The charge toward fee-for-value health care has accelerated the emergence of post-acute medicine, a medical provider model not bound by traditional delivery locales or roles. For certain population segments, bringing medical care out of acute and ambulatory settings and into the community is de rigueur. It delivers timely access and collaborative, team-based care — both required for success in a future defined by value.

Focus and Rationale

Post-acute medicine delivers care in community-based and other nontraditional settings. It ensures that a “patient-centered health neighborhood” is created for the chronically ill, often frail patients post-acute medicine providers serve. The settings include the patient’s place of residence, such as the home or assisted living facility, as well as the skilled nursing facility and, increasingly, complex care clinics. The focus is not only on delivering comprehensive primary medical care, but also on addressing the nonmedical needs of patients to ensure the best outcomes.

For hospitals and health systems, a post-acute medicine strategy can leverage services such as home health, hospice, transition programs and complex care clinics as well as integrate the “silos of excellence” that often characterize highly successful but disjointed programs. Post-acute medicine offers the direction and coordination an organization needs to extend its reach beyond the acute setting and flourish in a value-based environment — in which traditional roles and silos are giving way to integrated care partnerships.

Post-Acute Medicine Explained

There are two main categories of post-acute medicine: longitudinal primary care and episodic care. Longitudinal primary care seeks to create a patient-centered health neighborhood around the patient, including house calls in the home or assisted living facility.

Episodic care is for patients who are likely to successfully bridge the period from discharge to a visit in a primary care office, but who need more care for 30 to 60 days. Episodic care involves transitional care, skilled nursing facility specialists and complex care clinics. These programs are excellent complements to existing transitional care programs, such as those based on the models of Eric Coleman, M.D., or the Society of Hospital Medicine’s BOOST program — Better Outcomes by Optimizing Safe Transitions — or are part of the Centers for Medicaid & Medicare Service’s Community-Based CareTransition Program initiatives. They offer a level of intervention and coordination for medically complex and frail patients not suitable for these less-intensive transitional care programs.

While more in health care are appreciating the role of medical providers in skilled nursing facilities and in-home care, complex care clinics are also gaining recognition. These clinics focus on medically complex, chronically ill but ambulatory patients immediately after they have been discharged. Timely primary care follow-up visits after discharge have been shown to be essential for successful outcomes. Often, though, access to primary care can be a challenge. Even with access, the patient’s situation, including the need to coordinate an array of services — many of which address nonmedical needs — can tax a busy primary care office.

Physicians and advanced practice providers (nurse practitioners and physician assistants) are prominent in post-acute medicine. However, to achieve desired outcomes, an interdisciplinary team of health professionals representing the diversity of the target patient’s needs is required. Other key disciplines include social work, home health, nutrition and care management. To ensure a high-functioning team, the medical provider does not assume a role of team leader in a traditional sense, but rather the team’s player-coach. While addressing the medical needs is essential, the medical provider also ensures that team members are proactively involved, are working at the top of their license and are delivering all facets of care collaboratively.

While the language of post-acute medicine is evolving, it encompasses all medical provider types. Terms used today by providers include SNFists, or skilled nursing facility specialists, residentialists, medical house call providers and palliative medicine providers.   

Integrating a Post-acute Medicine Program

Health systems with employed, independent or hybrid medical staffs can develop a post-acute medicine strategy. However, because of the prevalence of provider employment models as well as the pervasiveness of advanced practice providersin post-acute medicine, many systems have employed providers to run these programs.

The growth of post-acute medicine makes identifying independent, community-based providers rather easy in most markets. Look to dedicated medical house call practices, as well as the increasing number of home health agencies that are employing advanced practice providers,to offer a post-acute continuum solution to health systems and accountable care organizations. Providers that offer both episodic and longitudinal care can be found.

Post-Acute Medicine in Health Systems

Here are a few examples of health systems that are successfully deploying post-acute medicine strategies:

A Medicare shared savings plan ACO seeks to lower inappropriate readmissions for medically complex, chronically ill seniors by developing an episodic medical house call program and a complex care clinic.Complementing the existing Coleman-model transitional care program, the episodic medical house call program offers coordinated care in the homes of frail, low-mobility seniors who are likely to bridge the discharge period well, but who cannot be managed adequately by a primary care office during the transition. The complex care clinic provides the follow-up care, thus decompressing the system’s overburdened primary care offices. Readmission rates typically plummet with these programs.

A health system establishes a risk relationship with a Medicare Advantage HMO that is struggling to manage the top 3 to 5 percent of its highest-cost enrollees, thereby reducing costs and improving its star rating.The health system develops a longitudinal house call program to collaborate with existing health system post-acute care assets to create a patient-centered health neighborhood for these chronically ill, often frail enrollees. Emergency department usage, admissions and readmissions are all reduced for this target population. While longitudinal medical house call programs have been well-suited for health systems with their own health plan, the recent increase in commercial ACO partnerships between health systems and payers has seen a marked rise in such programs.

A health system creates a preferred network of skilled nursing facilities in response to developments in value-based payment, such as the mandated Comprehensive Care for Joint Replacement Model and the Medicare Spend per Beneficiary.This network enables the health system to select skilled nursing facilities that will offer smooth transitions, superior outcomes and a competitive-cost profile. As part of this initiative, the health system starts a SNFist practice of a couple physicians and several advanced practice providersto offer not only timely access to regular medical visits in the facilities, but also to ensure best practice team collaboration and fidelity to the integrated care delivery model.

Assessing Organizational Readiness

Post-acute medicine is emerging as a key strategy for health systems while value-based payment models reshape care delivery. By extending the health system’s reach outside of traditional locales and enabling medical providers to integrate with other key health and social service providers, post-acute medicine will position health systems to flourish in an environment defined by outcomes. Here are some questions to consider in conversations with your management team:

Does your health system have a defined post-acute strategy? Do your post-acute services, vendor and partner relationships and joint ventures position your organization for success in value-based relationships? Post-acute medicine is not a strategy by itself. It needs to be a component of a robust post-acute strategy that includes a coordinated suite of owned, vendor- and partner-contracted, and joint-ventured services to ensure your organization’s success.

What understanding does your primary care physician base have of post-acute medicine? Do they view it as a threat to patient volume or as an asset to enhance the care, outcomes and cost profile for select patients?Key to the success of a post-acute medicine program is not only acceptance by the primary care physician base, but also significant support from each physician. Education often is required to ensure that primary care physicians understand which patients post-acute medicine seeks to serve. Education also demonstrates the extraordinary benefit afforded to the patient and the primary care physician, as well as to the overall health system.

How are advanced practice providers integrated into your health system? Are they valued partners in care delivery?Advanced practice providers are foundational to post-acute medicine. They care for the patient in all settings, and they are instrumental to the team’s effectiveness as well as to care model transformation. Advanced practice providers must be valued by the primary care physician base, and by the health system itself, if post-acute medicine is to have credibility and find success.

Is your health system committed to managing the unique clinical and operational dynamics of post-acute medicine programs? Is your organization prepared to devote the necessary resources to ensure success? Post-acute medicine is unique in many respects: It is not a volume-driven business. It requires extraordinary care coordination and team collaboration. And it has operational demands that are different from the traditional office setting. Your organization must manage post-acute medicine programs and dedicate appropriate resources to reflect this unique nature. Only then will you be positioned to realize their full potential.

Brent T. Feorene, M.B.A., is the vice president of Health Dimensions Group in Westlake, Ohio.