What happens in post-acute care
Cari Levy, MD, PhD, who does hospital coverage and post-acute care for a number of facilities and home health agencies in the Denver area, calls the changes coming to SNFs a thrilling time for post-acute care.
“Suddenly medical professionals care about what happens in the post-acute world,” she said. “Everyone is now looking at the same measures. If this works the way it should, there would be a lot more mutual respect between providers.”
SNFs that are concerned about their readmissions rates will want to do root cause analysis to figure out what’s going on, Dr. Levy said. “Maybe the doctor didn’t do a good assessment. Maybe it was just a tough case. Once you start talking, you’ll develop systems to help everyone responsible. Hospitalists can be part of that conversation,” she said.
Dr. Jerome Wilborn
Jerome Wilborn, MD, national medical director of post-acute care for TeamHealth, Knoxville, Tenn., says his company is one of the largest groups tackling these issues. “And we’re aligning around these precepts very quickly. If I’m a hospital administrator, I’m already under the gun with readmissions penalties and with Press Ganey patient satisfaction scores weighing heavily on me. Medicare will be paying more based on value, not volume, so our income will be more dependent on our outcomes,” Dr. Wilborn said.
“You can have a good outcome at Shady Oaks and a terrible outcome at Whispering Pines, for all sorts of reasons. The hospital wants to make sure we’re sending patients to facilities that produce good outcomes,” he explained. “But there has to be communication between providers – the SNF medical director, the hospitalists, and the emergency department.”
A TeamHealth doctor in Phoenix has convened a consortium of providers from different care settings to meet and talk about cases and how they could have gone better. “The reality is, these conversations are going on all over,” Dr. Wilborn said. “What’s driving them is the realization of what we all need to do in this new environment.”
Opportunities from reforms
Robert Burke, MD, FHM, assistant chief of Hospital Medicine at the Denver VA Medical Center, is lead author of a study in the Journal of Hospital Medicine highlighting implications and opportunities from reforms in post-acute care.3 Hospitalists may not appreciate that post-acute care is poised to undergo transformative change from the recently legislated reforms, opening opportunities for hospitalists to improve health care value by improving transitions of care, he noted.
Dr. Robert Burke
“Most post-acute care placement decisions are made in the hospital,” Dr. Burke said. “As hospitalizations shorten, post-acute care utilization is rising, resulting in rapidly increasing costs. Bundled payments for care improvement often include a single payment for the acute hospital and for post-acute care for up to 90 days post-discharge for select conditions, which incentivizes hospitalists to reduce hospital length of stay and to choose post-acute alternatives with lower costs,” he said.
“My sense is that payment reform will put pressure on physicians to use home health care more often than institutional care, because of the cost pressures. We know that hospitalists choose long-term care facility placements less often when participating in bundled payment,” Dr. Burke said. “I think few hospitalists really know what happens on a day-to-day basis in SNFs – or in patients’ homes, for that matter.”
According to Dr. Burke, there’s just not enough data currently to guide these decisions. He said that, based on his research, the best thing hospitalists can do is try to understand what’s available in post-acute spaces, and build relationships with post-acute facilities.
“Find ways to get feedback on your discharge decisions,” he said. “Here in Colorado, we met recently with the local chapter of the Society for Post-Acute and Long-Term Care Medicine, also known as AMDA. It’s been revealing for everyone involved.”
He recommends AMDA’s learning modules – which are designed for doctors who are new to long-term care – to any hospitalist who is entering the post-acute world.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010 Jan-Feb;29(1):57-64.
2. Brennan N et al. Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents. The CMS Blog, 2017 Jan 17.
3. Burke RE et al. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017 Jan;12(1);46-51.