Building a Post-Acute Network to Facilitate Patient Throughput

Recently, Meher Singh and Molly Shane from UCSF Health presented as speakers for our ongoing post-acute thought leadership series. Singh and Shane explored strategies health systems can employ to build a post-acute network and achieve the Triple Aim—improving the patient experience of care, improving the health of population, and reducing the cost of healthcare—across the entire care continuum. A summary of their discussion is below; you can view the slides and a full recording here.

Assessing the Environment and Evaluating Alternatives

With the implementation of the ACA, the formation of ACOs, and alternative payment methodology, there’s a national trend toward fewer and shorter inpatient stays. More patients are being discharged earlier from the hospital and are expected to complete recovery at a lower level of care. This shift is changing the post-acute care landscape.

Ignoring the national or even state trends, however, and understanding the unique challenges of local environments is the best place for health systems that want to build a network to start. Define your community, evaluate your organization’s internal resources – both inpatient and outpatient – and obtain and properly assess the data for your community.

Next, explore appropriate solutions for providing efficient care across the continuum – like forming an accountable care organization (ACO) or a collaborative.

Considerations on Collaborative and Contracts

On the most basic level, collaboratives dramatically improve communication between hospitals and post-acute facilities, and by improving communication you’re also likely to improve overall patient care. Beyond that, there are three significant outcomes that support the creation of collaboratives:

  • Quality and safety – coordination with post-acute providers can drive better clinical outcomes and reduce readmissions
  • Value – discharging patients to a safe post-acute environment reduces the cost of care and opens the door for the health system to participate in risk-based programs
  • Patient experience – seamless care transitions improve patient satisfaction and build loyalty toward the health system

Many federal healthcare reform initiatives – bundled payment programs, the hospital readmission reductions program and SNF value-based purchasing programs – encourage and require collaboration between organizations at various levels of care.

Developing Post-Acute Relationships

Now it’s time to select post-acute partners for the collaborative. To inform selection of partners, first:

  • Identify post-acute gaps – perform a needs assessment, interviewing case managers, social workers, and others involved in the discharge process to understand pain points and challenges
  • Review existing resources – internal resources may include an office of population health or a health navigator, and external resources may include senior centers, hospice, or other community programs
  • Analyze the data – look for trends and areas of opportunity around denials, outcomes for certain diagnoses, and congested units of the hospital

With this complete picture in mind, you can begin to gauge interest and enlist new post-acute partners. Options for partnerships and post-acute solutions run the gambit from easy to implement (e.g., spending money on low-cost, non-traditional partners like non-medical home care or assisted living) to very difficult (e.g., a collaborative involving multiple hospitals, organizations, and the county)—and everywhere in between.

Regardless of the solution, build appropriate infrastructure to support these new post-acute relationships.

To learn more about how UCSF built its post-acute network, and which pitfalls to watch out for as you build yours, download the complete webinar recording.