Many hospitals and health systems are developing preferred post-acute care networks to improve patient outcomes by collaborating with high-quality skilled nursing facilities, to participate in shared-savings arrangements such as accountable care organizations or Medicare or Medicaid Advantage bundled or capitated payments, or to reduce avoidable readmissions and unnecessary ED visits. In many cases, their goals include all of the above.

About 40% of Medicare beneficiaries receive post-acute care after a hospital discharge, which cost Medicare more than $60 billion in 2015. Building a post-acute care preferred provider network is particularly important for better management of total costs of care and to succeed in value-based purchasing programs.

Discharging patients to the most appropriate post-acute care provider is the right thing to do from a financial, efficient and experiential perspective. However, integration with post-acute care providers still represents a significant shift in a hospital administrator’s mindset, from wanting to fill every bed to ensuring the best care for a population.

Establishing a “continuity of care culture” that attends to the needs of patients beyond the hospital bed is a strategic initiative and an increasingly viable long-term care management strategy. 

Most health system leaders are on board with cross-continuum models of care.

For their part, PAC facility leaders must also consider the critical imperative in forging partnerships with acute care providers for the mutual benefit of both parties: the patient’s wellbeing. Collaborating with a post-acute care network on high-quality care solutions ensures a seamless transition and the best outcomes for the patient’s post-discharge journey. 

Whether you decide to own or participate via contract, thoughtful attention should be given to these six PAC network characteristics proven to improve care coordination, quality and outcomes while controlling costs:

Smooth care transitions

Transitions should be facilitated by dedicated care team members in both the acute and post-acute settings. This has been shown to improve communications, ensure appropriate treatment and aid the management of episodic patient needs.

Adverse event prevention

During the transition of care period, transparency of the patient’s care plan, including all necessary details related to a patient’s care (unique diagnoses and needs, medication administration record, nursing orders and more), can optimize the handoff process between acute and post-acute care sites. The care plan helps PAC care team members assess progress toward treatment goals and creates awareness around risk factors that point to early signs of infection or changes in vital signs. Its visibility and use prevents communication failures and other gaps in transitions of care that could negatively affect the patient’s experience. 

Streamlined, automated referral process

This component is critical for filling empty beds. For example, interoperable care coordination technology can increase efficiencies and savings by programming multi-faceted intake processes used by case managers during the patient’s discharge. This contributes to finding the right PAC facility referral to meet the patient’s specific acuity needs and a seamless, functional transition between care settings.

KPI tracking

You must have a means of measuring performance, e.g., health and operational outcomes, total cost of care, and variabilities and trends in quality and costs. The data reinforces why care quality is the most important factor in selecting PAC facility partners. Moreover, conducting a network evaluation can help you identify patterns of current resource utilization and any gaps.

A narrower network scope

Constantly look to see which facilities are populating your network, then maintain engagement with these preferred PAC providers. Create and share a list of guidelines that explains your organization’s best practices and expectations around the patient experience. Host preferred provider meetings to help hold each other accountable on important matters. 

Easy access for patients and families

Embrace digital technology to create visibility, stay connected and monitor the patient population. Visibility into your network’s performance and Medicare star ratings for PAC facilities reassures patients, friends, family members and caregivers — who are unsure of their options — that their loved ones are receiving the right level of care from providers. It also empowers these same parties during the decision-making process. Remember: the IMPACT Act requires patients and their family to have access to information that helps them make informed decisions about their post-acute care, while also addressing their goals of care and treatment preferences. Infrastructure that provides easy access to this information is thus critical for the success of your post-acute processes.

The increase in hospital and health system value-based payments — coupled with shared participant accountability for outcomes, the increasing use of preferred PAC networks, a strong correlation to reduced hospital readmissions and, of course, the graying of America — is among the chief factors setting the stage for the next generation of care delivery. 

The question is: Where do you stand in the rising efforts to optimize care across settings?

Mary Kay Thalken, RN, MBA, is Chief Clinical Officer of Ensocare in Omaha, NE. She provides executive, operational and clinical expertise to help hospitals better manage patient care transitions and achieve financial savings through reduced length of stay and preventable readmissions.