By Lauren Phillips

Two health systems are building continuing care networks with local post-acute care providers-with the goal of reducing readmissions and positioning for bundled payment.

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To achieve a seamless continuum of care, many hospitals and health systems are making progress in aligning with physicians. Just as important to care coordination are partnerships with post-acute care providers, including skilled nursing facilities and home health agencies.


Close working relationships with these providers will be a key success factor as hospitals prepare for readmission penalties, accountable care, and bundled payment. Hospitals discharge 40 percent of their Medicare patients to post-acute providers, but for the most part, hospitals have not made significant efforts to coordinate the care received there, let alone monitor or try to enhance its quality, says Kathleen Griffin, PhD, national director, post acute and senior services, Health Dimensions Group. As a result, some 18 percent of post-acute patients are readmitted within 30 days (see the exhibit below).


While there are several options for hospitals looking to enhance relationships with post-acute providers-including ownership, joint ventures, and management service organizations-the most common will be continuing care networks (CCNs), says Griffin. A CCN is an informal but structured way to pull together a group of providers to work in concert to achieve a number of benefits:

  • Reduced readmissions
  • Decreased post-acute care costs
  • Physician alignment
  • Reduced leakage
  • Improved continuity and quality of care
  • Higher levels of patient and caregiver satisfaction

Two early examples of CCNs illustrate the development process, best practices, and challenges associated with finding and cementing appropriate post-acute care partnerships.

Access related article: Bringing Post-Acute into the Fold  

Access related sidebar: Identifying Post Acute Care Partners   

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Making a Virtual Connection

Detroit Medical Center (DMC) includes eight acute-care hospitals and multiple outpatient facilities, but it owns just one post-acute care provider: the DMC Rehabilitation Institute of Michigan (RIM), an inpatient rehabilitation facility with 35 associated outpatient therapy sites.

"With the exception of RIM, all of our post-acute care is provided by independent, nonaffiliated providers in the community," says Linda Alexander, RN, MBA, administrative director of post acute services and physician relations at DMC. "Until recently, we had not really coordinated the care of patients we sent to those facilities. But we've been researching health reform expectations for a couple of years, and we really started looking at post-acute care and its impact on readmissions in June 2010."

After rejecting make-or-buy options for reasons of time and capital, DMC decided instead to form what it calls a virtual connection, using a joint operating committee to pull together trusted post-acute partners it already had in the community.

"The committee keeps everybody on the same page and allows for an open dialogue about patient care on an ongoing basis," says Alexander. "We look at outcomes and best practices together, we monitor performance and patient progress together, and we talk about community resources and how to tap into those together. Before we wouldn't have known if post-acute venues were up to our quality standards because we hadn't set any expectations. Now that we have, we hope our post-acute care partners will be eager to meet them. Having a joint operating committee also allows us to identify problems or barriers early on and figure out what needs to be done to solve those problems." 

It's a large committee. Hospital representatives include the vice president of medical affairs, the discharge planning leadership team, hospital administrators, and directors of nursing. Recently, representatives from ancillary areas, such as radiology, infusion clinics, and vascular labs, were added to the committee so the post-acute care providers can have direct access to these services, bypassing the emergency department.

The committee meets once a month, as does the internal steering committee of all the hospital representatives. "So every two weeks, at a minimum, we're meeting on this topic," says Alexander. "Right now, we're working to improve our hand-off communications to ensure a smooth transition to the next stage of care, and we're developing a quality dashboard of all our partners. We are also looking at data integration possibilities."

Leveraging Community Resources

HealthEast Care System in St. Paul, Minn., is a fully integrated healthcare system with three short-term acute care hospitals, clinics, and an emergency medical services division. It also owns a long-term acute-care hospital (Bethesda Hospital) and a home health agency, and has part ownership in a skilled nursing facility.

HealthEast is currently working to further extend its post-acute reach. "We've been working together collaboratively to align post-acute care services with the system for a number of years, well before health reform and accountable care came into the picture," explains Cathy Barr, MBA, RN, CEO of Bethesda Hospital and vice president for community care management for the system. "We know we can't provide all the services for the patient, so we've been working with our community partners to develop linkages to help us manage patient care across the entire continuum, from highest to lowest acuity."

HealthEast conducted an inventory of the independent agencies to which it commonly discharges its patients requiring post-acute care services, and came up with a short list of its most frequent partners. It does not have contractual relationships with those agencies. What it does have is a cross-functional linkage committee, which brings together executives from the independent home care and skilled nursing facilities with representatives from the HealthEast system, including care management, social services, hospital administrators, chief nursing officers, and the director of finances for post-acute care services.

The idea, says Barr, "is to leverage resources already out there in the community in a hardwired fashion because duplicating current capacity is going to do nothing to bend the cost curve."

The committee meets quarterly to share best practices, discuss protocols for medically complex patient populations, review data and dashboards, and identify service barriers. For example, HealthEast discharges a large number of patients with ongoing respiratory problems, says Rahul Koranne, MD, medical director of post-acute care services for the system. "So we talked with our transitional care unit and our skilled nursing facility partners. In response, several of them went back and advocated for the addition of a respiratory therapist and other needed clinicians to their staff.

Now our patients are getting a much higher quality of care when they move to the next step along the continuum."

Bethesda Hospital was among the first long-term acute care hospitals to start benchmarking quality metrics against national statistics, says Koranne. HealthEast is pushing its community partners to do the same by providing support for those efforts.

Getting Systems and People Talking

One of the barriers to putting together an effective CCN is being able to share clinical information in a timely manner to "put the patient's story together," as Koranne puts it. At HealthEast, this is a work in progress.

"One of the first things we did was to talk about exactly what information the post-acute agencies need from us when we discharge a patient to them, and we developed a standard discharge checklist that we are using now. But the need to exchange data extends right through the patient's journey along the care continuum, where everyone has a different IT system."

Download web exclusive tool: HealthEast's Post-Acute Discharge Checklist (subscription to Strategic Financial Planning required)

HealthEast has an electronic health record (EHR), and Bethesda's case managers, hospitalists, and specialists all have access to acute care records when a patient is transferred from an ICU, explains Koranne. "The same thing is true with skilled nursing facilities and home care. Our systems can't yet talk to each other fully, so there's no auto-population of the fields. But staff at the post-acute facilities we use most often have access to HealthEast information through our physician portal."

Another challenge for CCNs is steering patients toward partners with known quality without usurping patient choice, especially in an area like Detroit that is saturated with skilled nursing facilities. Physician alignment is a major asset in this context, says Detroit Medical Center's Alexander.

"We educate our patients about the benefit of a continuum of care," she says. "We tell them who to call if they need help and support, and we stress the importance of following up with their physicians and keeping appointments. We also let them know that we have physicians in certain facilities.

"It's very important that you understand your physicians' partnerships and objectives-and that they understand yours," continues Alexander. "And it's critical that the physicians help develop the care protocols for the CCN so they can help drive care to that standard. We're fortunate in that a lot of our physicians are participating in the Michigan Pioneer ACO, so they have a vested interest in improving quality and controlling costs in the post-acute care setting."

Once the hospital, physicians, and post-acute partners have adopted the care protocols currently under development, says Alexander, the hospital will need to have some mechanism for regular visits to the post-acute organizations to ensure the protocols are used consistently. "We're talking about having our people round at those facilities," she says.

Dealing with Complex Cases

One of the most important functions that CCNs need to work through, collectively, is the best way to deal with
problematic patient populations. At HealthEast, says Koranne, they were particularly concerned with the highest complexity patients. "These are the patients who come to the ICU and then go to a post-acute setting. These patients often are taking 15 to 30 medications and have as many medical problems. These are the patients with multi-organ failure, disabilities, dysfunctional families, mental illnesses, chronic diseases, poverty, etc.

"Any ACO that wants to control its utilization and costs needs to not only have a medical home model to take care of prevention, but it also needs to have a strategy to take care of these very complex patients following hospitalization."

For example, what is the best discharge option for patients needing extensive wound care? "A transitional care unit in a skilled nursing facility may be reluctant to take them because their staff isn't clear on the nursing requirements and clinical pathways," says Koranne. The same is true with some patients with behavioral health issues.

HealthEast's cross-functional linkage committee was able to come up with a solution. "That's the beauty of a multidisciplinary team where you can break down the barriers and solve problems quickly," says Koranne. "We were able to develop programs to support these patients when they leave the short-term acute care hospital. We did site visits, shared best practices, and helped train staff, and we have ongoing meetings to try and enhance performance."

Mitigating Risk

What advice would these CCN pioneers give to hospitals and health systems coming up from behind? The first thing, says Alexander, is to come to terms with the fact that you're going to have lower inpatient volumes as you work to reduce readmissions. "That's some of the risk you have to calculate, and each hospital will have its own strategy for making up that revenue." Hospitals often find it difficult to work with something they don't control, says Alexander, so it's important to understand the dynamics of the participating organizations, their resources, current usage patterns, and care protocols.

"Once you've seen one skilled nursing facility, you've seen one skilled nursing facility," she says. "One facility may have an all-RN staff or an RN on every shift. At the next, the director of nursing may be the only RN in the facility. One skilled nursing facility may have mid-level providers who come in three or four days a week to manage patient care, while another may rely on a single physician who rounds once every 30 days. But by and large, skilled nursing facilities don't have acute care resources, so we can't impose acute care expectations on them."

Finally, Alexander says, for competing organizations to be comfortable sitting down together on a committee, it's essential to preserve the integrity of their proprietary information. "For instance, when they submit their readmission data to the hospital, we share that information as part of our outcomes reporting, but not by facility. We blind it."

Identifying the Right Services

The #1 recommendation of the team at HealthEast: Avoid reinventing the wheel. Start by thoroughly assessing your own organization, says Barr. "Determine what post-acute care services are readily available internally and how these might be leveraged and enhanced. Identify the gaps, and then see if these are being filled in the community-and how you can make the connection for your patients."

For example, nationally on average, 12 percent to 14 percent of patients discharged from the hospital are sick enough to need home health care and are eligible for the services. But when HealthEast looked at its own referral patterns, two of its three acute care hospitals were discharging a lower percentage of patients to home health.

"We developed a plan of action," says Koranne, "in which our executives and case managers talked with our counterparts at the home health agencies to identify any barriers keeping our patients from getting home health. The biggest barrier, we found, is that acute care hospitals don't think beyond the nursing home. We need to educate ourselves about all the different aspects of the post-acute industry and how to capitalize on them."

Barr says it's a big mistake for a health system to try to do everything for its patients. "First, all that overhead may well cancel out the increased revenue. Also, these core competencies are hard to develop. At Bethesda, we have one of the highest ventilator weaning rates in the nation, with not a single ventilator-associated pneumonia in the last year. But we've been at this for decades.

"You have to look beyond the financial ROI at how you're going to develop the proper clinical pathways, attract physicians with expertise in caring for very sick patients, find the nursing staff and respiratory therapists-and then form linkages with other providers." It's better to home in on services that your patients need and that nobody is providing, and invest your resources there, he says.

Looking Ahead

Alexander says DMC is working on applications for bundled payment programs now, and ways to leverage its experience and expertise to encourage the post-acute providers in its network to participate. "That way, we'll be able to monitor progress on an ongoing basis and trend our results over time."

One trend that seems here to stay, regardless of what happens with health reform, is the use of post-acute networks to extend quality and cost control measures throughout the patient care continuum. It's all about the right care at the right time and the right place, says Barr.

"We have good readmission rates, but we're continuing to work on new programs and transitions of care within our CCN. You're never really done; you can always improve."

Lauren Phillips is president, Phillips Medical Writers, Ltd., Bellingham, Wash., and a frequent contributor to Strategic Financial Planning (

Interviewed for this article:

Linda Alexander, RN, MBA, administrative director of post acute services and physician relations, Detroit Medical Center, Detroit (

Cathy Barr, MBA, RN, is CEO, Bethesda Hospital, and vice president for community care management, HealthEast Care System, St. Paul, Minn.

Rahul Koranne, MD, is medical director of post-acute care services, HealthEast Care System. 

Publication Date: Wednesday, May 30, 2012