Q&A: Selecting Post-Acute Organizations for Joint Replacement Bundles

With mandatory bundles for joint replacement looming, many hospitals have worked through their financial impact analyses and sorted out their physician relationships. But it sounds like many have yet to develop a strategy for post-acute partners, especially selection tied to quality outcomes and post-acute clinical skill.

The comprehensive care for joint replacement ("CJR") initiative involves a 90-day episode of care, and the hospital component will typically involve only three or four of those days. Depending on the market, hospitals will likely need to consider both home health agencies and skilled nursing facilities as important players in their post-hospital continuum.

Hospitals often have a range of questions about picking post-acute providers. Here are some of the common questions that have crossed our inbox in the last few weeks.

Q: My hospital has reviewed our recent discharge data and determined that a lot of our post-acute discharges go to five providers. Can we just keep it simple and say these five are our partner group and leave it at that?

A: You could, but historical volume doesn’t always equal quality. In a lot of instances, it equals convenience. As you explore potential partners, there are three key things to consider:

  • Quality performance
  • Geography
  • Medical staff

There are ample options for learning about post-acute provider quality via state and federal resources – a fuller discussion is presented in the following question. Your hospital should look for providers in at least the top quartile of quality and seek out those who perform better than state and national averages. Second, consider the geographic distribution of post-acute providers in your service area. Discharging patients will want an option that is close to home or covers their community. Thus, balancing quality and geography is an important equation. Finally, you’ll want to make sure that your post-acute partners have consistent medical staff coverage that aligns with your patient needs. Skilled nursing facilities and home health agencies are required to have a physician as a medical director, but that physician oftentimes not directly involved in patient care nor following patients on a regular basis. Post-acute organizations can employ a range of physician models, some with open or closed staff models, or some using a “SNFist” – similar to a hospitalist but in a skilled nursing facility. You’re looking for post-acute partners with at least 30 hours per week of coverage, involving some combination of physicians and advance practice clinicians.

Q: What sort of resources can I access and what kinds of data should I review when it comes to selecting post-acute providers?

A: There are a number of resources readily available with information about post-acute organizations, especially skilled nursing facilities and home health agencies. Medicare’s beneficiary-facing website ( offers a range of information via its nursing home and home health compare tools. While much of this data is retrospective in nature, it can provide a good baseline around historical quality. It’s important to note, however, that a lot of the data regarding skilled nursing facilities is focused on aspects of long-term care and not on short-term, post hospital care. Other data that may be more pertinent to bundled payment is available via commercial data vendors or actuaries. If you’ve already completed any analysis about your organization’s costs and opportunity related to CJR, it’s likely that you should have some sense about who the high volume post-acute providers are, how long they keep patients with respect to benchmarks and how often they readmit patients. When considering post-acute providers for your discharges, post-acute length-of-stay is often the largest determinant of cost and should be an important data point for you. Readmission rates are also important.

Q: We’ve figured out which providers will be our network partners. Now we want them to follow our clinical protocols and perform. What’s the best way to get them on board?

A: While it’s probably easiest to just dictate terms and expectations, you’ll catch more flies with honey than with vinegar. One of the best ways to engage with post-acute providers is to acknowledge that they’re an essential part of your episode. Treating them like a true partner will get you halfway there. Beyond that, you should build the right infrastructure for ongoing dialog, education and problem solving. A dedicated workgroup or committee involving acute, post-acute and physician participants is essential. If you want post-acute providers to follow your protocols, sit down and work through the protocols together. Seek input from the post-acute organization about how their work meshes most appropriately with yours. Sort out how you will handle patient transfers, exchange data and report data. Meet regularly to address issues, share learnings and maintain the dialog. Most importantly, designate a resource in your organization to lead this effort. You’ll be happier for clearly-defined accountability, and the post-acute providers will always know who to call when they have questions.

Q: We obviously want to keep track of these patients after they’ve left post-acute. What’s the best way to do that?

A: For providers already down a value-based or population health road, keeping track of patients should flow automatically to your care management model. Absent this resource, you’ll want to create some kind of ad hoc approach that defines clear accountability and process for post-hospital/post post-acute follow through. You should consider some of the models around phone-based care management as a potential resource. Patient activation will play a key role – educating the patient about self-management or how to access support as needed. Post-acute providers can take on some of these function or assist, if you can create the right incentive for them take it on. One important requirement of CJR involves patient-reported outcomes. From an infrastructure perspective, your effort to gather this quality data from patients should ideally integrate with your patient monitoring efforts.

Q: We’re thinking about moving past a contractual arrangement with post-acute providers and are interested in exploring direct ownership or operation of post-acute. What do we need to know?

A: First and foremost, owning and operating post-acute carries as many challenges and pitfalls as any other healthcare business. How complicated can it be? Fairly complicated. Each post-acute setting currently retains its own unique payment system and regulatory framework. In some states, there are barriers to developing new post-acute settings; in other states, there are limitations about how you can move an existing provider from one geography to another. That said, there is a general spectrum of how hospitals and health systems can approach post-acute relationships, ranging from joint operating arrangements and networks through joint ventures and sole ownership. Each invites various pros and cons, and the right answer can be very organization and market-specific.

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