Care Transformation Center Blog

The 2-step process to revamp your post-acute care transition process

by Clare Wirth and Tomi Ogundimu

Earlier this month, Center for Medicare and Medicaid Innovation's (CMMI) top deputy Adam Boehler announced he may be looking to a bundled payment model for post-acute care (PAC) to save money and improve care. While actual implementation is far from imminent, CMMI's interest in PAC bundles underscores the opportunity to better manage populations with enhanced acute care-PAC partnerships.

Q&A: Unlock the benefits of your post-acute care strategy

This news builds on more than 10 years of momentum for post-acute and acute care collaboration. Initially, the ACA increased incentives for hospitals to work closely with PAC providers. In recent years, readmission penalties, value-based purchasing, and risk-based payment models such as Accountable Care Organizations (ACOs) boosted the importance of aligning post-acute and acute care services. But significant variability in PAC quality and cost, combined with increasingly challenging care transitions, have providers and CMMI alike agreeing that we have yet to realize the full value of these partnerships.

To optimize the efficacy of such networks, population health leaders need actionable data to highlight strengths and pinpoint improvement opportunities across the network. That's why we've created the Post-Acute Care Performance Improvement Assessment. This Excel-based tool pre-populates any hospital's Medicare fee-for-service data to help you evaluate opportunities to improve care transitions and manage PAC performance. Here's our methodology for an effective assessment tool:

1. Evaluate care transitions opportunities

A care transitions analysis can identify improvement opportunities in three ways:

  • Hospital discharge: Care transitions begin during patients' inpatient stays—so you should start your analysis by determining when to discharge patients to PAC in a clinically appropriate manner. To do this, narrow your approach to MS-DRGs commonly treated in PAC, prioritizing service lines and sites of service with lengths of stay significantly longer than national benchmarks.

  • PAC admissions: For the next set of opportunities improve the discharge planning process to right-site PAC utilization. Evaluate PAC referrals, adherence, and utilization against state averages. Then, compare outcomes across patients who received recommended PAC with those who did not. You can contextualize utilization and readmissions with your own risk-adjustment methodology or Hierarchical Condition Categories (HCC).
  • Return to hospital: Lastly, measure downstream acute utilization and its financial impact (e.g., HRRP penalties). Best practice organizations analyze ED visits and readmissions across different types of post-acute care settings, patient conditions, and inpatient service lines compared with national or market averages. This data is especially helpful to make the case for greater investment in PAC collaboration.

2. Manage PAC partner performance

Managing a high-performing PAC network is critical to influence downstream care decisions for which hospitals are often held accountable. However, PAC networks fall short when patients do not use their care. In fact, out-of-network utilization can minimize how effectively a high-performing network elevates patient outcomes, improves episodic efficiency, and streamlines cross-setting communication. A good analysis helps you assess if utilization is becoming more concentrated to select facilities over time, whether patients use this narrow network, and how your network is performing as a whole.

Beyond using the network, providers must ensure their partners provide high-quality care. Best practice providers directly compare cost and quality outcomes across their most-used PACs, including quantitative metrics (e.g., length of stay, cost, and readmissions) and qualitative metrics (e.g., preventive care, clinical improvement, safety).

Ready to draft your post-acute care dream team?

See how Population Health Advisor can help you design a Request for Information that includes key metrics for evaluating post-acute care partners on staffing practices, services, quality, care coordination, and strategic alignment.

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