Three very different health care organizations, all intent on patients get better care beyond hospital walls and into the post-acute arena -- where health care is increasingly being delivered. Part of their goal is reducing costly hospital readmissions, which nobody -- including Medicaid/Medicare, private insurers and patients -- wants.
[MORE: The 2014 Hospital of Tomorrow Conference]
Making a smoother transition depends on hospitals choosing the most effective partners -- and smart decisions go beyond directing patients to the nearest location or sticking with business-as-usual arrangements, according to health care executives speaking Tuesday at the "Managing the Care Continuum" session, part of the U.S. News Hospitals of Tomorrow forum held in Washington, District of Columbia, this week.
In his introduction, moderator Brian Fuller, director of post-acute care and long-term care practice at Avalere Health, brought up the issue of variance: Why, he asked, do some total joint replacement patients go to post-acute rehab facilities, others to skilled nursing facilities, yet others to home health services -- while other patients bypass them all? And he mentioned important factors in choosing skilled nursing facilities: nurse-to-patient ratios, clinical education, and specialty programs that meet needs of patients on ventilators, for example. It's not just a matter of patient choice, he said, with hospitals handing out A-to-Z lists of nearby providers, but also helping patients and families make informed choices.
[READ: Nursing Homes: How the 50 States Rank]
Jordan Asher, chief medical and chief integration officer for MissionPoint Health Partners, a population health management company of Ascension Health, spoke from his perspective as health executive and physician. Started four years ago in the wake of the Affordable Care Act, his company works with partners to improve the health status of the community, reduce health care costs, improve the patient experience and "enrich the lives of caregivers," he says. It's not enough to concentrate on episodes of care, Asher says -- a hospitalization, a doctor's office visit -- without helping patients navigate the "gray spaces" in between.
Kelvin Baggett, senior vice president of clinical operations and chief clinical officer with Tenet Healthcare, highlighted the contrast between the health care landscape then and now. In 2006, he said, his company described itself an operator of hospitals, and "the focus was on the care of patients for acute episodes of illness." Back then, "we weren't speaking to our expansion into the outpatient space," he said. Now in 2014, he said, Tenet describes itself as a provider of integrated health services, one that manages health and wellness -- and one which encompasses hospitals, outpatient facilities, physician practices, accountable care organizations and health plans.
Charleeda Redman, vice president of accountable care with UPMC, described how her group took on a Centers for Medicare & Medicaid Services grant-funded initiative to reduce hospitalizations and readmissions from nursing homes in Western Pennsylvania. Started in 2012, the program, known as RAVEN, introduced a model that includes daily coverage by at least one nurse practitioner; medication management with increased pharmacy engagement; the use of telehealth and information technologies to improve after-hours communication; and education of employees ranging from nursing assistants to dietary staff. In the next step, the RAVEN initiative is being "deployed" in partnership with 19 other, non-UPMC nursing facilities.
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