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How to reduce variations in post-acute care

February 21, 2014
by David Friend, MD, MBA, and Patrick Pilch, MBA, CPA
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Variations in treatments for those in post-acute care (PAC) settings with similar medical conditions have caught the eye of the Centers for Medicare & Medicaid Services (CMS), which recently announced that it will be concentrating more intensely on this issue. CMS hopes to uncover the reasons for the treatment differences as well as mitigate their negative financial and clinical effects. The increased scrutiny is a call to action for operators of long-term care (LTC) and PAC facilities. The good news is that several strategies can help operators increase consistency in care and costs.

The variation in care experience is nearly fourfold greater in the PAC setting than in the acute care setting, suggesting to CMS researchers that providers within the industry disagree on care protocols and treatments for some medical conditions. It also suggests a significant lack of evidence-based protocols or, where such protocols exist, an inability to follow them consistently.


The differences in outcomes and costs to patients and residents are highly correlated to deviations from proven treatment regimens for clinical care. The PAC environment, however, can learn from a system designed for hospital and acute care settings.

The Geisinger Health System in Pennsylvania launched its ProvenCare system in 2006 to closely track outcomes so that healthcare delivery can be continuously adjusted and advanced. The success of the program lies in Geisinger’s ability to monitor and evaluate the health of its patients and leverage that information to develop best-practice guidelines for all procedures targeted by ProvenCare: elective coronary artery bypass graft, elective percutaneous angioplasty, bariatric surgery and certain perinatal and lung procedures.

Through the ProvenCare program, Geisinger has seen reductions in average total length of stay, 30-day readmission rate and complications. A PAC equivalent to Geisinger’s program could be constructed with a focus on the "four Rs”—the right care at the right place for the right amount of time at the right cost.


Often, patients and residents suffer when they don’t receive the most appropriate and scientifically proven care. Further, the financial burden of receiving inappropriate and unproven care can be very high. Given CMS’ objectives of better health, healthcare and value for patients and residents, however, expect the focus on reducing variation within the PAC system to intensify as a government priority over the next several years. Operators of LT/PAC facilities must begin to implement strategies to address this issue now in the following ways:

  • System implementation. As the medical delivery system becomes more interconnected and LT/PAC providers partner with hospital systems to care for patients and residents, operators will need to put in place clinical, financial, clinical information technology (IT), operating and human resources systems to actively reduce clinical variation levels.
  • System, protocol and staff sharing. LT/PAC providers will need to be able to share clinical IT systems and treatment protocols as well as use the same physicians and nursing staffs, where appropriate.
  • Redefinition and alignment with hospitals. LT/PAC providers will need to begin to redefine themselves as “step-down units” of hospital systems and provide clinical levels of variation, quality and outcomes that are similar to those provided by their partner hospitals. They must understand how they can provide transitions of care within the clinical networks that they operate and serve.
  • Cost examination. LT/PAC providers will be expected to provide this capability at a lower cost. Some of the aforementioned strategies may help toward that end, by creating new efficiencies and savings associated with the elimination of inappropriate care.

Winning LT/PAC providers will adapt their strategies to focus on improving the flow of patients and residents from the most expensive and inappropriate clinical settings to those settings that offer the best value and appropriate levels of care. Those that do not adapt quickly and instead continue to operate under a "heads in beds" business model will find that their operating model no longer is valid. Those that adapt rapidly will find that they have an enormous advantage as health systems begin to narrow their networks and select their partners. Those providers that focus on the four Rs will further increase their demand among patients and residents, too.

David Friend, MD, MBA (left), and Patrick Pilch, MBA, CPA, are managing directors of BDO Consulting Healthcare Practice.