• Bridging Acute and Post-Acute Care

    Laura Ramos Hegwer Nov 06, 2013

    Health systems recognize they cannot go it alone and are partnering with post-acute providers to achieve higher quality and lower costs. 

    Today, heart failure patients at the skilled nursing facilities (SNFs) that partner with North Shore-Long Island Jewish (LIJ) Health System receive similar protocol-driven care and treatment while at home in the SNF as they would if they were admitted to the hospital. By following a standardized protocol developed by North Shore-LIJ inpatient nurses, SNF staff are better equipped to care for patients—and keep them from returning to the hospital.

    The push for more coordinated care is why North Shore-LIJ and other health systems around the country are making partnerships with post-acute providers a strategic priority. Accountable care organizations (ACOs) and other providers are assuming more financial risk (i.e., under bundled payment and other value-based payment structures) when they assume cross-continuum responsibility for entire patient populations.

    Attacking post-acute care costs is becoming a common tactic under these arrangements, which makes sense given that post-acute costs are growing faster than any other category of Medicare spending (Chandra, A., et al, “Large Increases in Spending on Postacute Care in Medicare Point to the Potential for Cost Savings in These Settings,” Health Affairs, May 2013, vol. 32, no. 5, pp. 864-72).

    Another motivating factor is the financial penalties for hospitals with high 30-day readmission rates. More than one-fifth of all hospital discharges to SNFs are readmitted, which costs Medicare $4.34 billion a year (Mor, V., et al, “The Revolving Door of Rehospitalization from Skilled Nursing Facilities,” Health Affairs, January 2010, vol. 29, no. 1, pp. 57-64).

    With quality and cost savings as key drivers, several forward-thinking health systems are reaching out to post-acute providers that share the same philosophy and patient-centered goals. Together, they are working toward better communication, smoother patient transfers, and standardization of care.

    Case Study: Improving Continuity for Better Quality

    A drive to improve quality across the continuum was what triggered North Shore-LIJ, a 16-hospital system with a service area of more than 7 million, to develop a continuing care network of non-owned, post-acute providers focused on better care coordination in 2008. A continuing care network is an informal but structured way to pull together providers to work together on a number of objectives, such as reduced readmissions, decreased post-acute care costs, and improved quality of care.

    “Since the majority of system discharges were going to nonsystem facilities, partnering with these subacute providers became a priority to ensure continuity of care across the continuum,” says Maureen McClusky, FACHE, executive director of North Shore-LIJ’s Stern and Orzac Centers for Rehabilitation. She also oversees the system’s affiliations with post-acute providers.

    Selecting the SNFs. Leaders at North Shore-LIJ assessed potential post-acute partners using several quality metrics, such as nurse staffing ratios and star ratings on Medicare’s Nursing Home Compare. They also reviewed geographic proximity to system hospitals, referral patterns, and other criteria. From a list of 266 potential facilities, the health system selected 19 for its SNF affiliate network.

    When developing its affiliate agreement, the health system chose to focus on quality, not on creating a financial link between the organizations, McClusky says. In the agreement, the health system and SNF agree “to work together to identify areas where they can seek to improve the safety, quality, and efficiency of care transitions.”

    Improving quality together. One of the first quality initiatives that the health system and SNFs collaborated on as a group was implementing an advance directive tool across the continuum. Called the Medical Orders for Life-Sustaining Treatment (MOLST), this New York state initiative helps staff better understand patients’ end-of-life preferences across the continuum of care. It is similar to the national program, Physician Orders for Life-Sustaining Treatment (POLST). Between 2008 and 2010, the partners increased MOLST orders by 40 percentage points, from 10 percent of patients to 50 percent.

    Soon after, they worked together on a standardized treatment protocol for SNF patients with heart failure. Heart failure is often tricky to manage in a SNF setting because symptoms can worsen rapidly and the patient can be relatively asymptomatic until the situation is critical, according to Howard Guzik, MD, FACP, senior medical director of SNF services, North Shore-LIJ Health System and the Stern Family Center.

    Nursing leaders from North Shore-LIJ helped affiliated SNF staff implement a variation on the hospital protocol that includes patient assessment on every shift by an RN (who is on duty 24/7), daily weights, a low-sodium diet, frequent monitoring of vital signs, pulse oximetry readings, and other components.

    “This joint initiative has successfully improved quality across the continuum and fostered a greater partnership between the hospitals and affiliate SNFs,” Guzik says. Guzik credits the standardized care for helping reduce the heart failure rehospitalization rate within the SNF affiliate network from approximately 6 percent in 2010 to 2 percent in 2012.

    Better communication and collaboration have also reduced the all-cause readmission rate within the network from approximately 13 percent in 2010 to 7.5 percent in 2012. But there is still some room for improvement, Guzik says. To that end, North Shore-LIJ plans to roll out a universal transfer form by the end of 2013. The standardized form will help staff capture critical patient information to ensure smooth hand-offs between the hospitals and SNF affiliates.

    Standardized Heart Failure Care

    Reporting what matters. Selecting the right metrics has been critical to North Shore-LIJ’s ongoing efforts to standardize care and improve quality across the continuum. To identify and define what to measure, leaders turned to their system’s data analytics division.

    The division developed a set of 26 metrics, including: 

    • Long-term care mortality rate
    • Long-term hospitalization index
    • Total readmission rate within 30 days
    • Total readmission rate within 72 hours
    • Total short-term readmission rate within 30 days

    SNFs in the affiliate network report their facility- specific data each month using a web-based reporting tool developed in-house. The tool automatically calculates the key rates associated with the data—such as mortality rates and 30-day all-cause readmission rates—and creates reports that allow affiliates to compare their numbers to the network average.

    During quarterly meetings, high-performing facilities discuss their strategies with other affiliates in the network. The aim is to “benchmark and share best practices in an environment of mutual trust and support,” McClusky says.

    Parker Jewish Institute for Health Care and Rehabilitation, New Hyde Park, N.Y., was the first SNF to join North Shore-LIJ’s affiliate network. Since then, staff at the 527-bed SNF have reported smoother care transitions, says Michael N. Rosenblut, president and CEO.

    “Understanding what the clinical pathways and the expectations are, and gaining more precise information from North Shore-LIJ have helped us deliver better care,” Rosenblut says. “When our physicians or nurses have a question about a treatment protocol for one of the patients, we are able to get the right person on the telephone at North Shore-LIJ, who can explain what the expectation is and what they told the patient. We rely on them, and they rely on us,” Rosenblut says.

    Having a closer relationship with the system was also an advantage during Hurricane Sandy. When Parker took in nearly 40 evacuees from other facilities, North Shore-LIJ was able to assist with equipment and resources to care for the displaced residents.

    Preparing for bundled payments. Health system leaders expect that all of this groundwork will help North Shore-LIJ as it prepares to participate in several Medicare Bundled Payments for Care Improvement (BPCI) initiatives, which include post-acute care. Members of its SNF affiliate network will be included in one of the models of care.

    Case Study: Partnering for Accountable Care

    In December 2011, Indianapolis-based Franciscan Alliance, which has 13 hospitals in Indiana and Illinois, was awarded a Pioneer ACO contract. After doing a deep dive on three years of Medicare fee-for-service claims, ACO leaders realized they had an opportunity to improve post-acute care transitions for their 20,000 attributed Medicare patients, says Jenny Westfall, regional vice president, Franciscan Alliance ACO.

    “We wanted to communicate better with post-acute providers that were receiving our patients, and we needed some quality measures in place so they would be accountable if patients were readmitted,” Westfall says.

    120 days to partnership. In late 2012, Franciscan Alliance ACO set out to develop a continuing care network of providers to help them manage patients in the post- acute care portion of the care continuum. It started by reviewing the top 20 high-use, post-acute facilities in its community based on 12 months of discharge data. After gauging providers’ interest and reviewing their quality metrics, ACO leaders invited six SNFs, one long-term acute care facility, one home health agency, and one acute inpatient rehabilitation facility to participate in their continuing care network.

    Together, the facility and ACO leaders designed the quality metrics that would document post-acute care progress on an ongoing basis, including new metrics that providers were not already reporting to the state, such as catheter-associated urinary-tract infections (CAUTIs) and patients scheduled to be seen by a primary care provider within seven days of post-acute setting discharge. Additionally, they are asked to report and monitor progress on returns to the ED within 72 hours of post-acute admission, inpatient readmission rate, readmission to acute care within 30 days of post-acute discharge, and average length of stay in the post-acute setting.

    From start to finish, building the continuing care network took just four months (see the related sidebar). 

    Better communications, better care. With the network in place, ACO leaders recognized that they had a unique opportunity to smooth transitions by improving communications between acute care and post-acute providers, says Joseph LaRosa, MD, MBA, the ACO’s medical director. One priority was getting patients’ hospital records to their post-acute partners more quickly.

    “Indiana doesn’t require physicians to send discharge summaries to post-acute facilities for seven days. That is the standard, but we realized that was way too long,” LaRosa says. “Now, hospitalists must complete discharge reports before patients leave the hospital, and these reports are transferred with the patient to the post-acute facility.” SNFs also can tap into the system’s electronic health record (EHR) to get hospital records and lab reports on patients, which improves care coordination.

    24- to 48-hour follow-up. ACO leaders hired a dedicated care coordinator and clinical nurse specialist for the network to monitor patients along the continuum of care. Once it is determined that a patient will most likely require a post-acute facility, the care coordinator (who is a nurse) visits with the patient and their family at the hospital. Within 24 to 48 hours of discharge to a provider in the post-acute care continuing care network, the patient receives a visit from the care coordinator to ensure the care plan is being followed. The clinical nurse specialist regularly monitors the quality measures and assists the network participants to implement processes and optimize practices to achieve expected outcomes.

    Although patients and their families are free to choose a facility outside of the continuing care network, many choose network facilities. One benefit they cite is the network’s policy of having a Franciscan Alliance care management team visit patients at post-acute facilities within 24 to 48 hours of admission, as well as the ongoing monitoring provided by the post-acute setting, says Kim Kolthoff, BSN, RN, CPUR, director of integrated case management and clinical services. “Families perceive that choosing a provider in the continuing care network is a benefit to their loved ones because the ACO is measuring the quality of post-acute care and helping to manage patients’ care after they leave the hospital.”

    Case managers on-site. The ACO post-acute transitions care coordinator visits the patient within 24 to 48 hours of inpatient discharge, guides the continuing care network facility staff in weekly care plan meetings, and helps facilitate whatever needs the patient might have after discharge through the design and implementation of a transitional plan of care. He or she also works cooperatively with the system’s case management team as needed. One example is when an ACO patient at a network facility is readmitted to the ED. The facility’s case manager will work with a case manager from the hospital’s ED to create a discharge transition plan.

    Better medication management. Franciscan Alliance ACO has organized a medication reconciliation workgroup for its continuing care network partners, led by the system’s director of pharmacy. The ACO is also piloting a program using pharmacists to conduct medication reconciliation at the time of discharge. The goal is to reduce duplicate medications and prevent dangerous drug interactions.

    Staff engagement. The ACO’s early efforts to improve continuity of care have had a positive impact on the Franciscan Alliance system overall, leaders say. “One of the benefits of building our continuing care network was that it got our system’s management team engaged,” says Jay Brehm, the system’s senior vice president for strategic planning and business development. “The ACO had been viewed as a pilot that only a few people understood. But the continuing care network has gotten more people involved in our accountable care strategy, which is fundamental to our goal of developing a team approach to caring for patients.”

    Case Study: Integrating with the Community

    Like Franciscan Alliance, OSF HealthCare, an eight- hospital system in Peoria, Ill., also views collaborations with post-acute providers as a critical piece of its Pioneer ACO strategy. “Our focus has been on how to play better together,” says Tara Canty, COO for accountable care and senior vice president for government relations. “We are trying to achieve better integration in our system and at the same time, work on better integration within our community.”

    With 51 accredited medical home sites and one EHR that connects inpatient, physician, and home care sites, OSF already had a strong foundation for its ambulatory care management program. It wanted build a similar program for patients moving from the hospital to a skilled nursing facility, and the ACO gave it an opportunity to experiment.

    SNF standards. With better community integration as its goal, OSF launched a preferred skilled nursing network with 17 member facilities in late 2012. These members are required to meet the following standards:

    • Overall rating of four or five stars from CMS
    • Quality rating of three, four, or five stars from CMS
    • Registered nurses on-site 24/7
    • Ability to start IV lines 24/7
    • Ability to admit patients within two hours

    House calls to SNFs. To make sure that ACO patients receive the therapies they need across the continuum, OSF employs a dedicated physician who rounds at facilities in the preferred network each week as well as four advanced registered nurse practitioners who visit the facilities nearly every day.

    The SNF staff appreciates these “house calls” because the physician and nurse team can respond to acute issues, such as confusion and UTIs, says Stephen Hippler, MD, vice president of quality and clinical programs for OSF Medical Group. “When there is a status change, the nursing home is in a tough position,” he says. “Someone needs to assess the patient. All too often, it has been the ED and the hospital doing this assessment. We are able to do that on-site through the dedicated team.”

    To identify older adults at high risk of readmission, OSF uses an assessment tool based on the Society of Hospital Medicine’s Better Outcomes by Optimizing Safe Transitions (BOOST) project. OSF’s care transitions risk assessment tool includes “8 Ps” to assess during transitions:

    • Presentation of patient
    • Patient support
    • Poor health literacy
    • Psychological issues
    • Prior hospitalization
    • Principal diagnosis
    • Palliative care
    • Problem medications

    These strategies have helped bring readmissions from the SNFs down from 27 percent in 2012 to 11 percent in 2013. Visits to the ED also have been cut by more than half.

    Learning from Pioneers

    The leaders involved in building post-acute networks shared the following lessons on how to make them work:

    Choose your strategy. If health systems cannot serve their market with their existing post-acute assets, a continuing care network that includes owned and independent facilities is one option. For those that own a comprehensive post-acute portfolio, another option is a management services organization (MSO). In an MSO, the system manages its hospitals’ post-acute operations.

    Get support from the top. Partnering with post-acute providers requires buy-in from senior leaders, including physicians, who understand the value of collaboration. Case in point: The oversight committee for Franciscan Alliance’s continuing care network includes the director of emergency medicine, the head of the hospitalists group, and geriatricians.

    Understand what moves post-acute providers. Like acute care providers, SNFs want what’s best for the patient. Collaborating with hospitals can help them smooth transitions, which ultimately improves patient satisfaction. Being in a select network also can help them boost their reputation and keep their occupancy high with a regular influx of new patients at a higher reimbursement level.

    Share your GPO savings. North Shore-LIJ allows SNFs in its affiliate network to purchase discounted drugs through its GPO. The goal is to allow for standardized care and treatment across acute and subacute organizations while creating savings.

    Implement care paths. North Shore-LIJ encourages members of its SNF network to use standardized care paths for UTIs and other conditions to improve quality of care and reduce unnecessary readmissions.

    Consider requiring round-the-clock RN staffing. Some SNFs are simply not staffed to care for today’s higher- acuity patients, such as those on ventilators or who require extended wound care. Requiring 24-hour nurse coverage was a priority for OSF and Franciscan Alliance when selecting its post-acute partners.

    Make data transparent, but nonthreatening. At quarterly meetings of its SNF affiliates, North Shore-LIJ presents aggregate, blinded performance data and distributes individualized report cards detailing a facility’s performance against quality indicators. Franciscan Alliance presents unblinded performance data each month at its post-acute care partner meetings and uses this data to collectively create and implement processes.

    Use SBAR as a learning tool. Franciscan Alliance ACO requires providers in its continuing care network to provide SBAR (situation, background, assessment, recommendation) reports of all patients readmitted to the hospital as well as any unanticipated or adverse events. This helps providers identify areas for improvement.

    Share your classroom. Many post-acute providers lack the resources to offer in-depth staff training. Both Franciscan Alliance and North Shore-LIJ invite providers from their post-acute networks to receive free or reduced-cost education and training at their systems’ educational centers. Similarly, OSF sends wound care specialists to train staff at SNFs in its preferred network.

    Be flexible on size. North Shore-LIJ is tracking system discharges to see if 19 SNFs is the magic number for its network. Despite the importance of the affiliate network, by virtue of its size, the health system continues to work with a variety of SNFs across the region and seeks to use similar strategies that have been successful within the network.

    Leading with a Purpose

    As collaborations between health systems and post-acute providers move forward, there is a lot on the line, leaders say. Patients’ health and safety is the top priority, followed by the need to keep costs under control.

    With so much at stake in these partnerships, picking the right leaders will be critical. Collaborations should be led by “people with an understanding and sensitivity toward the SNF industry,” says McClusky of North Shore-LIJ. “You need people with a strong knowledge of all the moving parts, the complexity of the continuum, and an ability to lead through change. They need to be able to go back to their teams and inspire them to sail through this uncharted territory.” 

    Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill. 

    Interviewed in this article (in order of appearance): Maureen McClusky, FACHE, is executive director, North Shore-LIJ Stern and Orzac Centers for Rehabilitation, Manhasset, N.Y. Howard Guzik, MD, FACP, is senior medical director of SNF services, North Shore-LIJ Health System and the Stern Family Center, Manhasset, N.Y. Michael N. Rosenblut is president and CEO of the Parker Jewish Institute for Health Care and Rehabilitation, New Hyde Park, N.Y. Jenny Westfall is regional vice president, Franciscan Alliance ACO, Indianapolis, Ind. Joseph LaRosa, MD, MBA, is medical director, Franciscan Alliance ACO, Indianapolis, Ind. Kim Kolthoff, BSN, RN, CPUR, is director of integrated case management and clinical services, Franciscan Alliance, Indianapolis, Ind. Jay Brehm is senior vice president for strategic planning and business development, Franciscan Alliance, Indianapolis, Ind. Tara Canty is COO for accountable care and senior vice president for government relations, OSF HealthCare, Peoria, Ill. Stephen Hippler, MD, is vice president of quality and clinical programs for OSF Medical Group, Peoria, Ill.


    120 Days to Launching a Continuing Care Network for Post-Acute Care

    In 2012, Franciscan Alliance ACO set an aggressive target: to create a continuing care network for post-acute care in just four months. Here are some of the key steps it took along the way.

    120 days to launch

    • Review the top 20 high-use, post-acute facilities based on 12 months of discharge data.
    • Assess post-acute beds needed for 20,000 Medicare beneficiaries.
    • Determine quality metrics for network partners.
    • Engage system leaders and physician leaders in top-level discussions.
    • Reach out to post-acute facilities to gauge interest.

    90 days to launch

    • Invite six skilled nursing facilities, one long-term acute care facility, one home health agency, and one acute inpatient rehabilitation facility into the network.
    • Create an affiliate agreement for network partners.

    60 days to launch

    • Establish the network’s coordinating committee and subcommittees.
    • Require hospitalists to complete discharge reports before patients leave the hospital.
    • Establish care coordination processes.
    • Recruit and hire a care coordinator and a clinical nurse specialist for the network.

    30 days to launch

    • Finalize quality metrics for the network.
    • Finalize care coordination processes.
    • Launch and post-launch
    • Go live with the network.
    • Educate beneficiaries and families regarding the network.
    • Require network partners to conduct SBAR (situation, background, assessment, recommendation) reports on all readmitted beneficiaries and any unanticipated or adverse events.
    • Share results with network partners at monthly meetings.
    • Keep physicians informed through a monthly ACO newsletter.