Out of sight can't be out of mind when hospitals discharge patients into post-acute care if they hope to keep up with changes being wrought by the 2010 Affordable Care Act.

The act requires that in 2013 Medicare financially penalize hospitals for what it determines are excess readmissions. About 13 percent of hospital patients are discharged to nursing homes and other long-term care facilities, government figures show. In 2007, the risk-adjusted rate of potentially avoidable rehospitalizations within 100 days for five conditions was 18.5 percent among Medicare-covered, skilled nursing facility patients, according to a 2010 MedPAC report.

So skilled nursing, inpatient rehab and long-term acute care facilities must be part of hospitals' strategy for reducing readmissions, which "will drive everyone's attention for the next couple of years," says Terrence O'Malley, M.D., medical director for non-acute care service for Partners HealthCare in Boston.

In the longer term, the ACA's accountable care organization program and Medicare payment bundling project will attempt to create reimbursement models that encourage acute and post-acute providers to work together to coordinate care across the continuum.

Many hospitals and health systems divested their post-acute inpatient facilities in the late 1990s and early 2000s because of a combination of Medicare payment changes and the challenge of managing that complex patient population. Consultants don't expect the ACA to spur a rush by hospitals to buy these facilities, but hospitals must get choosier about where they refer patients.

They have their work cut out for them. Sg2, a Chicago-area health care analytics company, applied a risk-adjusted methodology similar to that of Medicare on the firm's own national database to calculate a 30-day readmission index. The index shows observed readmissions versus expected readmissions for various post-acute providers. The analysis found that for skilled nursing facilities, the readmission rate is 27 percent higher than expected.

"If I were running a hospital, I would want to know a readmission index on the facilities that I was referring to," says Joan Moss, R.N., Sg2 senior vice president. "This raises a whole lot of questions, and it's the beginning of a discovery process: Is there a communication or information transfer problem? Is there something about our discharge process that isn't working? Is there something about the staffing mix at the facilities we're transferring patients to? Is there an opportunity for improvement in the medical director leadership at the skilled facility? Is it staff education?"

Finding Strategic Partners

About two years ago, Sg2 began advising its members to develop an inventory of the post-acute care providers to whom they're sending patients. Hospitals should know, for example, who the medical director is and what the facility's level of quality is, Moss says. "Then you've really got to make a decision about which organizations you are going to have strategic partnerships with," she says. "The patient has choice, but that does not preclude the hospital from being able to say, of this list of 20 organizations, we have strategic partnerships with these five or six."

The strategic partnership should involve quality measurement. Moss recommends that a team from the hospital and post-acute facility review the data monthly so it can identify problems early and intervene. A further step is to develop jointly a care pathway that incorporates the acute and recovery phases of care.

Other measures hospitals are taking include investing in staff education at skilled nursing facilities and even sending nurse practitioners to round at SNFs on the patients discharged from their hospitals. Both tactics help build relationships between the hospital and post-acute nursing staffs. "Up to this point, a CNO of a hospital, because she may refer to six to eight to 10 SNFs on a regular basis, hasn't had a particular incentive to get to know the directors of nursing at these facilities," Moss says. "Now there is an important reason, professionally and from a business perspective, to create those relationships."

Assessing outside post-acute providers is important not only as part of the effort to reduce readmissions, but it also helps determine with whom a hospital or system might want to link if it goes the ACO route. That's what is happening at Partners, O'Malley says. The health system owns a wide array of post-acute care facilities called the Spaulding Rehabilitation Network, which includes inpatient rehab, long-term acute care and SNFs. But about half of the system's acute care patients who need post-discharge care go to outside facilities. "That's the 50 percent we need to figure out how better to manage," he says.

Finding outside providers that will work with the system to reduce readmissions and improve quality sometimes has been difficult, O'Malley says. "We're identifying SNFs that right now want to work with us to reduce readmission and absorb a lot of the quality metrics, processes and projects that we're working on. They're basically speculating that we're going to be standing when the ACOs roll around, and they want to be standing with us. It's a very small group of SNFs that recognize that is strategically important."

Hospitals committed to reducing readmissions from post-acute inpatient providers can't simply look outside their walls for solutions. They have to look at their processes, from assessing patients' risk of readmission as soon as they're admitted to the hospital, to evaluating discharge planning and the handoff to the next setting. Many of the lessons apply not only to inpatient post-acute care but also to home health care.

A Facility to Fit the Patient

An essential piece of the puzzle is to make sure hospital discharge planners are adept at matching patients with the facilities that can best meet their continuing medical needs, says John Collins, M.D., chief medical officer at Northeast Health, Troy, N.Y. The system owns Sunnyview Rehabilitation Hospital and a range of post-acute facilities known collectively as The Eddy. The discharge planners at its two acute care hospitals communicate directly with the nursing directors at the skilled nursing, rehab or assisted-living facility.

Because the system owns the post-acute care pieces, "discharge planners at the hospital level get much more expert at being able to match the level of service needed by the individual and the level of service available at whatever part of the system they're working with," Collins says.

To help ensure patients get to the appropriate facility for continuing care, Partners developed software called 4Next. The program allows patient liaisons, who facilitate transfers, to search electronically for facilities inside and outside of the Partners system that meet the patient's medical needs and are approved by their insurance. The liaisons then print out a list of appropriate facilities for the patient's family so the family can visit them.

As soon as the family makes its choices, the case manager, with the push of a button, can send a pre-populated set of clinical information to the facilities in a format much like a secure e-mail, O'Malley explains. For example, it could say, "We have a 65-year-old female who is VRE-positive with congestive heart failure with this type of insurance. Do you have a bed? Would you like more information?" The software significantly cuts down the time involved in getting a patient placed in the next care setting, he says.

Collins and O'Malley also stress the need to send the necessary clinical information to the post-acute provider.

At Northeast, this task is simplified because all the post-acute facilities it owns are on the same computer-system platform. "If a person is going from one of our acute care hospitals to Sunnyview, the medications, lab results, imaging study results are all available at Sunnyview," Collins says. "We're doing the discharge planning, and we have a unit that works on the intake at Sunnyview, so they know exactly what the patient's situation is and can pick up on their care needs on Day 1."

Partners uses the 4Next program to share clinical information with its internal Spaulding network and outside post-acute inpatient providers. Among the host of data that can be sent via 4Next are discharge summaries, operating and nursing notes and lab results. In addition, the receiving facility can go back into Partners' clinical data repository to pull limited information, such as lab data and X-ray notes.

'Absolutely Astounding'

Effectively addressing the readmission issue requires working together on the acute and post-acute side. Both Partners and Northeast participate in the Institute for Healthcare Improvement's State Action on Avoidable Re-hospitalizations. The STAAR project calls for hospital participants to engage representatives from their post-acute providers. At first these cross-continuum teams focused on changes that could be made in the hospital to reduce readmissions, O'Malley says. Now they're starting to look at the post-acute setting to determine what can be done differently there.

The STAAR initiative has brought the acute and post-acute staff together in an organized way that hadn't been done before. "Nobody got the emergency room, the acute hospital team, case management and the post-acute care people around the same table. So it's absolutely astounding," O'Malley says. "If nothing else comes out of STAAR but cross-continuum teams, they will have done more in a year than health care has done in 60."

For hospitals that own post-acute inpatient facilities, reform accentuates the critical task of ensuring they provide high-quality care in those settings and avoid readmissions.

Partners has undertaken several efforts along those lines. It is developing a pilot project in which patients at high risk of readmission will be identified in the hospital and the inpatient teams' management responsibility for those patients will extend into the post-acute setting. "So, for example, the stroke team who is discharging a patient to Spaulding will be available to consult and help manage care long after they've discharged the patient," O'Malley says. "It's no longer 'they're off of my service, they're out of my mind.' "

As part of the project, Partners collected data on all of the readmissions from its Spaulding Rehabilitation Network that occurred within 72 hours of discharge. It found 120 such readmissions over a five-month period. The data is being analyzed, and the result will be targeted interventions to prevent readmissions among high-risk patients, O'Malley says.

In addition, for a year Spaulding Nursing and Therapy Center North End has used a tool called Interact II, designed to reduce avoidable nursing-home patient transfers to the acute care setting. Nursing aides are given cards that allow them to identify changes in residents' status early on. Negative status changes prompt a protocol-driven assessment of the patient. The cards also are shared with patients' families. The tool "has reduced our number of emergency-department transfers and our readmissions," O'Malley says.

Integral to hospitals' efforts to ensure care quality in their post-acute facilities is performance measurement and quality improvement. Northeast is participating in Advancing Excellence in America's Nursing Homes. It offers quality-improvement monitoring tools in such categories as reducing staff turnover, prevention and treatment of pressure ulcers, and use of restraints.

At Partners, all of its continuing care components are measured monthly using a quality dashboard. The metrics include falls with injury, line-associated infections, pressure ulcers and clinical transition measures, O'Malley says.

Having all the pieces of the acute and post-acute care continuum working together will be essential for coping with reform, Collins and O'Malley say.

Under ACOs, it won't matter how long a patient stays in the acute care hospital as long as that's where the person needs to be, notes O'Malley. "The pressure will be to put them in the place where they can get the most appropriate care. That means the rest of the network has to be more flexible and able to take patients appropriately to the level of their acuity, to get them in and out quickly and appropriately, and to be able to do the transitions of care safely. You have to have all of the infrastructure in place to make that work."

The health care community increasingly recognizes the value of providing a full range of services, especially given the increase in chronic conditions, Collins says. "You can't just look at acute care any longer," he adds. "You need to look across the entire care continuum, so you have to have readily available rehab services, you need good home care, you need the long-term care piece. You're really talking about a life care-type system."

Geri Aston is a contributing editor to H&HN.