Tips to Maintain Visibility Into Patients’ Post-Acute Care

According to data from CMS, 73% of the 14,959 skilled nursing facilities in the US that will be receiving medicare payments in 2019 will be financially penalized for poor 30-day readmission rates. Over the past 5 years, and especially in response to CMS’s value-based-care compensation models, like BPCI; patients being discharged from acute facilities and admitted to post-acute rehabilitation are of higher acuity (US National Library of Medicine National Institutes of Health).

Collaboration, and specifically physician teams’ visibility into the status and condition of their patients in post-acute care is critically important. It’s important in improving financial performance in risk models, important in reducing readmissions, and critical in coordinating care in a way that results in the best health outcomes for the patients.

We recently sat down with a care coordinator at a central-Indiana hospital that compared managing a caseload of patients receiving post-acute care to a “goat rodeo” – a disorganized and unmanageable situation.

Legacy systems and workflows established to give physicians and their teams visibility into the condition of their patients receiving post-acute care are inadequate. Past processes may have worked in a fee-for-service healthcare model, but in the models of today and the future that focus on value and outcomes, they fall short. Whether you build a process and/or system yourself, or use Olio’s platform, these tips will help you maintain visibility into patient condition in post-acute care:

  • Single Source of Truth – Maintain a shareable, but secure, database that contains patient information and the post-acute facility in which they are receiving care.
  • Templatize Progress Logs – Knowing where patients are is only half the battle. Patient condition is the critical information needed to guide care. Ensure all post-acute care providers are using the same progress/therapy log format. To ensure the acute care team has only the right information, these progress logs should be unique to each disease state or episode type, but consistent across the network of post-acute partners providing care.
  • Everyone Needs Visibility – A knee surgeons, for example, may entrust their care team with the coordination of care of patients in a post-acute settings, but there are times when escalations require surgeon interventions. Ensure everyone on the acute care team has the option to access and see the patients care history delivered in the post-acute setting.
  • Visibility Is a Two-Way Street – Much of this post has been focused on ways for acute care teams to maintain visibility into the status of their patients receiving post-acute care. However, in the essence of collaboration post-acute care teams also need visibility. Thoughtful care protocols are an excellent way to give post-acute teams visibility into an acute team’s expectations for care to be delivered in the post acute setting.