If hospitals or others seek to bring order to this chaos, scripting the patient's passage through all these varying modalities is essential, something that can be done with a post-acute protocol. According to the American Hospital Association, only 28 percent of hospitals reported using a post-acute “continuity of care” program in 2014. So much work lies ahead.
But scripting isn’t enough. Someone needs to be in charge of assuring that the script is followed. In two of the three surgeries I experienced, I — with my family — was the “owner” of the post-acute phase, with consequent confusion about when and where to connect with the care system. In the first two surgical episodes, this confusion was compounded by the logistics of medical tourism — returning home from care 500 miles away. I remained in contact with my surgical teams if I had questions, but my family and I had to manage the day-to-day logistics of the post-acute process as best we could.
In the third case, though, the replacement of my left hip here in Charlottesville, ownership of the post-acute phase of my episode was unambiguous. To my and my family’s great relief, the owner was my orthopedic surgeon. Historically, the surgeon’s clinical responsibility ended at the door of the operating theater. For my young surgeon in this instance, however, a successful surgery meant an event-free return to functioning. She used a "rapid recovery" protocol that required two home visits a day beginning the morning after my discharge: one to begin the rehabilitation of the joint and the other to make sure that post-op complications such as bleeding, infection or problems with blood pressure or dizziness did not arise. She received reports on my condition from my home visits and was in direct contact by text if issues arose. Her aggressive surveillance of my recovery continued for almost a month.
It is important to add that my surgeon’s motivation in doing this was not obviously financial or incentive-driven; she neither received bonuses nor was paid extra for her attention to my recovery. While her hospital is participating in the new Medicare Comprehensive Care for Joint Replacement bundling model, the details of how clinicians are connected to the hospital under this program were not worked out at the time of my surgery. Rather, her reward was that there were no readmissions or postoperative infections and that she earned glowing patient satisfaction scores and future referrals of friends and family members.
The patient experience
Many health systems are counting on the patient’s primary care physician to fill the coordination vacuum. They are scheduling post-discharge visits with the patient’s primary care physician, in major part to avoid readmissions. While this is not as rigorous as using a post-acute protocol, it has proven effective in many ACOs — hospital- or physician-sponsored. This referral returns patients to the place where historical information about them and their risk factors is likely to be richest. However, even the best primary care providers often do not understand the full requirements of post-operative care, and the connection with the surgical staff is often less than optimal.
Alternatively, many health systems are beefing up their discharge planning function with post-acute care managers who take on caseloads generated by the hospital. There is also a new generation of care coordination firms such as NaviHealth as well as established multimodality post-acute providers such as Kindred Healthcare that are seeking to fill the post-acute coordination vacuum on behalf of employers and health plans.
Hospitals seeking to fill this vacuum face multiple hurdles. One is the hospital’s historical cultural bias toward acute medicine; the post-acute world is terra incognita for many traditional hospital organizations and their physicians. Another hurdle is the understandable anxiety of post-acute providers about the hospital or its representatives becoming gatekeepers to their services. The post-acute community may be highly fragmented and competitive, but its members view the hospital as an octopus extending its tentacles into their incomes and professional spheres. The ability of hospitals to selectively contract with post-acute providers also is impeded by freedom of choice provisions in the Medicare law that guarantee patients the right to choose their post-acute providers.
The spread of bundled payment is going to force hospitals and their clinicians to make more explicit who owns what comes after acute care. Ultimately, it may not be the economic rewards associated with managing care under the bundle that drive health systems toward establishing ownership of what comes after acute care. As with my hip surgeon, the more lasting reward for caregivers will come from strengthening patient loyalty and guaranteeing a first-class patient experience.
Jeff Goldsmith, Ph.D., is the president of Health Futures Inc. and associate professor of public health sciences at the University of Virginia, Charlottesville.