Alternative payment models for value-based payment, including the comprehensive care for joint replacement bundled payment model, put hospitals and health systems at risk for patient outcomes and the cost of care for a time period well beyond the acute hospital stay. With 42 percent of Medicare patients discharged to a post-acute venue, hospital executives must learn how to establish formalized partnerships with unaffiliated post-acute care providers and to create seamless continuing care models to meet the Triple Aim goals of improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost of health care.

Continuing care models

PAC venues provide recuperation and rehabilitation services following an acute hospital stay. Medicare considers post-acute providers to include skilled nursing facilities, home health agencies, inpatient rehabilitation facilities and long-term care hospitals. Specific rules and regulations govern admissions to each of these providers. The vast majority of post-acute care is furnished by skilled nursing facilities and home health agencies.

To effectively oversee and manage patients after hospital discharge, hospitals, health systems and accountable care organizations are forming post-acute care continuing care networks composed of preferred post-acute providers. While Medicare patients can choose their post-acute venue, acute providers are using “soft steering” — providing information to patients about quality outcomes and the integration of members of the PAC-CCN with acute care.

There are two critical success factors in establishing a PAC-CCN. First, hospitals must use a rigorous process in selecting their PAC-CCN partners. Second, they must establish a method for helping PAC-CCN members achieve targets related to patient outcomes, patient and family satisfaction, and efficiency, as well as for regularly and meticulously measuring and reporting on PAC-CCN members’ performance.

Before selection begins, a team of clinicians from the acute venue must be identified and dedicated to selecting and liaising with members of the PAC-CCN. The team often includes a physician champion, a PAC-CCN coordinator, a representative from case management and discharge planning and a nurse practitioner.

Selecting partners

The selection process begins with establishing PAC-CCN credentialing criteria. These criteria define the characteristics and minimal performance levels for post-acute providers to be accepted into the preferred network.

Typically, credentialing criteria are applied to the entire list of post-acute providers to which the hospital or health system has discharged patients over the previous 12 months. Decisions on compliance with the criteria usually are based on internal data from the hospital on the volume of patients discharged to specific post-acute provider venues and a request for information from, at minimum, the PAC providers that received the highest volume of discharges.

Credentialing criteria may include geographic access for all patients and easy access to the PAC venue (e.g., admissions 24/7 and start of home health within 24 hours of hospital discharge), compliance with federal and state regulations and lower-than-average survey deficiencies.

For skilled nursing facilities, credentialing criteria also may involve at least a three-star quality rating, a separate subacute unit for PAC patients with a registered nurse care provider 24/7, a ratio of at least one RN to 15 patients in the subacute unit, and the hospital or accountable care organization’s physicians and extenders serving as skilled nursing facility clinicians in the unit dedicated to PAC patients.

For home health agencies, the following credentialing criteria may apply: scores equal to or better than state average on the Medicare Home Health Compare website and recertification rates at the state average.

Many hospitals and health systems own one or more PAC venues, most often inpatient rehabilitation facilities and home health agencies. However, the hospital- or health system–owned venue may not cover the entire geographic market and may not have the capacity to admit all post-acute patients. Therefore, usually one or more additional PAC venues of the same type is added to the preferred network to ensure easy access for all patients.

After reviewing data returned by PAC providers, members of the PAC-CCN team should conduct site visits to the “short list” of PAC venues, using a standard questionnaire about nurse intake and continuing education, nursing competencies, medical management of post-acute patients, processes for initial assessment, care planning, discharge planning and post-discharge follow-up, and emergency room visits and rehospitalizations, as well as the ability to report performance on monthly metrics.

A partnership agreement between the selected members of the PAC-CCN and the acute care provider can outline conditions for continuing membership in the PAC-CCN. Often, this agreement incorporates the benefits to PAC venues of the partnership, such as materials used by hospital discharge planners to inform patients about the PAC-CCN, education provided by the hospital for PAC nurses and the potential for future shared savings with PAC-CCN members. A shared savings arrangement can be highly motivational for post-acute providers to optimize their quality and efficiency.

Care redesign

Careful and methodical selection of members of the PAC-CCN is only the first step. Successful PAC-CCNs also require a redesign of care to optimize patient outcomes, patient and family satisfaction, and efficiency throughout the acute and post-acute continuum. Ongoing engagement and dialogue between PAC providers and acute providers is essential.

In order to remain in the PAC-CCN, PAC providers should report on and be held accountable for the achievement of metrics important for patient care. Common target metrics include 30-day hospital readmissions, patient and family satisfaction ratings, emergency room visits within three days of admission to the PAC venue and scheduling of a primary care visit within seven days after discharge from the PAC provider.

Monthly or quarterly meetings among the PAC-CCN team and all PAC partners encourage discussion of issues and provide opportunities for care redesign. Redesigning care for a seamless continuum involves process re-engineering in both the acute and post-acute settings as well as improved transitions of care between venues. Medical reconciliation measures, transfer of patient information from acute to post-acute care and verification of end-of-life plans are examples of processes that may be revised through open dialogue between the acute and post-acute providers.

Transparently reviewing achievement of targets for monthly metrics helps identify gaps in post-acute nursing skills that can be addressed by measures such as opening the hospital’s in-service or other educational programs to post-acute nurses. For example, one health system in Ohio created a modified version of its nurse intake program in its PAC-CCN partners' skilled nursing facilities.

Health systems that have followed this rigorous process to establish and manage their PAC-CCN partnerships have reported positive results. After the first year of fully operational PAC-CCNs in three markets, Catholic Health Initiatives reported a reduction of 30-day hospital readmissions by 10 percent to 30 percent and a 10 percent drop in average length of stay in skilled nursing facilities.

Like any successful partnership, an effective acute and post-acute care continuum requires a well-thought-out and well-executed selection process as well as ongoing attention to the relationship between acute and post-acute providers to achieve the best outcomes.

Kathleen M. Griffin, Ph.D., is the president and CEO of Care Management Innovations LLC in Scottsdale, Ariz. Jade Gong, R.N., MBA, is the president of Jade Gong & Associates LLC in Arlington, Va., and a member of Health Forum's Speakers Express.