There’s major variability in post-acute quality and cost performance across individual providers, especially in peri-pandemic times, and many hospitals don’t have information to assess a potential partner’s performance. Yet, it is critical to find the right post-acute partners.

Many hospitals have formed post-acute networks with high-quality, low-cost partners to help reduce outcomes variability, as well as facilitate meaningful collaboration on care transitions and other initiatives that are not possible with a wider range of stakeholders. However, in the peri-pandemic era, some hospitals are starting their networks over, some are rebuilding, some are building on their COVID-19 strategy, and others are doing it for the first time.

Where to begin for providers starting from square one? First, build a scorecard with the key clinical, operational, and strategic metrics that are relevant to system goals. Then, ask potential post-acute partners to report data in those areas—and gather external data to validate that information when possible. Be sure to engage directly with post-acute partners during this process as an initial step toward building a long-term partnership.

Here are five key metrics to get started:

• 30-day all-cause readmission rate
• Average length of stay (for SNFs)
• Average response time to referrals
• Existence of specialty programs

Once the initial assessment is complete, providers should collaborate to build a strong working relationship with post-acute partners. Regular, in-person forums give partners the ability to share best practices or collaborate on clinical objectives. Take it a step further by establishing targeted work groups that focus on specific challenges, such as readmission reduction, and encourage ongoing performance improvement.

For a comprehensive scorecard to measure the viability of potential post-acute partners, see our Hospital Scorecards for Post-Acute Providers.

CMS typically restricts certain types of coordination between health care providers. However, there are two main opportunities within CMS programs that hospitals can take advantage of to more effectively collaborate with post-acute partners:

1. Gainsharing with post-acute partners

Post-acute providers’ Medicare incentive structures are often at odds with those of hospitals. Offering to share savings with post-acute partners can encourage aligned behavior—and reward them for supporting hospital goals. However, gainsharing is rare due to hospitals not making much of a bonus on value-based payments, so they are hesitant to share with partners. Additionally, it’s usually easier to attribute care to specific doctors in a patient’s journey, thus giving them a gainshare as a result.

2. Leveraging waivers

Some payment programs, including Medicare Advantage, offer waivers of certain requirements to encourage cost-effective care. Hospitals, in partnership with post-acute providers, can use these exemptions to discharge patients earlier, or to lower services’ cost structure by using telehealth. See specific information on waivers available through Medicare and COVID-19-era waivers extended past the end of the PHE.

3-day stay waiver

Overview
Waives the requirement of a 3-day inpatient stay for subsequent SNF stay coverage.

Limits
Available for all SNFs during the PHE, expired on May 11, 2023. Now available only for SNFs with 3-star rating or higher; CMS will keep an updated list of eligible SNFs.

Telehealth geographic and originating site waiver

Overview
Allows providers to bill for telehealth regardless of patient’s geographic location or care setting.

Limits
Only for services on CMS’s approved list; for those in an HH episode, cannot be visits covered under HH PPS. Set to end for physical health by end of CY 2024; permanent for mental health.

Post-discharge home visit waiver

Overview
Permits home visits incident to physician care to be delivered without direct physician supervision.

Limits
Home health and community-based providers are excluded from offering home visits under this waiver.

An efficient episode post-discharge begins during hospital admission. Care teams should develop a comprehensive understanding of each patient’s needs early, to optimize the hospital stay and beyond. Failing to do so can result in delayed discharge, improper post‑acute patient placement, or unnecessary readmissions.

To succeed in this area, hospitals should equip discharge planners with comprehensive risk stratification assessments—including both clinical and psychosocial factors—and conduct assessments soon after admission.

Discharge planners also need to be aware of the possible ways that care transitions can be delayed between hospitals and post-acute sites of care, especially SNFs. Since the onset of the pandemic, there is a significant shortage of available beds at SNFs due to low staffing levels and facility closures, which has contributed to a sizeable uptick in length of stay (LOS) at hospitals.

Early engagement with patients ensures that hospital and care management staff can effectively provide needed interventions and support. Discharge planners also will have the information they need to more efficiently prepare for discharge—without a last-minute scramble. Removing logistical hurdles is crucial to a timely, effective discharge.

For an in-depth look at the delays in downstream care transitions, and what acute providers can do to mitigate them, see Delays in transitions to post-acute care.

Placing patients in the appropriate post-acute setting is no easy task. There’s a wide range of post-acute care settings, with limited standardization around appropriate patient placement criteria for each. Even within providers of the same setting, specialized capabilities can vary significantly. For example, some SNF providers may be able to care for patients on ventilators, but many can’t. This lack of standardization creates a confusing environment for discharge planners to determine the best post‑acute options for a given patient.

Due to the circumstances around SNF bed availability described on the previous page, some patients may be sent home, even if that is not the most appropriate setting for them. Patients who require assistance with their activities of daily living, especially if they do not have family nearby, will need to turn to aides paid out of pocket, due to the lack of insurance coverage for non-medical home care. Patients who skip that support due to expense or lack of access are at risk for deterioration and readmission.

The longer it takes a discharge planner to determine the right setting, the more unnecessary time the patient spends in a hospital bed. At the same time, patients placed in settings that are unequipped to care for them may end up returning to the hospital, while patients placed in unnecessarily high-acuity settings can drive up costs.

How can providers facilitate easy and accurate post-discharge placement for patients?

1. Implement a post-acute level-of-care decision guide

A level-of-care decision guide is a set of criteria mapping specific clinical parameters to the post-acute sectors generally equipped to care for these patients. Case management teams can create their own guide or select an existing guide such as InterQual® in partnership with referring clinicians.

2. Work with partners to create a contact and capabilities database

Given the variation in individual providers’ capabilities, discharge planners should collaborate with local post-acute partners to develop a centralized database with regularly updated information on each post-acute partner’s capabilities and a phone number for 24/7 contact. This enables discharge planners to tell at a glance which post-acute providers can meet a patient’s needs.

Creating a high-quality preferred provider network is only the first step. To see improved outcomes, patients must actually choose in-network providers for their post-acute care.

During the discharge process, tell patients which providers are preferred—while respecting their freedom to choose any provider. Medicare patient choice requirements prevent hospitals from selecting a patient’s post-discharge provider, but that doesn’t mean discharge planners can’t simply inform patients about the clinical quality of their post-acute options.

Working with the post-acute partners in your preferred provider network is integral to ensuring more patients choose them upon discharge from the hospital. Hospital systems can follow these steps to improve in-network utilization:

1. Understand what patient choice laws allow
2. Educate physicians and discharge planners about preferred providers
3. Equip discharge planners to support patient decision making
4. Develop informative discharge education resources
5. Track whether your network is narrowing

To learn how to engage the entire organization in promoting in-network utilization with resources on patient choice laws, discharge education, and monitoring, see The Guide to Promoting In-Network Utilization.

Sharing complete yet concise information about patient care with downstream partners is a crucial step to ensure quality and efficiency post-discharge. Post-acute providers are better able to customize patient care and prevent deteriorations when they have critical clinical details about the acute care stay. Unfortunately, post-acute providers often receive data that are incomplete or arrive too late to act upon.

Train discharge planning staff on the types of information to share with post-acute providers and consider creating targeted teams to oversee the exchange of critical information like patients’ lab results. Using “warm” handoffs—transitions where hospital staff and post-acute staff speak directly—can enhance the process.

Although many post-acute providers have read-only access to a hospitals’ EMR, this is not the be-all-end-all solution. Hospitals sometimes assuming the read-only display is enough, however it is purely communication with the option for interoperability. It’s important to understand that, while technology is important, extending active communication with downstream providers will improve the patient care journey and quality outcomes.

Effective information exchange between acute and post-acute providers:

• Complete: all critical information is sent
• Clear and concise: critical information easily and quickly identified
• High-speed: timely exchange avoids service gaps

Helping post-acute partners improve and sustain high quality measures is an integral part of the process in preventing readmissions. One way to succeed in this area is to extend care pathways into the post-acute setting. Evidence-based care pathways support efficient, high-quality care in the acute space by minimizing variation.

To ensure patients continue to receive cost-efficient, high-quality care after discharge, collaborate with post-acute providers to adapt existing acute-care protocols to the post‑acute setting—and build new pathways that go beyond inpatient treatment and address common challenges to care plan execution in the post-acute setting. Examples of acute care protocols include:

• Fall risk protocols
• Protocols for prevention of pressure ulcers, including skin checks and turning patients
• Protocols associated with care of central lines and IVs

Evolving industry incentives and outcomes transparency have resulted in a concerted effort among post-acute providers to strengthen clinical capabilities. However, the complicated relationship between highly complex patients, low staffing requirements, and a lack of clinicians interested in working in post-acute settings can pose challenges to continued improvement.

One way hospitals can support their downstream partners is to provide training around the needs of specific patient populations and offer on-site clinician support. Collaborating to upskill post-acute staff, especially around high-risk patient populations, helps post-acute providers better meet hospitals’ post-discharge expectations and placement needs.

Sharing staff with post-acute providers gives downstream caregivers an in-the-moment resource for clinical questions and helps align post-acute operations with episodic goals. During the height of the pandemic, hospitals provided post-acute partners with additional staff to help deal with overflow patients, patients with COVID-19, and shared infection control protocols.

Further, post-acute providers’ financial incentives are not aligned with health system priorities related to episodic or total cost management. Extending clinical support into the post-acute setting can both improve outcomes and reinforce alignment with system goals.

To influence episodic outcomes beyond their site of care, providers must successfully engage patients in self-management initiatives focused on real-world education and skills building. Patient self-management is crucially important to avoiding readmissions, especially for those with chronic illness. One key factor in the self‑management process is a patient’s activation level, which refers to an individual’s ability and likelihood to practice self-care.

Tactics to activate patients

Interactive patient education

• Electronic education modules provide and reinforce teaching throughout stay, promote discharge readiness
• Fulfillment of education modules incorporated as a discharge requirement

Bedside care conferences

• Facilitates patient goal-setting to tailor discharge requirements to realistic patient and family goals

Standardized supplies

• Coordinated with hospital and home care for teaching consistency

For a collection of best practices to embed a patient-centric culture, encourage patient activation, promote self-management, and deliver palliative care services, see the Patient engagement resource compendium.

Ensuring quality and efficiency throughout an episode means supporting patients beyond their care journey, when they return to their daily lives.

For a hospital managing a 90-day episode of care, a patient may be discharged from a post-acute setting, or conclude a home health encounter, before the episode ends. This means the hospital remains financially responsible for the patient once they have exited the health care system. Simultaneously, research indicates that patients are especially vulnerable after a hospital or post-acute stay.

This means that providers must prioritize continuing recuperation via primary care and community programs, such as meals on wheels, adult day services, and community health workers, while ensuring a patient’s social needs are met.

Other examples of community programs that providers can collaborate with are explored below.

PACE

PACE provides comprehensive medical and social services to those still living in the community who are 55 or older, live in a PACE service area, or are eligible for SNF-level care.

Senior living

Independent senior living provides needed services, like dining and laundry, while offering social activity opportunities and a personal residence.

Non-medical home care

Non-medical home care provides support at home that does not involve medical skill, including housekeeping, running errands, and offering social interactions.