Care Transformation Center Blog

Where to start on your biggest post-acute care network challenges

by Jason Glaw and Natalie Dawe

As our colleague Tomi Ogundimu wrote earlier this year, actively partnering with post-acute care (PAC) providers on cost, quality, and care coordination should be one of your top population health resolutions in 2015. However, health systems face three challenges in developing the post-acute network and in managing performance of selected partners:

  • Incomplete understanding of utilization of each post-acute service
  • Inability to consistently measure ongoing performance
  • Lack of integration to improve quality levers

Incomplete picture of post-acute care providers in the market

One of the challenges of optimizing a post-acute care network is managing the sheer number of partners involved. Hospitals work with an expansive set of PAC providers, yet often have limited knowledge about the organizations’ capabilities or strategic goals.

On average, hospitals work with 60 different PAC facilities each year. However, across research conducted by our Population Health Advisor team, we’ve seen that number vary from 10 facilities to 200 facilities.

Analysis of the utilization trends in a health system’s current post-acute network—including provider capacity and volume shifts—can illuminate opportunities for collaborating with post-acute care providers.

Inability to measure PAC provider performance

Often, hospitals cannot feasibly collaborate on performance improvement with all of the PAC providers their patients use. Organizations should then select strategically aligned partners and identify areas of concern in existing partnerships. However, few organizations have the data they need for this type of evaluation.

Frequently, data on PAC performance is either incomplete or not current. Limited communication between the acute provider and PAC provider can lead to insufficient information exchange. The sheer volume of potential metrics can also lead to inconsistent tracking across organizations and overwhelm the providers that must track different metrics for each of their referring hospitals.

As a first step for tracking PAC performance, many organizations examine 30-day readmission rates, with a focus on Medicare penalty-eligible conditions. While informative, readmission rates aren’t the whole picture.

Insufficient integration with PAC providers to improve performance

Even with preferred PAC partners identified, performance improvement will stagnate without meaningful collaboration between the acute and PAC providers. Integration barriers, such as underdeveloped information exchange channels, as well as a lack of shared accountability, inhibit achievement of population health goals. To address these gaps, the partners should:

  • Communicate expectations for partnership and set timeframes for improvement
  • Identify opportunities to share resources, including staff, best practices and care management protocols
  • Establish recurring forums to communicate and update leadership on progress

How Cedars-Sinai made SNFs its readmissions reduction partner

For more information on how Population Health Advisor can help review and assess your post-acute care network, email us at or

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