Editor’s note: This is the second part of a two-part series on post-acute care strategies and tactics. See part one at ow.ly/AzymB.
Post-acute care (PAC) partnerships with clinically integrated care networks made up of physicians, hospitals, rehabilitation providers, skilled nursing facilities (SNFs) and community-based services are burgeoning, driven largely by the need under the new rules of pay-for-performance reimbursement to control Medicare expenses and shift utilization to lower-cost settings. Working closely with hospitals, in particular, to adapt to the multifaceted dynamics of value-based payment is absolutely critical to the financial vitality of these integrated networks.
Hospital stays no longer are an isolated event; rather, they have become part of the continuum for an entire episode of care. Traditional hospital inpatient stays, in fact, are on the decline as outpatient clinics and other alternative settings move to the forefront. Lower-cost PAC options, meanwhile, are benefiting from a higher profile in this new risk-based environment, with case management that maximizes Medicare margins superseding the push for Medicare admissions volume.
Data provide insights
PAC operators and hospitals are following several tactics to fine-tune their interactions. At the same time, they also are repositioning themselves for better alignment within the broader context of clinically integrated care networks.
One of the keys to forging partnerships is developing data-driven metrics that track outcomes to validate a PAC operator's qualifications and measure its ongoing performance. (For more details, see the first report in this series, published here: ow.ly/AzymB.)
At the same time, PAC organizations also must analyze Medicare-related trends at their referring hospitals to identify performance-improvement opportunities that their acute-care counterparts may have overlooked.
Medicare billing and cost report data provide detailed insights into hospital-related trends that directly affect PAC utilization. This financial and statistical information from Medicare assesses patient/resident origin using zip code data, analyzes total hospital discharges by discharge disposition, identifies the total number of discharges to SNFs and inpatient rehabilitation facilities (IRFs), enables a PAC operator to determine its present market share based on number of admissions captured in comparison with total hospital discharges to SNFs and breaks out the number of discharges in individual diagnosis-related group (DRG) categories to SNFs and IRFs. It also compares the hospital length of stay with the Centers for Medicare & Medicaid Services (CMS) geometric length of stay (GMLOS) for DRGs that are commonly treated in PAC settings, and it measures how hospital readmission rates stack up against CMS targets.
Specialized, high-acuity post-acute care
Tracking these Medicare trends points the way to reducing hospital lengths of stay, minimizing readmissions, expanding PAC programs based on high-volume DRGs and enhancing throughput/access. Another benefit of this ongoing analysis is that, by identifying the highest-volume of MS-DRGs that result in SNF placement—and these often rack up excessive costs in the hospital by surpassing the national GMLOS benchmark for SNF-bound length of stays, an opportunity exists for PAC operators to collaborate with hospitals to develop a series of clinical care pathways and protocols. Grounded in evidence-based practices, these interventions can deliver impressive results by streamlining transitions for patients in high-volume DRGs that are related, for example, to congestive heart failure, chronic obstructive pulmonary disease, stroke/cerebral vascular accidents, cardiac events, urinary tract infections, post-orthopedic events, septicemia and pneumonia.
Care pathways play a critical role in clinically integrated networks by providing detailed guidance for each stage in the management of a specific condition in a patient/resident over a given time period. They encompass an entire episode of care and have the potential to improve multidisciplinary communication, teamwork and care-planning by supporting continuity and coordination of services across the continuum of care. Adhering to explicit and well-defined standards for care helps reduce variation by promoting consistency.
Information technology/electronic health record systems with interoperability capabilities linking multiple care delivery sites are the backbone of clinically integrated care networks. Information access is how evidence-based care plans, quality outcomes and reimbursement benchmarks are shared. These systems identify, assess and stratify target populations, use care management interventions, exchange data and information across the care continuum, manage contracts and financial information and monitor and analyze performance.
Physician alignment also is growing more important with the emergence of the medical home model and its emphasis on case management. Engaging physicians in PAC settings who influence referrals and have strong hospital ties strengthens the link with networks.