Connecting Acute Care with Post-Acute Care

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Ever wonder what would be the biggest cost reduction for your hospital? Doesn’t everyone! In a recent survey by the American Society for Quality (ASM™), results showed that reducing readmission rates would have the most significant impact on reducing U.S. healthcare costs.1 Data also supports that there has been a slight downward trend in readmissions: 18.4% in 2012 as compared to 19% from 2007 through 2011.2

Already realizing a readmission penalty of 3% for 2014, CMS has an answer to drive outcomes: utilize the ever-present penalty system to motivate hospitals to improve rates.2 However motivated they may be by penalties, hospitals still have a difficult time analyzing the root cause for readmissions, especially since causes for readmissions vary by as much as 60%.3 The prevailing thought has been that preventing readmissions is out of the hospital’s control. With the advent of EMR and the ability to utilize data to drive better patient care outcomes, savvy hospital administrators are now partnering with post-acute leaders to develop a strategy driven by information exchange to prevent these costly readmissions and the resulting disruption to the patient’s overall well-being.

This is a monumental challenge, so where to begin?

Success has already been realized by involving the patient with a facilitator from post-acute while the patient is still in the acute facility, ultimately streamlining the transition process from acute to post-acute. One-on-one contact and personal conversation has helped to ensure the patient understands the plan and that the plan has all of the “right” elements for successful transition to post-acute care: the right staff, right services and right equipment.

In addition to this personal contact with the patient before transition, additional elements of the strategy have been executed to optimize the communication connection between acute and post-acute care, resulting in fewer admissions and better outcomes.

Share data to enhance knowledge. Information exchange between the acute and post-acute is critical at the point of transfer, though what facilities may not recognize is the importance of continuing that information exchange throughout the entire timeline of care. Sharing information between physicians, acute care providers, and post-acute care providers enables all involved to evaluate symptoms and progress in order to track patient improvement and augment care plans across the continuum.
Use technology to support care protocols. Use technology-supported protocols to direct decisions and increase the probability of ongoing, sustainable reduction in readmission rates. Data collected due to these protocols can also assist in future cooperative development of care improvement initiatives.

Leverage data and analytics to improve quality. Sharing quality metrics information that the hospital is responsible for helps the post-acute care provider set similar expectations and assist the hospital in collecting relevant data. Integrating acute care and post-acute care systems provides for a full patient care overview, enabling development of new protocols for specific populations based on previously experienced outcomes.

While integrating information from acute care to post-acute care may seem like an overwhelming challenge, it is possible. Even if acute care and post-acute care EHRs are not integrated, post-acute care facilities can still use resources such as open web-based systems, software vendor partnerships, and cross-continuum quality improvement programs to assist in tighter integration and efficient communication with acute care referral sources.

Quality improvement programs, like INTERACT® (Interventions to Reduce Acute Care Transfers), can help skilled nursing facilities implement cross-continuum communication tools to reduce potentially avoidable hospitalizations. With proper training on how to use the INTERACT tools, skilled nursing facilities can improve readmission rates by targeting three key strategies:

Prevent conditions from requiring acute hospital care, Manage selected acute conditions in the nursing home with collaboration from the acute care facility, and
Improve advance care planning for residents for whom a palliative comfort care plan is appropriate. Incorporating technology with strong staff education can help post-acute care facilities better partner with their referral sources to safely reduce unnecessary hospital transfers and hospital readmissions.

What are you doing to partner with the acute care facilities in your continuum to reduce readmissions? Share your thoughts and successes below!




About the Author
Sue MacInnes

Sue MacInnes

Sue MacInnes is Medline’s chief market solutions officer. With more than 30 years of healthcare experience as a clinician, chief executive and thought leader, MacInnes is driving new strategies designed to help Integrated Delivery Network (IDN) systems successfully manage integration, cost, quality, and outcomes as well as patient preference, loyalty and awareness.

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