Because the pace of a PAC facility is slower and a patient typically stays in a PAC facility longer than at a hospital, there’s time for a hospitalist to have more in-depth conversations with patients and their families.
“Building a deeper relationship with a patient may give the hospitalist an opportunity to discover the cause of an acute problem,” Dr. Nazir says. “They can go in-depth into the psychosocial aspect of medicine and may be able to find out what led to the initial problem and the real root cause, which can help prevent future recurrences, such as repeat falls or forgetting to take a medication.”
5. Using EHRs can improve transitions.
Care transitions between a hospital and PAC facility can be compromised by a lack of information sharing, and they can affect the quality and safety of patient care, says Dori Cross, a doctoral candidate in health services organization and policy at the University of Michigan School of Public Health in Ann Arbor. Handoffs between providers require information continuity – information that is complete, timely, and in a usable format – to ensure appropriate medical decisions and to provide high-quality care during and after transition.
Electronic health records (EHRs) as well as health information exchanges (HIEs) allow providers to communicate and share patient information. For example, hospitals can send information electronically to PAC facilities (“push” exchange) or make information available online securely for PAC providers to log in and access (“pull” exchange). According to a 2014 survey data by the American Hospital Association, more than 50% of hospitals report sending structured summary-of-care records electronically to long-term care settings; a little less than half of those hospitals (23% of the total sample of hospitals) were also receiving information electronically from long-term care sites.1
“This bidirectional exchange, in particular, can make it easier to share information across provider organizations electronically and, in turn, improve care delivery,” says Ms. Cross, who authored an accepted paper on the subject in the Journal of Post-Acute and Long-Term Medicine.
6. Hospitalists can work with providers in PAC settings to improve transitions.
Despite improvements in the electronic transfer of medical information, gaps still exist and can cause problems. One chasm when discharging patients to a PAC facility, is when a hospital IT system is incapable of communicating with the PAC facility system. In this instance, Dr. Nazir says, the hospitalist “can help bridge the gap.”
“[We] can verbally relay relevant information to physicians at PAC facilities so they understand the patient’s status, needs, and expectations,” he says. “Furthermore, hospitalists and a PAC facility’s administration can brainstorm methods to improve the systems of care so the patient receives more effective and timely care.”
7. Hospitalists switching to the PAC setting should have formal training.
The two main obstacles for hospitalists who change from working in a hospital to a PAC facility are the lack of exposure to PAC work in training and the assumption that it requires the same skills sets of a typical hospitalist, according to Manoj K. Mathew, MD, SFHM, national medical director of Los Angeles–based Agilon Health. The PAC setting has quite a number of differences compared with a hospital setting. For example, some regulations apply specifically to PAC facilities. In addition to formal training, hospitalists can benefit from using SHM’s Post-Acute Care Transitions Toolkit, having a mentor, or using resources from other organizations that function in this space such as The Society for Post-Acute and Long-Term Care Medicine, Dr. Nazir says.
Dr. Manoj K. Mathew
Dr. Mathew points out that hospitalists working in a PAC setting should have specific skills sets that focus more on being a social worker, a care manager, and on dispensing palliative care than simply on being comfortable with acuity of illness. “Don’t assume that a good hospitalist is easily a good candidate to work in a skilled nursing facility [SNF],” he says.
8. A variety of payors and payment models are in play.
Commercial insurers continue to be major payors for PAC, especially for individuals younger than 65 years. Medicare and Medicaid, administered by the Centers for Medicare & Medicaid Services, are the primary payors for patients aged 65 years and older.
Gina Zimmermann
“Fewer patients are paying privately for PAC today than in the past,” says Gina Zimmermann, executive director of nursing care center accreditation at the Joint Commission in Oakbrook Terrace, Ill. “Bundled payments and value-based purchasing are becoming more of a reality for PAC, and it’s inevitable that originators of various bundled payment and purchasing arrangements currently in place or being developed are including some type of ‘scorecard’ process to help rank or judge the various providers that want to be involved in these arrangements.
“These scorecards are using a variety of criteria to rank providers, such as length of stay, cost, readmissions to hospitals, and quality.”
Because Medicare Part A covers many patients discharged to a PAC setting, any changes in payment incentives or benefit structures by the Medicare program will drive changes in PAC.
“For example, as Medicare implements payment adjustments for hospitals that have high rates of readmissions, hospitals have a new incentive to work closely with SNFs and other providers of PAC to ensure patients can avoid unnecessary readmissions,” says Tiffany A. Radcliff, PhD, a health economist and associate professor in the department of health policy and management at Texas A&M University School of Public Health in College Station.
Providers must follow the billing rules for each payor. The rules for Medicare payments are outlined on CMS’ website. Bundled payments for PAC under the Medicare Part A program are scheduled to be implemented by 2018.