have more capability to care for a patient, whatever his or her needs may be. This means that when a hospital leader communicates with one of its allied LTPAC facilities to discuss sending a patient to home care, inpatient rehab or skilled nursing, that LTPAC provider will be able to give the best recommendation for the patient without competing with other facilities.
Sometimes, the first step in building that strategic relationship with an LTPAC facility is simply ensuring that leaders in both organizations are communicating openly with each other. Keeping the lines of communication open will ultimately lead to a smoother transition of care for the patient.
3. Identify communication barriers
As a part of the American Recovery and Reinvestment Act, health care providers were required to adopt the "meaningful use" of electronic health records by Jan. 1, 2014. However, this mandate does not apply to the LTPAC space.
Usually, when a patient transitions from the hospital to an LTPAC facility, the majority of their health information — the data stored on their electronic health record and the reason for their transfer — is printed on paper and goes in a binder in the back of an ambulance, is faxed over or is conveyed via a phone call between staff at either organization.
There's almost no electronic communication between a hospital and the majority of LTPAC facilities, which opens the door to a lot of issues. Critical information about the patient — such as medication dosages or allergies — is often left to manual entry, which is not immune to human error. This is a serious and common communication barrier that can have fatal consequences for the patient.
4. Leverage technology
There are some emerging networks, such as CommonWell, that are facilitating the transfer of information between these venues of care at a national level. This way, information is able to flow bilaterally between care venues and can be reconciled into a patient's medical record.
Rocky Mountain Care, an LTPAC organization with locations throughout the western U.S., is one example of how successful implementation of health IT in the post-acute space can lead to improved patient outcomes. In 2016, a patient was transferred to one of their facilities from a nearby hospital; the hospital sent over information about the patient, noting an allergy to codeine. When staff at Rocky Mountain Care registered the patient in CommonWell, the system found additional records stating that the patient was allergic not only to codeine, but to all opiates.
That's crucial information for the LTPAC facility. If that patient's additional allergies hadn't been caught and had any other opiates been administered, it could have had severe consequences — including an allergic reaction and a potential rehospitalization.
Getting that critical medical information from all venues of care the patient has visited is invaluable and can contribute to the long-term success of an LTPAC facility. In the case at Rocky Mountain Care, not only was a rehospitalization avoided -- which would have resulted in a financial penalty for the hospital and damaged the relationship between the hospital and the LTPAC facility — but a life was potentially saved.
5. Improve patient care and lower expenses
Improving patient care comes down to two main things: ensuring that the patient is transitioning to the proper care facility after discharging from the hospital and helping that patient avoid unnecessary rehospitalization.
Getting the patient to the right venue of care
A patient isn't going to get the best care if they're in the wrong venue to begin with. If someone is a poor candidate for home care because they don't have the right support system, or because they have issues with Alzheimer's or another significant disability, and yet they end up there because of cost, they'll likely end up in the hospital again. Getting the right care for a patient is about making sure that they're in the right venue and are receiving the best care in that venue, which sometimes comes down to having intelligent solutions that can predict when problems are going to occur.
Avoiding unnecessary rehospitalization
Unnecessary rehospitalizations aren't just costly for the hospital, they can have severe consequences for the patient and his or her family.
Imagine an Alzheimer's patient in a skilled nursing facility. That LTPAC facility has become his or her home, and if the patient has to be ripped out of their room at two in the morning to go back to the emergency room, it should be for a reason that was not preventable. That kind of scenario would be extremely traumatic for that patient, as well as the family member who received the early morning phone call and would probably be headed to the hospital. Inserting that patient back into that family member's life at the LTPAC facility can become difficult and have a negative impact on someone that is already toward the end of their life.
Aligning LTPAC organizations for success isn't just about reducing rehospitalizations and avoiding unnecessary cost — it's about doing what's best for the patient.
We share a commitment with long-term and post-acute care (LTPAC) providers to help make care management better than it is today. Learn more here.
