Cardiac Care Bundles and the Need for Post-Acute Partnerships

By Erin Byrne, Consultant, GE Healthcare Camden Group

Post-acute care continues to be an increasingly important component of the care continuum, as evidenced by the recently proposed expansion of CMS’s Episode Payment Models (“EPM”) focused on 90-day cardiac care episodes. More than ever, post-acute care providers are playing a crucial role in the care of patients across care settings, which is especially relevant to the current 90-day mandate for Medicare patients undergoing hip and knee replacements, as well as the newly proposed 90-day mandate for cardiac episodes, such as AMI and CABG.

Under this new value-based paradigm, successful management of risk and increased accountability for patient outcomes requires healthcare organizations to expand their focus beyond their individual care settings. This is especially true as it relates to post-acute care where a considerable amount of the total 90-day episode cost may be incurred. Through the proposed cardiac mandate, CMS is requiring hospitals to better control costs and decrease variability in service utilization patterns, which often is attributable to the post-acute portion of the episode of care. Acute care providers must prepare for the continued expansion of value-based payment arrangements by actively pursuing purposeful partnerships, strengthening care coordination and communication, and managing patients as they transition across the care continuum during their recovery.

Creating Purposeful Partnerships: Who Is the Right Partner?

Selecting partners is no simple task, and post-acute providers are no longer just referral partners. Hospitals must pursue post-acute care providers whose patient outcomes andclinical service capabilities will support value-based care under CMS’s cardiac EPM. With the clinical and financial responsibility of the patient’s care extending beyond the four walls of the hospital, hospital-based clinicians and their support teams have a heightened accountability for the quality of care being delivered in the post-acute setting. As such, skilled nursing facilities, sub-acute rehab facilities, home health agencies, and outpatient physical therapy providers are being closely evaluated for their ability to collaborate as well as their overall performance, including:

  • Performance on star ratings
  • Geography for convenience of the community or patient population
  • Medical staff that aligns with patient needs, with staffing coverage including physicians and advanced practice clinicians
  • Length-of-stay compared to benchmarks, the largest cost driver of post-acute spend
  • Readmission rates

CMS provides a range of resources and information on nursing homes and home health agencies in the public domain. Hospitals can utilize tools like Nursing Home Compare in their partner selection process, which provides detailed information about every Medicare- and Medicaid-certified nursing home in the country. Throughout the evaluation of post-acute care providers, a hospital self-assessment is also recommended to determine where patients are being referred and discharge to when they leave the hospital. Specifically, this assessment should consider length of stay in various post-acute settings, readmission rates, and how historical performance on these metrics compare to industry benchmarks.

Collaboration Across the Care Continuum

Proactive post-acute care providers will seize this opportunity to seek out partners, present their value proposition to hospital leadership, and collaborate with at-risk hospitals in the new value-based arrangements. Partners must collaborate to devise a cross-continuum strategy and implement new care models to support cardiac episodes from the time of hospital discharge through the patient’s full recovery. Once partnerships and post-acute care relationships are established, data and information will need to be shared and reported by acute and post-acute care partners including:

  • Deployment and adherence to evidence-based clinical pathways
  • Best practice protocols
  • Cost and utilization data
  • Quality measures
  • Patient-reported outcomes

Acute and post-acute partners must create cross-functional work groups to drive accountability and ensure adoption of protocols and best practices. Work group members should seek input from all post-acute partners about how work processes will most appropriately link together across care settings, solve problems, share learnings, and continue to improve collaboration.

Coordinating Care and Communication

Creating new lines of communication between multi-functional cross-organization teams is necessary to coordinate patient care throughout the 90-day cardiac EPM. A methodology and supporting infrastructure for ongoing information flow and problem solving must be developed to foster smooth care transitions and care coordination to deliver patient-centered care. These teams must sort out how each partner will handle patient transfers seamlessly to include all pertinent information, monitor patient adherence to clinical pathways, exchange and report data. Partners must work together to enhance use of care managers, information system integration, handoff protocols, and discharge instructions. The outcomes of this collaboration and planning will help guide care coordination, stratify hospital discharges by risk of readmission, complication or care plan non-compliance.

Hospital and post-acute care partners should assess resource needs to coordinate cardiac patients throughout the continuum, creating a comprehensive view as to how current or additional resources will work together in a revised, multi-partner care pathway to coordinate care incorporating post-acute care managers, SNFists, cardiac rehab clinicians, inpatient case managers, and cardiac services line leaders. Communication is important not only between care teams, but more importantly to the patient. Setting realistic patient expectations on how their episode will progress, while keeping the patient informed and involved in any revisions needed to their care plan establishes the patient at the center of the process, and should help drive better outcomes reported by patients on their actual experience of care.

Start Building Post-Acute Partnerships Now

Full episode and recovery planning must occur early and thoroughly to give patients a complete understanding of expectations of care before their surgery, while they are in the hospital, post-discharge and post-acute. Patient education should focus on self-management and support resources available to the patient and their care-givers. Identifying best practices to monitor patients’ care is crucial to manage risk of patient complications and potential readmission.

In today's value-based world, tracking patients throughout a bundle should be informed by the care management model. Patient outcomes will improve with monitoring and management of patient care throughout the 90-day bundle. Now is the time to begin the pursuit of aligned post-acute care partnerships. Pursing purposeful partnerships with post-acute providers are necessary to improve care coordination and communication to monitor and manage risks of bundle patients through CMS’s expanding Episode Payment Models.

Cardiac Care Bundled Payments

Byrne.jpgMs. Byrne is a consultant with GE Healthcare Camden Group, specializing in planning, strategy, and analytics in the bundled payment practice. She works with organizations to plan and implement bundled payment programs within Medicare, Medicaid, Commercial, and Employer markets. She may be reached at 




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