The Transition to Post-Acute Care: A Challenging Juncture in the Patient Journey

Imagine coming to the end of a hospital stay and expecting to go home, and instead being told that you need to spend two more weeks continuing to recover in a nursing home. While this would be an atypical experience for the general population, it’s a harsh reality for many Medicare patients. More than 40% need post-acute care following a hospital stay. So how do patients and families find a facility that’s the right fit, one that’s not only geographically convenient but that also has a bed available, takes their insurance, offers desired amenities, and meets their clinical needs?

Unfortunately, more often than not, patients are simply handed a paper list of provider names and addresses during the discharge process. They have a very short window of time to select a facility, and they are given little to no contextual information to help them make a choice. This process is also blind for the case managers who are tasked with facilitating post-acute referrals. They too suffer from lack of information. Why is this critical juncture in the patient journey so challenging, and what is being done to streamline the transition to post-acute care?

The Patient Perspective

The Medicare population—high-risk, aging patients requiring complex disease management—needs post-acute care for a variety of reasons. Cognitive issues, atrophied muscles, inability to complete the activities of daily living safely, or some combination of these and other risk factors often make it unsafe for Medicare patients to go straight home after a hospital stay. Here are two prime examples.

  • Penelope: Penelope is 66 years old and suffers from kidney failure. She was admitted to the hospital through the ER due to an infection from dialysis, which she has been doing at home. Although the infection is now under control, because she lives alone and is also managing a mental health issue, her doctor doesn’t feel comfortable sending her back home.
  • Mary: Mary is 97 years old and was recently diagnosed with Alzheimer’s. After discovering that she fell at home, her son brought her to the ER, where she was admitted and then had surgery for a hip fracture. Because Mary needs help with daily tasks such as bathing and dressing and her son lives over an hour away from her, Mary’s doctor recommends that she receive rehab at a skilled nursing facility.

Both of these patients have been given a list of facilities within a 15-mile radius of their homes and been asked to select a few they’d be willing to go to, but neither Penelope nor Mary know how to make the choice. Penelope is afraid her mental health will be mismanaged if she goes to the wrong facility. In Mary’s case, her son is actually the one making the decision, and he thinks that it’s more important for Mary to be close to him than her home, which she may not return to due to her dementia.

The Case Manager’s Perspective

Tom is the case manager who is tasked with helping Penelope and Mary make the decision about post-acute care, but he faces similar challenges. It takes diligence and detective work—conducted primarily via telephone and fax—for him to find out which nursing homes are a fit clinically, which have beds open, which accept these patients’ insurance, and which have 4- and 5-star quality ratings from CMS. Not to mention which facilities fit each specific patient’s requirements. In Mary’s case, Tom needs to consider proximity to family and look for a locked dementia unit. In Penelope’s case, he has to find facilities with adequate mental health support that offer dialysis. Like these patients and their families, he’s working on a tight deadline, under pressure from the hospital to decrease length of stay for his patients. In addition to Penelope and Mary, Tom is responsible for 50 other patients, a high percentage of whom need post-acute care. He’s a diligent worker and a strong patient advocate but always feels behind.

Overcoming Challenges with Technology

The transition to post-acute care is bumpy for many reasons, the main one being that post-acute care was a neglected area of healthcare for a long time under fee-for-service reimbursement. With the rise of value-based care models and risk-based contracting, however, healthcare organizations now have an incentive to pay attention to this end of the continuum. For the first time, hospitals, health systems, and payers have a vested interest in post-acute care and that has created a demand for technology that streamlines the transition from the hospital to these settings.

Closing the loop on the patient scenarios above, Penelope, Mary, and Tom can all benefit from this technology. With an automated tool that is capable of running targeted searches on facilities across the nation, Tom can generate much more comprehensive and appropriate lists of potential post-acute facilities to share with Penelope and Mary. He can comply with the IMPACT Act and facilitate informed patient choice, not just for Penelope and Mary, but for his entire Medicare panel. No longer bogged down by the administrative burden of calling and faxing facilities and waiting for responses, Tom will also be able to spend more time with his patients. He can appease Penelope’s fears about her mental health treatment, and he can adjust Mary’s search so that it encompasses nursing homes near her son, as well as engages her son in the process. In just one day, he can do more to support Penelope and Mary than he previously would have been able to do in a week. He can increase patient engagement, improve patient outcomes, and decrease the likelihood that Penelope or Mary will be readmitted to his hospital.

Learn more about the cutting-edge technology that bridges the post-acute care gap and helps both patients and providers.