Recently, the Centers for Medicare & Medicaid Services finalized payment and policy rule changes related to post-acute care. The new regulations, including changes to the accountable care organization and skilled nursing facility payment models, seek to improve patient care and outcomes for challenging populations and reduce costs.

These changes will accelerate the move toward value-based care, necessitating successful alliances between ACOs, SNFs and home health agencies. SNF survival may be dependent upon partnering with ACOs to secure consistent referrals.

Additionally, as patients and their caregivers rely on these provider organizations to guide them to the right path of care, it is mutually beneficial for all post-acute care providers to work together to ensure the most optimal and cost-effective course of recovery.

Many organizations who have become increasingly uncertain about the operational impact of these changes will look to industry experts for guidance, as they adapt to this evolving atmosphere. Navigating the new post-acute framework will require a patient-centered approach, especially in determining the most clinically and economically appropriate treatment plan and site of care. Collaboration across the post-acute care continuum, especially among ACOs, SNFs and HHAs, is essential and can lead to improved outcomes, better patient experience and decreased spend. 

While the goal of these changes is better quality of care and overall cost-reduction, some ACOs’ focus is skewed toward maximizing savings, due to the new provisions requiring them to take on more risk. Many ACOs are now looking for ways to circumvent SNF visits all together, not realizing the implications this could have long-term.

According to a recent New England Journal of Medicine article, reducing SNF admittance to increase profit could  have three potentially unintended negative consequences: (1) some patients who need SNF-level care may be discharged home, which could lead to worse patient outcomes; (2) families may become overwhelmed with taking on more caregiving responsibilities, which could increase hospital readmissions and (3) SNFs may lose volume and be forced to close, which would reduce access to long-term care for patients who need them. While providing long-term care is a potential issue, premature discharge and overburdened caregivers can be prevented through the use of patient-centered assessments and care planning. These situations can also be avoided through strategic coordination between ACOs, SNFs, and HHAs. 

Although some ACOs are resolute in their determination to evade SNFs, others see the advantage of integrating SNFs into their business models. In the recently released Care Coordination toolkit, CMS shares findings obtained during a series of ACO-participant focus groups and interviews around the most effective methods of managing post-acute care for the most vulnerable patients. Notably, the majority of ACOs stressed the importance of working in tandem with SNFs to administer the most effective treatment protocols. Moreover, the consensus among ACO participants was that teaming up with SNFs can lead to continual enhancement of performance and quality improvement. Overall, ACO representatives were supportive of SNF collaboration. 

Recent innovations in analytics and predictive modeling have spurred the creation of intelligent technologies that enhance collaboration among ACOs, SNFs and HHAs. These tools help hospital discharge planners determine the best path of care for the patient post-discharge. They may include recommendations on appropriate length of stay, as well as identification of readmission risk that can be used for patient stratification. Additionally, these tools can leverage machine learning either to support SNF care or recommend discharge home. 

Interestingly, some Medicare Advantage plans find themselves with the same needs to enhance care collaboration as ACOs. They may feel some pressure to partner with SNFs and HHAs. Some organizations, especially health plans, are turning to companies who specialize in managing and coordinating post-acute and home health care, to help them break down traditional post-acute care silos. These post-acute and home health companies typically use evidence-based predictive modeling tools and advanced analytics to ensure health plan members are receiving the right care, at the right place, and at the right time. If care is managed effectively, patients can avoid readmissions, achieve better post-acute outcomes, enhance patient experience and lower costs. 

As we look ahead to the future of post-acute care, it is clear that collaboration across all phases of the spectrum is necessary to achieve a patient-centered system that ensures the most appropriate patient care setting and safe and effective transitions in care. Acclimating to the new post-acute ecosystem will require organizations — in particular health plans, ACOs, SNFs and HHAs — to partner effectively. If implemented successfully, everyone wins. 

Michael Cantor, M.D., J.D., Chief Medical Officer for CareCentrix, is a geriatrician and attorney with extensive experience in designing and implementing population health and quality improvement programs for health plans and healthcare providers. Most recently he served as Chief Medical Officer for the New England Quality Care Alliance, the 1,800-physician network for Tufts Medical Center in Boston.