Collaboration in Post-Acute Care

In recent years, post-acute care has become an increasingly essential piece of the healthcare delivery system.  From 2001 to 2013, Medicare post-acute spending more than doubled, hitting a total of $59 billion in payments to post-acute care providers.  In 2014, more than 28.6 million adult patients were discharged from hospitals, with 33% being referred to some level of post-acute care.

Clearly, the amount of patient care taking place outside of the hospital setting is growing rapidly.  As the number of dollars being spent on post-acute care services continues to increase, so does the pressure to smoothly guide the patient from hospital discharge to home environment, taking care to avoid any unnecessary readmissions.  This transition to post-acute care is an extremely critical phase for both patient and caregiver, and, if poorly managed, this period can result in setbacks to a patient's recovery.

So how can we create the most seamless transition possible for the patient?  Here are some of the steps healthcare organizations are taking right now:

- Developing strong partnerships with post-acute care providers (e.g., inpatient rehab facilities, long-term acute care hospitals, skilled nursing facilities, and home health agencies)

- Identifying the most appropriate post-acute care setting for each patient, which starts with recognizing the patient's unique clinical situation

- Employing an evidence-based approach to care management, which furthers the ability to tailor each patient's plan to his or her individual needs

- Integrating health plan, patient, and provider activity, which requires a high degree of communication, collaboration, and the sharing of information among entities

- Establishing methods that engage both the patient and caregiver in care decisions.

A Common Thread

All of these strategies have a common thread running through them: collaboration.  Healthcare organizations are becoming more actively involved in managing their patients to ensure that they receive the most appropriate setting and type of care.  Gone are the days when a patient was simply discharged from the hospital and sent home with fingers crossed.  Now, transitional care teams can guide patients through the healing process, from discharge, to the most appropriate post-acute setting, to the home.  Nurse case managers work with the post-acute care facility case managers and a discharge planning team to determine the best path of care for the patient, and support the staff in transitioning the patient to his or her next site of care.  These managers are skilled at assessment, education, and medication management oversight, and they communicate with care providers and families to help resolve any identified warning signs with early interventions before they become emergencies.  As the patient's condition improves, the care team can ensure that he or she progresses toward established short- and long-term goals.

Beyond the Basics

A good post-acute care solution also directly engages patients and their families to help them understand the clinical, psychosocial, and environmental factors that may impact rehabilitation.  Asking questions about the patient's resources, health literacy, daily activities, and home environment is vital to tailoring a care plan to the patient's real-life circumstances outside of the hospital.  Further, the care plan should be updated continuously, based on any changes to the patient's condition, home environment, or other relevant factors.  It's also important to be creative with methods of engagement: in-person visits, telephonic coaching, and secure email are all methods that can be appropriately used to keep lines of communication clear and open.

Served by a team of professionals and an individualized plan for recovery, patients today are much better equipped upon leaving the hospital.  As post-acute care continues its current upward growth trajectory, healthcare organizations must also continue to foster collaboration and accountability within their post-acute care solutions.