Guest Columns

Navigating the discharge process

John Mach, Evolent Health
John Mach, Evolent Health

Not long ago, my mother broke her hip and spent time in the hospital. Upon discharge, the social worker gave us a list of post-acute care facilities. Being the good son I am, I asked for her opinion on which facilities provided the best quality of care because mom only deserves the best. However, she was prohibited to give me a recommendation due to regulations. I also discovered that although that type of information exists, it is difficult to access and interpret, which proved to be a barrier to getting mom the best care possible.

As the chief medical officer at Evolent Health, I have a front-row seat to the attention value-based models are receiving these days, particularly when it comes to post-acute care. Health systems are now increasingly accountable to meet certain cost and quality standards across the continuum of care, and as a result have to change their traditional ways of doing business.

One of our partners, Deaconess Health System in Evansville, IN, is doing just that. In its research, Deaconess found two alarming post-acute care statistics:

  • Indiana is among the top three states in the country when it comes to the highest average standardized payment amounts per stay.
  • The post-acute care spend for the Next Generation ACO (Next Gen) population was twice as much as a well-managed benchmark. It also discovered that when it came to post-acute care, readmission rates were higher than desired. 
Something had to change. Despite the recent CMS announcement of its postponement of bundled payment expansion, there are three ways I've seen value-based models create impact and efficiencies across the care continuum.

Systems are rethinking informal referral networks

Historically, hospitals and post-acute care facilities had informal and unintentional referral programs — a sort of quid pro quo that developed naturally. In mom's case, the post-acute facility list was based on geographical convenience, not quality. With hospital systems on the hook for the cost and quality of post-operative care, the outdated referral model has to change. Health systems must become more sophisticated in their approach to identifying and partnering with facilities that provide high quality care.

For example, Deaconess built a post-acute care network of SNFs with which it can share data, set up collaborative goals and learning programs, and improve handoff processes so the SNF has the info it needs when accepting patients.

Providers are paying attention specifically to the continuum of care 

With the shift to value, orthopedic surgeons must consider potentially lower-cost post-acute care alternatives that coincidentally might promote faster independence for the patient. Additionally, providers are focusing more on PREhabilitation to get patients in shape prior to surgery. As a result, providers are opting for same-day joint replacements and skipping hospital admission altogether, or skipping the SNF and going straight to more cost-effective and desirable home rehab.

Deaconess learned that the post-acute care spend for its Next Gen population was double that of a well-managed benchmark. It has since incorporated post-acute care planning with patients, initiated pre-op education, implemented prehab, standardized products and started monitoring outcomes to achieve the Triple Aim.

Post-discharge care facilities are blending 

Post-acute care has traditionally been subdivided into four siloes: palliative and/or hospice care; long-term acute care hospital space and high-intensity rehab facilities; traditional nursing home companies and SNFs; and skilled home care and related services. Value-based care has initiated some consolidation of post-acute organizations as they increasingly take on financial risk for the post-acute episode. We're seeing a blending of the four siloes into a “one stop shop” that can optimize post-acute care and reduce the likelihood of readmission. Health systems, providers and health plans are now keen on what happens when a patient leaves the hospital and are paying attention to post-acute care coordination.

At Evolent, we work with provider organizations to optimize post-acute care and reduce readmission, often leveraging a specialist on the front-end to organize the care, coordinate the facilities and create a transitional care program for patients. In our experience, though, success comes only when physicians are at the helm to design and govern the process. Deaconess created a clinical leadership model and operational structure that pulls together all the post-acute care services under one umbrella in order to triage patients to the correct facility. Establishing this post-acute care service line ensures consistent leadership and understanding of the clinical and operational elements that are essential to delivering the right level of patient care at the right time.

And that's something all our moms deserve.

John Mach is the chief medical officer at Evolent Health. He has more than 30 years of clinical and business leadership experience improving care and lowering costs for people with complex medical conditions, disabilities, advanced illness and end-of-life needs.



Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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