The Changing Landscape of Post-Acute Care

Historically after a patient had a hospital admission, they were discharged home to recover on their own. Hopefully they were able to understand and follow doctor's orders for recovery and not have to be readmitted to the hospital. At best, they might have a check-up appointment a few weeks later for follow-up care.

Since the advent of the DRG (Diagnosis related groups) payment system by CMS in the early 1980's, hospitals caring for acute stay Medicare patients have had significant incentive not to keep those patients in the hospital any longer than absolutely necessary. This change in payment policy, along with the rise in importance of facilities and services that could assist these patients after hospital discharge (Skilled nursing facilities, inpatient rehabilitation facilities, and home health agencies), have led to rapidly growing healthcare costs in the “post-acute” portion of the care continuum. 

Fortunately, post-acute care (PAC) has come a long way. Healthcare systems and providers across the country are now focused on PAC. This is improving patient outcomes, reducing costs and preventing avoidable readmissions.

More than 28.6 million adult patients were discharged from hospitals in 2014, and 33% of those were referred to some level of post-acute care. The right facility or provider choice for PAC matters both in terms of their speed of recovery, costs, and quality of care including overall health outcomes. Post-acute care can be provided at home, in skilled nursing facilities, inpatient rehabilitation care, and long-term acute care hospitals.

Patients may also use more than one type of PAC in a single episode of care. For example, a patient discharged from a skilled nursing facility may then receive additional services at home, including home health, outpatient PT/OT, DME or home infusion. During the PAC continuum patients will require coordination of all PAC services. 

Home healthcare is the most frequently used PAC. In 2013, about 3.5 million Medicare members discharged from a hospital stay were receiving home health services, while 1.7 million members were discharged to skilled nursing facilities. A report by the Institute of Medicine indicates that readmission rate for home health is 18.1% while the readmission rate for skilled nursing facilities is 22%.

One 2016 study profiled in The Journal of Post-Acute and Long-Term Care Medicine (JAMDA) found that of 3,246 acute hospitalizations followed by PAC facility stays, 739 (roughly 23 percent) included at least one hospital readmission. The largest reason for readmission included impaired function, due to non-compliance with PAC discharge recommendations.

PAC Utilization Improvement Efforts

Post-acute care is important in reducing the sheer number of readmissions through some of the following actions:

• Appropriate referral for a patient based on their diagnosis to a PAC provider or facility based on outcome metrics-specific to that provider
• Use of home health or nursing facilities to identify potential at-risk patients for intervention before an emergency room visit or hospital admission occurs
• Collaboration between hospitals, home health providers and skilled nursing facilities to create a patient centered care plan to avoid a potential readmission.
• Since PAC provides the biggest opportunity to reduce cost, improve care and quality of life, it's become the central focus in the fight against readmission rates.

Experts think as many as two-thirds of readmissions are avoidable, and the biggest causes include:

1. A poorly planned or lack of understanding by the patient and/or caregiver of the discharge plan

2. Lack of care coordination between the PAC transitions including follow-up visits

3. A lack of information sharing and communication between patient and the physician and care providers. 

4. Early warning signs of a patient's worsening condition, medication adherence and reconciliation on a timely basis.

5. Insufficient quality of care or lack thereof at home, where the care provider may not be skilled or educated in the discharge plan. 

6. Discharged patients often go home alone without support.

The timing of PAC also matters; for example, according to a paper on PAC by the Chartis Group, patients who spend an extended time in a skilled nursing facility or inpatient rehab may incur higher costs than if they had been discharged directly home or home with home health services. 

A CMS initiative used to avoid readmissions targets preventable readmissions with the penalty program introduced by the Affordable Care Act. Nearly 75% of acute care providers have been penalized for “excess" readmissions in the first 2 years of the CMS Readmissions Reduction Program. Private payers are likely to follow this trend towards the application of penalty.

Keeping Patients Out of the Hospital

Increasingly more patient care is taking place outside the hospital setting. The use of transitional care management nurses are also being utilized to employ a more coordinated team approach to effectively reduce hospital readmissions.

These patient advocates are skilled at assessment, education, medication management oversight, and communicating with care providers and families to help resolve any identified warning signs with early interventions before they become emergencies. One of the most common reasons for the readmission of patients within 30 days of PAC, is medication-related incidents. These can be caused by a poor understanding of treatment plan by patients or family or noncompliance with medication regimen, poly pharmacy, or accidental overdose. 

No matter what direction or strategy the healthcare systems take or already have in place, they must also consider how to effectively use their resources and assess how PAC can deliver higher value and achieve savings across the care continuum.

EviCore understands the importance of PAC and the need for organizations to be more actively involved in managing their population to keep patients out of the hospital. PAC must allow a successful transfer of care responsibility from the hospital to the care team, which allows for improved outcomes for the patient and overall reduced costs for the Health Plans and members.