Panelists: To improve patient outcomes, connect patients to the right post-acute care


One of the key ways to improve patient outcomes and reduce readmissions is to ensure that patients are connected to the best post-acute care at discharge, according to a panel of experts.

Win Whitcomb
Win Whitcomb

There are a number of levels of post-acute care, panelists said at the CAPG Colloquium last week in the District of Columbia, and it’s imperative that hospitals and healthcare facilities develop ways to ensure that each patient is sent to the location that best meets his or her needs.

Win Whitcomb, M.D., chief medical officer of Remedy Partners, a firm that assists hospitals with bundled payments, said it’s difficult for hospitals to optimize their decision-making about patients’ next site of care because there is so much emphasis on reducing the length of stay. It’s important, he said, for care teams to take time to identify patients who would do well at home or in home health care, as that can reduce unneeded costs for patients.

There are four key actions that doctors can take to better direct patients to the appropriate post-acute care, said Whitcomb, who is also a hospitalist and “SNFist”:

  • Order an evaluation to explore the possibility of home health
  • When discussing next site of care, ask, “Why not home?” to ensure the topic is broached
  • Consider palliative care options, which may best be administered at home
  • Communicate closely during handoff to a post-acute care facility (or with home caregivers) for high-risk patients
Tracey Moorhead
Tracey Moorhead

Remedy Partners, he said, also created a decision-making tool called CARL--Care at the Right Location--to assist providers with choosing the appropriate post-acute care. It asks targeted questions that can assess a patient's’ ability to perform day-to-day tasks on his or her own and if there are any mental health or memory issues that can lead to medication adherence difficulty or other problems, he said.

In addition to discussing ways that doctors can better divert patients, the panelists shared innovations in the home health industry and ways to treat patient issues who may not require medical interventions at all. Tracey Moorhead, president and CEO of the Visiting Nurse Associations of America, said research proves the need for home health and its benefits to patients.

“We fully believe the capacity and evidence of the need for expansion of home health providers,” Moorhead said.

June Simmons
June Simmons

An emphasis on home health--which is often cheaper for patients than other post-acute care options and allows patients to be where they want to be--began with the Affordable Care Act, she said, and data indicates that ensuring it is an option is in line with the Triple Aim and patient wishes.

June Simmons, president and CEO of Partners in Care Foundation, said that social determinants of health are another key way to determine which patients can go to the least restrictive sites of post-acute care.

Her organization, which works with health providers to offer non-clinical interventions for patients where possible, promotes options such as the use of social services and home visits using telemedicine as potential ways to avoid unnecessary stays at a skilled nursing facility or rehabilitation center.