Leveraging Post-Acute Care to Address Acute Readmissions

For most hospitals impacted by readmission penalties, post-acute care represents a key bulwark in improving readmission performance and reducing penalties under CMS’ Hospital Readmissions Reduction Program. Two out of every five Medicare fee-for-service acute hospital patients are discharged to post-acute care, and most of these to either a skilled nursing facility or home health agency. As we shift from volume to value, our relationships with post-acute organizations become critically important. However, collaborating with post-acute providers is unsure ground for many.

If you are thinking about confronting your readmission challenges, here are some key thoughts about selecting and engaging more directly with post-acute partners.

Post-Acute Provider Capabilities

All post-acute providers are not the same, and the typical hospital will historically refer to 20 or 30 different providers with little regard for quality or outcomes. Winnowing this list down is an important first step. Start with the “choice list” you most likely give to patients headed to post-acute care. You’ll want to sort through this accumulated collection of nursing homes and home health agencies and start strategically downsizing. Using publicly-available quality data, surveys, or even direct visits to providers, identify which providers show measureable quality and are clinically prepared to address your readmission challenges. Understand what kind of physician coverage they have (or will need), and discuss the disconnects that currently exist between your organization and them. Combine your findings and rank providers based on your organization’s needs. If the process of selecting quality providers seems daunting, seek assistance from someone with post-acute knowledge and experience. At the end of this process, you should have identified a list of key organizations that have the right skill sets (or the ability to learn) and can partner with you to address readmissions. This is the beginning of your network.

Redesigning Post-Acute Discharge and Transfer

With the beginning of a network in hand, you can get to the meat of leveraging post-acute to tackle readmissions. The bulk of post-acute discharged readmits typically bounce back in 48-72 hours or less, so re-thinking the acute to post-acute discharge and transfer process represents a key starting point for changing behavior. What happens just before acute discharge and right after post-acute admission often involves many steps, but here are three important areas that usually benefit from greater review and redesign:

  • Universal Transfer Documentation – The volume of information transferred from acute to post-acute (whether via paper or electronic means) is oftentimes chaotic and inconsistent. Practices can vary a lot: there can be wide variation among acute discharge planners about “what to send” and post-acute provider preferences for “what they want.” Standardizing the transfer is an important step towards consistency. Working in collaboration with your network, evaluate the current range of behaviors and re-design a universal process that everyone will use. Eliminate all of the unnecessary forms and data to focus on essential information that supports and informs the transfer. A standardized checklist as a dedicated cover sheet is often helpful and provides a tangible reference for both sides.
  • Readmission Risk Assessment – Stratifying discharges for their risk of readmission has been a results-oriented solution for many organizations, and acute and post-acute organizations can draw from a handful of simple scoring tools to help. One excellent example is the LACE index scoring tool. LACE evaluates four aspects of patient condition or behavior, including acute length-of-stay, if the acute admission occurred via the emergency department (“ED”), patient comorbidities, and ED visits in the preceding six months. The combination of these four results in a score ranging from one to 20, with higher scores indicating increasing likelihood of readmission. Patients who score at high risk (commonly 10 or greater) are noted appropriately at transfer and the readmission risk score is shared with the admitting post-acute provider.
  • Warm Hand-Offs – Direct communication among caregivers in a defined setting can be challenging enough, but interaction across settings is sometimes entirely non-existent. Improving (or daresay requiring) communication via warm hand-offs among physicians, nurses, and case managers is absolutely critical – even with a foolproof integrated electronic health record solution. Within 24 hours of patient transfer (either prior to or soon thereafter), an acute hospitalist should confer with the post-acute attending (commonly called a “SNFist”) or attending physician to review hospital care, discharge orders, and priority areas of concern that might lead to a readmission. Absent physician interaction, an acute RN case manager should connect with the post-acute intake nurse or case manager. Establishing a specific protocol about what should be communicated during the hand-off is helpful in reinforcing a change in behavior.

Understanding post-acute provider capabilities and redesigning practices around discharge and transfer represent mere opening steps in a longer journey of utilizing post-acute care to leverage readmission issues. In a future post, we’ll take a closer look at the role of care management in post-acute settings, reinforcing multi-disciplinary thinking across the continuum, and the post-acute to home discharge process.

The Camden Group, Hospital Readmissions, Readmissions Reduction

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