Effective post-acute care management requires a multidimensional approach that incorporates effective communication, data analytics and clearly defined care coordination roles, according to a new white paper from Leavitt Partners. The benefits, however, are clear, as better post-acute care management can reduce readmissions, allow providers to more easily manage length of stay in skilled nursing facilities and better monitor discharge.
Post-acute care is the "next frontier" for integrated delivery networks, health systems under payment risk, accountable care organizations, bundled payment awardees and MA plans, according to the report. “However, significant complexities exist on the road toward PAC integration.”
The report offers five “essentials” to building an effective post-acute care management program:
- Build strong relationships with post-acute providers. Effective teaming means sharing resources and accountability while building trust across different sites of care.
- Identify the right site of care first, and coordinate care better. Effective post-acute management plans can apply experience and historical data in tandem to find the correct solution earlier. Once patients are discharged, coordinated care can monitor medication adherence and offer home assessments for better outcomes.
- Embrace data analytics. Analytics is key to value-based care programs, according to the report, but for post-acute care, effective use of data can help providers determine the best site of care for patients and provide feedback to partners across the continuum.
- Engage patients, their families and caregivers. This is particularly important for high-risk patients who may be receiving home care, as the role of caregiver can be overwhelming.
- Use technology to foster communication. Remote monitoring and video visits can allow providers to track patients after discharge while avoiding unneeded, costly stays in skilled nursing facilities. A good care coordination team will also provide clear instructions patients can follow at discharge, according to the report.