- To achieve the ultimate goals of value-based care, healthcare organizations will need to assume greater responsibility over the patient’s experience across multiple care settings based on the appropriate level of acuity.
While the process to move away from the fragmentation associated with episodic, fee-for-service care will take some time, it is now requiring the attention of these organizations in the near term to identify areas where alignment and integration with other parts of the care continuum are possible to truly lower care costs and at the same time maintain a high level of care quality.
The continuity gap between acute and post-acute care providers represents an obvious opportunity and one leading organizations are already expending significant effort and resources to address. And at Partners HealthCare, post-acute care has become a vital component of the integrated health system’s work in value-based care, according to Partners Continuing Care CIO John Campbell.
“Within Partners, we’re a critical part of the care continuum, especially the work that we are doing in accountable care, population health, and other alternative care models,” he told RevCycleIntelligence.com.
“Alternative reimbursement models really put the emphasis on post-acute as a way to reduce cost,” Campbell continued. “We should be able to optimize the patient journey starting at the acute all the way back to home, hopefully being able to move the patient sooner in the process to lower-care, lower-cost settings while still being able to maintain the safety of the patient.”
The approach of Partners to aligning acute and post-acute settings is relatively unique and very much a work in progress.
“That’s the journey we’re on. I wouldn’t say we have it perfected by any means, but the fact that we’re all in system is a huge asset for Partners and it’s allowing us to have conversations and do integration and even understand cost in ways that other systems will be challenged to do,” added Campbell.
“We should be able to optimize the patient journey starting at the acute all the way back to home, hopefully being able to move the patient sooner in the process to lower-care, lower-cost settings while still being able to maintain the safety of the patient.”
But that approach points to the road ahead for most of the healthcare industry insofar as forging connections between care facilities specializing in different levels of acuity.
“Post-acute is sometimes overlooked,” said Campbell. "In part, that’s because not all acute hospitals are part of a fully integrated system like Partners HealthCare. All acute hospitals have to leverage post-acute services, but unless they are within the system, it’s not something these hospitals have direct control over or financial exposure to.”
According to Campbell, visibility into lower acuity settings is integral to plotting a successful path to value-based care moving forward.
“A previous attitude of ‘it’s over there and I don’t really have control over it, so I’m going to focus on things that I can control’ is not going to be sustainable,” he asserted. “Obviously, that will change with some of the alternative reimbursement models. Over time, these organizations will have to care about it more. Whether in- or out-of-network, post-acute care represents a huge part of the cost equation and warrants more attention and a focus on integrated delivery strategies.
The burden of post-acute care reimbursement
Ideally, a patient admitted to an acute care facility gradual progresses through sub- and post-acute settings and eventually moves back to the home. Making that process more efficient allows organizations to reduce the high costs of high acuity to the low costs of low acuity. Doing so is by no means a simple task given the requirements on post-acute care organizations and providers.
“Our top two challenges are we are underfunded and overregulated compared to our acute colleagues. Post-acute was identified a decade ago by CMS as being a huge cost issue within the system — a cost growth area instead of an opportunity,” Campbell explained.
“In fairness, there was probably some abuse of post-acute going on,” he conceded. “You had what CMS called a hospital within a hospital where an organization designated the fourth floor as an inpatient rehabilitation facility and the fifth floor as long-term post-acute care and kept the patient for the whole time. We’re just going to move them to different floors and call it different things. That’s not what CMS wants nor is it really improving the cost of the outcome equation.”
An increased focus on post-acute services means that these types of organizations are under heavy scrutiny that shows no signs of lessening.
“CMS has come down pretty hard. Every year reimbursements are under increasing scrutiny and the regulatory burden is massive,” Campbell observed.
Organizations working toward post-acute alignment and integration will need to come to terms with a different way of doing things than is common in acute settings.
“Acute settings typically have to submit a claim and maybe CMS comes back and asks for documentation to perform an audit,” Campbell stated. “Post-acute care organizations have to submit documentation prospectively. We have to submit it throughout this day. We have to submit it at the end of this day. Documentation is voluminous, cumbersome, and costly.”
In light of these differences, post-acute care providers face unique challenges tied to documentation and with it demands on their time.
“Therapists and nurses who should be treating patients are spending 20-30 percent of the time completing paperwork frankly that supports revenue cycle but does not really contribute to the clinical care of the patient,” said Campbell.
And that documentation burden is not just a matter of ensuring reimbursement. It is also tied to protecting payment against retrospective audits.
“In other words, it’s not good enough to say the patient needs 25 percent assistance to walk,” noted Campbell. “You have to provide detailed information almost on a day-to-day, shift-to-shift basis. How many steps did the patient walk? Were they were they sitting or standing? Was it in the hallway or in the bedroom? We’re literally gathering that detailed information so that if we get audited, it’s defensible.”
Working toward a streamlined continuum of care
Post-acute integration at Partners began more than a handful of years ago from the very top of the organization.
“Our CEO took the bold step at the time to basically say, ‘We need to get it more efficient. We need to start tightening our belt.’ The work we did at Partners Community Care was sort of a test for the work that needs to happen and is starting to happen at the Partners level,” Campbell recalled.
Prior to that realization, parts of the health system were functioning rather independently and without much regard for its implications for the network as a whole.
“It’s really hard to get people to change behavior. It does not come easily. It takes an extraordinary amount of effort, communication, and reinforcement measurements for us to get to value-based care.”
“Six or seven years ago, each of our entities was a separate entity with a separate leadership team — these almost semi-autonomous hospitals and delivery sites within our own network within the larger network of Partners,” added Campbell.
In working to address fragmentation across the Spaulding Rehabilitation Network at Partners, the post-acute component of the system in conjunction with the academic medical centers, affiliated hospitals, and other specialty facilities to create a means of placing patients in the most appropriate setting and limit variation in doing so.
“We now have a single admitting office that basically from the time the patient is identified as a candidate for discharge begins to manage that whole process,” Campbell revealed. “They are dealing with the case management group at the academic medical centers, payers, and admitting offices at the different levels of care within post-acute and gathering all the supporting clinical information and documentation to that ultimately determines where is the patient going to get placed.”
That unified methodology carried over to other aspects of the health system.
“On the operations side (nursing, therapy, physicians, etc.), we also have a single executive leadership team — a vice president of nursing, a vice president of therapies, a vice president of physician staff for the network. Having a single leadership team also helps create homogeneity,” said Campbell.
The level of behavior change and change management required of these novels approach to streamlined care delivery makes the transition a complex and difficult one. But the payoff of improved patient experience, population health, and cost reduction provides sufficient incentive for staying the course.
“It’s really hard to get people to change behavior. It does not come easily. It takes an extraordinary amount of effort, communication, and reinforcement measurements for us to get to value-based care,” Campbell concluded.