Are people undergoing a hip or knee replacement likely to have better outcomes by recovering at a rehabilitation facility or by recovering at home?
If you guessed that rehab is always better, you may be surprised by the findings of a study published in JAMA Internal Medicine (“Patient Outcomes After Hospital Discharge to Home with Home Health Care vs to a Skilled Nursing Facility,” March 11, 2019). With certain exceptions, outcomes for total joint replacement recovery in home and rehab settings were similar. For example, Medicare patients who were discharged with home health services had the same level of functional improvement, such as ability to walk and climb stairs, as those who went to a skilled nursing facility (SNF). Not surprisingly, costs were significantly lower for patients who recovered at home.
Now, don’t shoot the messenger. I am citing JAMA-published data. And I am not suggesting formal post-acute care settings are always inappropriate. This is simply an example of the need to look beyond the acute care domain in the industry’s ongoing quest to reduce the total cost of care, and to use cost and outcome data to do so. For several years, I have been encouraging healthcare leaders to pay attention to health conditions and issues — such as behavioral health, substance abuse, chronic conditions, social determinants of health and end-of-life care — that have been largely out of bounds for those focusing on traditional acute care. Post-acute care represents another, often more-immediate opportunity for using data to identify appropriate care settings while maintaining quality.
HFMA’s analysis of the Bundled Payment for Care Improvement (BPCI) for hospital-initiated care episodes found that reduced spending on post-acute care was the largest source of overall cost reduction, accounting for 70% of care episode savings among episodes that experienced statistically significant savings. The savings in BPCI came from changes in post-acute care settings (SNF versus home health) and from reduced length of stay in SNFs. It’s not difficult to see why managing spending for total episodes of care is a necessary capability for health systems participating in risk-based models.
Health systems that can successfully navigate post-acute care are experts at high-touch skills such as communication and education. They engage patients and caregivers in planning discussions early to understand patient goals and the care team’s opportunities to support them and to prepare patients and families for what’s next. They educate patients and family members on the role of home health providers. And they recommend appropriate care settings based on patients’ comprehensive needs for assistance after leaving the hospital.
The takeaway messages: First, always consider the full episode of care. All too often, a bundle or other value-based payment model is built around acute care. Second, when evidence shows that care practices don’t add value, change them. Although the JAMA study was limited to joint replacement, the conclusions about total cost of care likely apply to other common care episodes as well. If we hold on to care models because “that’s the way it’s always been done” or because we are hanging on to fee for service, we will get the same results we’ve always gotten. And that won’t get us where we need to go.