How two health systems are advancing value-based care with post-discharge strategies
As Medicare’s value-based programs evolve, providers are increasingly responsible for patient outcomes outside the hospital walls. Analytics and technology can help foster a deeper understanding of the patient beyond the acute care environment, but a more comprehensive approach is needed to drive down readmission rates and costs while retaining optimal patient experience. Ron Austin, vice president of system inpatient care management/ utilization management at AMITA Health, and Ryan Catignani, vice president of managed care and accountable care services at Beaumont Health, shared lessons learned from their experiences with post-discharge care at their respective health systems during a recent webinar.
1 Begin the discharge strategy when patients are admitted
Recovering from home when safe and appropriate can be a key part of the care continuum and is a crucial component of Medicare bundled payment programs. When services are coordinated with providers and communicated with the patient, health systems see better health outcomes, lower readmission rates and cost savings. Starting the discharge process at admission allows the health system to begin planning the post-acute care strategy earlier, allowing for more seamless coordination with relevant stakeholders and clinicians. The attending physician should be the main driver of the post-discharge strategy, but patients should be presented with appropriate choices, allowing them to make informed decisions.
2 Collaboration can address barriers to patient recovery
It’s not just nurses and social workers who should collaborate on care plans when a patient is sent home. With a bundled service, care planning should also include service line leaders, doctors and care management team members. Interdisciplinary collaboration encourages more innovative practice and leads to higher quality patient care and outcomes.
3 Data is crucial to post-acute care management
With bundled care, it’s vital to track patient and financial data. Data from Amita and Beaumont Health showed how care coordination and collaboration improved post-acute care and improved financial results. Metrics showed lower 90-day readmission rates, fewer days spent in skilled nursing facilities (SNFs), fewer discharges to SNFs and inpatient rehabilitation facilities (IRFs), increased discharges to home when appropriate, and increased savings rates. Data helps with benchmarking and monitoring trends over time and between facilities.
4 Health systems must capture and address social determinants of health
Patients’ social and personal circumstances heavily influence their outcomes after discharge. These can include access to medications, food and transportation. An at-home program should coordinate solutions to close any gaps. Communicating with the patient about what to expect is important as well and helps decrease unnecessary emergency department visits. This can be as simple as following up with phone calls to ensure patients have what they need and providing a phone number so patients can call with questions. Palliative care can also work with the patient and family to determine care and health goals.
5 The future of home-based recovery shows growth
During COVID surges, families and patients did not want to use SNFs, fearing disease spread and visitor restrictions. Discharges to home increased, even for more complex conditions and when it was the safest and most appropriate next site of care. Given success and positive results, it’s possible that Medicare bundled payment programs will increase. Pay for performance models broadly are also projected to increase. Sophisticated technology to electronically monitor vital signs with mobile tracking is becoming more prevalent and accepted. Discharge to home can also keep patients safer as fewer people need to enter the home. All these factors point to the continued popularity of home-based recovery.