Care Transformation Center Blog

Three ways to rethink your post-acute partnership

by Jared Landis

Hospital leaders know that developing strategic partnerships with post-acute providers can greatly enhance post-discharge care quality, smooth care transitions, and reduce readmission rates.

But too often, these preferred post-acute provider networks' performance improvement efforts never evolve beyond the initial focus on care transitions and readmissions. 

To transform your current partnership into a truly strategic one, you can:

Leverage post-acute partner clinical expertise broadly

Because of the generally lower acuity nature of post-acute care, hospital leaders rarely recognize the unique expertise possessed by their post-acute partners.

But that’s not the case at Sparrow Health System, where expert respiratory therapists from the system’s long-term acute care hospital (LTACH) staff units within the inpatient setting, while the LTACH’s wound care team partners with the outpatient wound clinic to tailor care plans and support home and community-based services.

And at Hebrew Senior Life, a multi-service post-acute provider in Boston that offers geriatric expertise to their acute care partners.

  • Case in brief

    Hebrew SeniorLife
  • • Not-for-profit post-acute care provider offering long-term acute care, inpatient rehabilitation, skilled nursing, senior supportive housing, home health, and community geriatric care
  • • Developed ReAge, an initiative to redefine the aging experience and create comprehensive health care solutions for seniors
  • • Offers consultation services to local hospitals on developing a geriatric-specific ED
  • • Engages local ACOs to provide geriatric specialists to manage senior population

To learn common characteristics of geriatric ED programs, Marketing and Planning Leadership Council members can read our research briefing.

Create a specialized cross-continuum program

All acute care hospitals have opportunities to build cross-continuum programs—typically defined by shared clinical leadership, cross-setting care pathways, and ongoing patient support.

HealthEast Care System in St. Paul, Minn., did just this for its medically complex behavioral health patients. To learn ways to be more proactive about identifying these patients and getting them the care they need, watch our brief video.

  • Case in brief

    HealthEast Care System
  • • Not-for-profit, four-hospital health system in St. Paul, Minn.
  • • Medically complex behavioral health patients lingering in acute care hospitals because post-acute providers were reluctant to admit them
  • • Partnered with Cerenity Senior Care to establish formal clinical training and ongoing support to manage population
  • • Training addressed key SNF challenges for managing complex medical and behavioral health needs

Build complementary care management capabilities

Before hiring more care management staff, take a look at your post-acute partners, because they may already offer the skills you need. For example, instead of building its own care transition guide program, Greater Baltimore Medical Center partnered with Johns Hopkins Home Care Group.

  • Case in brief

    Greater Baltimore Medical Center
  • • Not-for-profit, 280-bed acute and sub-acute hospital in Baltimore, Md.
  • • Contracts with preferred home health provider, Johns Hopkins Home Care Group, to provide transition guides for COPD1, CHF2 patients
  • • Transition guides responsible for disease-specific population coordination, providing transitional care to skilled nursing, home health, and the patient's home
  • • Program reduced readmissions for GBMC and solidified Johns Hopkins Home Care Group’s preferred partnership through performance recognition, increased presence in discharge transition process

What Else Do Post-Acute Partnerships Have to Offer?

Partnerships between acute and post-acute care providers is particularly important for managing dementia patients. I blogged earlier this year about five strategies for improving care coordination for this challenging and growing patient group.


If you would like to discuss ways to optimize your hospital’s post-acute alignment strategy, feel free to email me at