Post-Acute Care Management Guide

It’s no secret that healthcare is a complex and broken system. Patients are shuffled from one facility to another, going from provider to provider, with little communication from one to the next. This ultimately harms the patient’s outcome and leaves them receiving suboptimal care. Post acute care is care received after discharge from an acute facility, meaning the hospital. This may include rehabilitation or therapy services, most oftentimes being performed at a skilled nursing facility (SNF) or at the patient’s home through home health agency (HHA) services. The lack of communication, transparency surrounding location-and generally uncoordinated systems has left a gap in the system. The road between the hospital and skilled nursing facility is empty, when it should be filled with information. This matters now more than ever as models such as bundled payments and Accountable Care Organizations (ACOs) are shifting healthcare to a value-based system. This means for the first time, health systems are financially responsible for the patient after they have left. This is where post-acute care management comes into play, managing patients after discharge is necessary. But what does post acute care management encompass and how can we move forward in healthcare with it? 


Table of Contents: 

What is Post-Acute Care Management?

Post acute care management, sometimes referred to using the acronym PACM, is the relationship between acute and post-acute facilities across the care continuum on patients’ care. Being aware of where a patient is, how they are progressing post-discharge, and communicating with a new care team are all part of the post-acute care management process. Additionally, to be successful after discharge, post-acute facilities must have a means of communication to the acute provider team in order to ask questions, exchange documents and easily get in touch if something goes wrong. The World Health Organization recently released a publication titled, “Continuity and coordination of care”, to share it’s opinion on the importance of care across environments. The practice brief states that “without good continuity or coordination of care and support, many patients, and carers and families experience fragmented, poorly integrated care from multiple providers, often with suboptimal outcomes and risk of harm due to failures of communication, inadequate sharing of clinical information, poor reconciliation of medicines, duplication of investigations and avoidable hospital admissions and readmissions.'' Post acute care management’s purpose is to encompass that continuity and collaboration of care to reduce poor outcomes and improve the care of a patient across environments. 


Why Does Post-Acute Care Management Matter? 

In the past, health systems have not needed to stay involved with a patient’s care after they have left their facility. In traditional fee-for-service healthcare, which is being phased out, health systems could celebrate a job well done when patients improve to the level of discharge. Value-based healthcare represents an evolution of the reimbursement model to focus on value over volume of services. In an effort to improve the quality of care across the nation, healthcare has moved into a value-based system. This has brought about new programs such as Accountable Care Organizations (ACOs) and bundled payments. These models mean that providers are fiscally responsible for patients’ care across different care environments. In other words, a health system is responsible for a patient’s care even if they have moved on to receive care from a skilled nursing facility. 


3 Reasons Why Your Health System Should Care about Post-Acute Care Management:


Reduce readmissions

Along with the shift to value-based care, CMS has implemented programs such as the Hospital Readmission Reduction Program (HRRP). It was created in 2012 to “support the national goal of improving healthcare for Americans by linking payment to the quality of hospital care.” Strong post-acute care management greatly reduces the risk of readmission as provider teams are coordinating care and covering the gap between facilities. Reducing the risk of readmission inherently means reducing the risk of penalty from the HRRP program, making health systems more fiscally stable. 

Improve quality of care, be successful in value-based care models

Achieving strong post-acute care management will greatly improve the quality of care that patients are receiving from the moment they enter the acute facility to the moment they leave the post-acute care facility. According to the peer-reviewed article, “The role of accountable care organizations in delivering value” published on NCBI, Accountable Care Organizations are set up to be successful “through the use of performance and quality measures that facilitate efficient, cost-effective, evidence-based care.” Investing in efforts that improve quality of care and save a system money are in the best interest of the health system and the patient in order for both to achieve the desirable outcomes. As value-based models are becoming the standard, the greater quality of care a health system can achieve- the more successful they will be in programs such as bundled payments or ACOs

Improve coordination of care

At the heart of post-acute care management is coordination of care. Care should never stop at the doors of a facility but should follow the patient through every step of the care continuum. Closing the management gap between facilities, and collaborating around the care of a patient will improve coordination of care, which will in turn increase the quality of care, reduce readmissions and ultimately- allow a health system to thrive in the age of value-based care. 

How to Succeed in Post-Acute Care Management: 


Build relationships with PAC providers- create a list of preferred partners

In order to communicate effectively around patient care, it is important that relationships are built between the providers in the acute setting and at the post-acute facilities. As well as building relationships, health systems should establish a preferred list of facilities that patients can be discharged to. This will ease the transition for patients and families as they have the resources to make an informed decision about where to receive the next stage of care. Establishing a preferred network has operational advantages too, such as referral patterns and established communication.

Track patients’ location and status in real-time

Knowing where patients are after they leave the acute facility is the most basic level of post-acute care management. This is vital to remain involved in patient’s care and gives systems the ability to understand the level of care facilities are providing. Secondly, tracking patient progress is the most basic level of remaining engaged in care. From the acute perspective, providers need to be in a position that they can stay up to date in real-time on a patient’s condition in order to know if something goes wrong and intervene where necessary. To achieve this successfully, information must be received and sent in real-time so that all providers get the right information at the right time in order to have the ability to intervene. 


Implement technology that fosters communication and collaboration across the care continuum

In a day and age where technology is standard, technology should be applied to post-acute care management. Archaic means of communication needs to be done away with, such as email or fax. More importantly, HIPAA compliant technology needs to be implemented into healthcare facilities to cross the care continuum. The only way to achieve this constant communication is by implementing a technological platform that can achieve that and allow providers to communicate across the gap. A priority solution, WHO says in it’s practice brief, is “the availability of information and communication technologies that support the management of people’s care,” which in turn “makes it easier to ensure continuity and care coordination.” Olio is thrilled to be benefiting patients by playing a critical role in improving the continuity and coordination of care.


Post-acute care management is vital for a health system to be successful in the age of value-based care. Knowing where patients are, tracking their progress, and being able to communicate across the care continuum will not only lower costs and readmissions but will improve the quality of care and ultimately, improve patient’s lives as they transition across environments. Implementing a collaboration solution to communicate and engage across the care continuum is the best way to achieve the goal of post acute care management.Greater collaboration between acute and post-acute healthcare providers on their shared patients will result in better patient outcomes at lower costs. 


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Topics: Hospitals, Product, Industry, acute
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