Although nearly 40 percent of inpatients covered by Medicare fee-for-service are discharged to skilled nursing facilities and other post-acute providers, hospitals traditionally have done little to coordinate or monitor the care patients receive in those settings. Until now.

Shared savings payment models and new penalties in Medicare's reimbursements to hospitals with high 30-day readmission rates, which kicked in this fiscal year, are giving health systems powerful motivation to help make post-acute care work well for patients.

"What you really want is a group of [post-acute] providers that are going to partner with you to manage the cost, quality and outcomes of care, integrate your care pathways into their programs, and integrate your primary care physicians into their facilities and programs," says Kathleen M Griffin, national director of post-acute and senior services at Health Dimensions Group in Scottsdale, Ariz. "And you want a partner who is going to be able to have the right kind of care transitions to whatever the next level of care is."

That is exactly what HealthEast Care System in the St. Paul, Minn., area, is working to achieve. For nearly two years, representatives of HealthEast's three short-term acute care hospitals, its home health agency and its hospice have been meeting monthly with leaders who represent about 40 independent skilled nursing facilities. The goal of the linkage committee, as it is called, is to improve transitions of care and identify best practices for the management of medically complex patients.

The group has developed a checklist of the information needed for a smooth hospital-to-nursing facility or hospital-to-home health transition. "We asked the facilities, 'What do you need to pick up the care of this patient we're sending to you?'" says Barb Stricker, director of care management services at HealthEast's Bethesda Hospital. "We can send no information, which isn't OK, but we can also send too much information, which is hard for facilities to review and find the key things that they need to take over the care plan."

Now the group is working on a transfer form that post-acute providers will use when they are sending a patient to the emergency department.

The collaborative approach allows acute and post-acute providers to improve care jointly for some of the frailest patients that hospitals treat, says Rahul Koranne, M.D., HealthEast's medical director of post-acute care services.

"There is some amazing work happening inside the long-term acute care hospitals, inside the home care agencies, inside the hospitals, inside the skilled nursing facilities and transition care units, and that's where our power lies," he says. "Don't think of the post-acute network as a black hole that cannot be defined, but treat its members as equal partners and work together to help the neediest patients who really deserve our attention and care."