Acute care hospitals are the hub of the inpatient care network: They are the “mother ship” from which post-acute care facilities admit patients and to which they send patients when necessary. These facilities, acute and post-acute, are interdependent, collectively responsible for delivering safe, reliable, consistent and quality care in their communities.
Yet in many cases, interfacility relationships are best described as informal or even casual. Team members often do not document or even explicitly discuss mutual objectives and expectations; even if they do, agreements can become lost in the shuffle of administrative turnover and shifting circumstances. The upshot is that hospitals typically lose control over patients and the quality of their care after discharge. Too often, hospital administrators fail to anticipate the consequences of sending patients to (and admitting them from) post-acute care facilities with which they have undefined or distant relationships.
The Affordable Care Act is designed to make effective interfacility relationships an imperative. This interdependence may be codified in formal relationships connecting various points along the continuum of care, such as electronic interfaces, shared staffing or preferred partnerships.
Here are eight steps that acute care hospitals can take to develop closer relationships with their post-acute care neighbors, deliver better patient outcomes and lay the groundwork for a smooth transition of care:
1. Set up site meetings at each PAC facility where your patients are regularly admitted and discharged. Include in those meetings both the senior administrative team and medical staff from your hospital and the facilities you visit. Present your business objectives and, in turn, attain a solid understanding of the PAC’s business model, without preconceptions. Schedule these meetings periodically, at least annually. Share feedback, make constructive suggestions for improvement and hold individuals accountable for following up.
2. Encourage the medical staff, especially physicians, to take a leadership role in these meetings to ensure that the focus is on improving transition of care. Doctors should review in advance with their discharge planning team all recommendations and options offered to their patients. While it’s essential to offer patients a choice about their care after discharge, recommending a specific PAC facility may be justified because of medical necessity and evidence-based care. Patients respond well to specific recommendations when the information is presented to them in this context.
3. Set up an evaluation system for each PAC facility where your hospital’s patients go after discharge. Create a series of key metrics by which you can grade each facility. For example, a hospital would list all skilled nursing facilities in its catchment area and grade them on a scale of 1 to 5, evaluating the condition of the physical facility, readmission rates, quality and access of medical staff, patient satisfaction scores and other factors. Assign a weight to each of these criteria and develop an overall ranking for the PACs in your area. In the interest of transparency, share your evaluations with all the PACs, as well as your own medical staff and discharge planning teams.
4. Track your patients’ post-discharge progress. When patients are discharged from the PAC facilities, ask those facilities to send a copy of the discharge documents to the hospital. The documents should be sent when the patients leave the PAC facility and should indicate where they are going as well as provide an update on their medical condition and an updated list of medications. You may want to establish criteria for stratifying your discharged patients by levels of acuity or diagnosis-related group and arrange to track their location as they move through their episode of care. Patient tracking software, already in use on a limited basis, will enable your hospital to track patient retention rates (and “leakage” rates) as a proxy for measuring patient satisfaction and loyalty. Patient tracking can be highly useful for forecasting future patient volumes and resource requirements.
5. Ensure that prior to hospital discharge, the attending physician reviews a patient's medication regimen for potentially adverse interactions and for unnecessary medications. For a patient leaving the hospital, this is the best and perhaps only opportunity for a physician to complete such a review. Ideally this task is performed by the discharging physician in consultation with the discharge planning team. Once the meds list goes to the PAC facility, those orders will need to be filled quickly, and the new admitting physician may not be available. Recently discharged patients are especially vulnerable to polypharmacy, and the likelihood of a resolution greatly diminishes once they leave the hospital. It is in the hospital’s and patient’s best interest to address this issue, as readmissions due to adverse drug events and polypharmacy are avoidable.
6. Encourage the PAC facilities to install an electronic health record system if they haven’t already done so. New health care reform legislation is prompting acute care hospitals to require more objective, quantifiable and transparent measures of both performance and quality data from PAC information systems. PAC facilities are several years behind hospitals in developing this capability, but many are committed to EHR implementation over the next several years. It is important to understand the specifics of their EHR plans and intentions, with an eye toward interoperability and ease of use. Assess whether the PAC facility’s EHR plans are realistic. Also, seek assurances that the PAC facility is following sound clinical documentation procedures and that a workable system is in place for sharing health records in a manner that is responsive, accurate and reliable.
7. For each PAC in your community, select a hospitalist on your medical staff to serve as a liaison. This hospitalist may be employed by your hospital directly or by an outsourced practice. The physician liaison should get to know the facility well and round on patients there on a regular basis, ensuring there is good agreement between the hospital and PAC facility. The liaison should meet regularly with the facility’s medical director and assess the director’s commitment to spending time in the facility, rounding on patients and delivering quality and performance. The liaison should establish the director’s PAC experience and qualifications and ask what other clinical affiliations the director has. The liaison should ask how the director trains, educates and communicates with the PAC’s medical staff, including doctors and nurses who round in the facility on a limited basis.
8. Study the pattern of patient referrals between your hospital and each PAC facility in your area. Keep track of how many patients your hospital sends to and receives from each PAC facility. Get down to the details of who is making those referrals and the supporting documentation for those decisions. Sometimes a PAC will develop a reputation for excellence in caring for patients in specific DRG groups; understand the post-acute care clinical landscape in this regard. Seek assurance that decisions on patient referrals are solidly grounded in evidence-based care and not on the basis of personal relationships.
In the drive toward value-based care and bundled payments, hospitals will become increasingly accountable for the quality of care delivered to their patients at all points along the care continuum — before hospital admission (or readmission), during their hospital stays and after discharge. A deeper level of hospital-PAC facility engagement will become a necessity in building the architecture for a population health management program in the community.
By implementing the eight steps above, health care administrators will be better prepared to take an interdisciplinary, comprehensive approach to health care management based on population and community health. Achieving a more meaningful level of engagement with their community’s PAC facility partners is an important step for hospital leaders intent on meeting this important goal.
Todd J. Kislak is a health care consultant based in Los Angeles.