The future of post-acute care

Address, change, and improve the future of post-acute care by putting the patient in the center. Lean more about the integral role healthtech plays in uniting a fragmented industry.

Russ Graney

CEO & Founder, Aidin

We have a free-market healthcare system in the United States, and yet we, the consumer, don’t seem to benefit from any of the usual things that make a free market valuable — transparency, quality, choice, and price. Take, for example, post-acute care.

Each year about one in five hospital patients in the U.S. require follow-up care after hospital stays for major surgery or illness. What does the “free market” look like in post-acute care?

Patients and their families usually ask a doctor or nurse at the hospital for a recommendation because they have never considered post-acute care until they need it. Or a hospital staff member whose job it is to process your discharge provides some options close to patients’ homes. Or a representative from a rehab facility pays a visit to the hospital to market their services.

Too often, patients do not have the critical information they need to carefully assess their options and make informed choices when they are at their most vulnerable. They rely on faith, instead of facts.

Decisions on where to go for post-hospital care usually have to be made quickly, and patients are just relieved to find a bed. The result is that people end up choosing lower-quality providers. One study found that only 16% of Medicare recipients using services at a skilled nursing facility chose the best provider that’s available to them.

And unfortunately, poor care transitions end up having negative consequences for patients, including additional hospital stays, longer recovery times, and long-term complications.

The coronavirus pandemic exposed how fragile and disconnected care transitions are. Hospitals didn’t allow family members, let alone representatives of post-acute providers, also known as community liaisons, to make bedside visits. As skilled nursing facilities closed their doors to control outbreaks in their facilities, patients had fewer choices. Post-acute care companies had staffing shortages and struggled to find personal protection equipment. Patients stopped health aides from entering their homes because of COVID-19 fears.

Where does that leave us? How does the post-acute environment evolve to improve the quality of care while lowering costs and empowering the consumer?

Aidin recently hosted a webinar featuring our partners at health systems and post-acute care providers. The pandemic forced them to quickly come up with ideas to address capacity constraints in the hospital while also providing appropriate follow-up care. Their insights provide a roadmap to better align hospital incentives to reduce unnecessary discharge delays and readmissions with providers’ goals to earn more referrals and patients’ desires to find the best possible care.

Upgrade care through telemedicine and remote monitoring

Vanderbilt University Medical Center created a “Covid to home,” program, which is an enhanced home health strategy for Covid patients. The medical center was able to put the program in place within a few days and has taken care of more than 500 patients to date. Nurses and physicians used the hospital’s telemedicine platform to connect with patients. To make these virtual visits more productive, patients were given simple medical devices like pulse oximeters and blood pressure upon discharge to allow the hospital to better monitor their respiratory status.

“The use of these simple technologies has caused us to ask, ‘How can we do even more,’” said Dr. Tara Horr, outpatient clinical service chief at Vanderbilt. “We can start to look at remote patient monitoring devices to enhance the care we provide in the home.”

She said Vanderbilt can apply this experience to improve chronic disease management and keep people at home and out of the hospital.

More collaboration between hospitals and post-acute care providers

Providers rely on community liaisons to generate referrals and evaluate complex cases to determine the appropriate level of care. When Loma Linda University Medical Center barred liaisons, the health system gave providers access to patient electronic medical records. Access to the records satisfied a lot of the providers’ information needs that would have normally come through a liaison, said Paul Arias, assistant vice president of care coordination at Loma Linda.

Improving the flow of information between the hospital, provider, and insurer can shorten the time between referral and admission. Eliminating unnecessary delays during the discharge process was critical in the past year as hospitals looked for ways to increase bed capacity as well as protect patient safety.

Leveraging advanced digital tools to modernize the referral process

Without liaisons, hospitals had to lean on digital communication and workflow tools to match their patients to the services and providers that best suit the patients’ needs as well as meet their expectations.

The industry now has software technology that gives case managers visibility into the entire market of clinically appropriate post-acute options and insight into the quality of care offered at each provider. Patients also can review detailed outcomes and partnership data about their available options to find the best possible care, not just the care closest to their homes.

“We teach patients how to interact with us by making it easy for them to do the right thing,” said Stephen Blau, senior director of care management and transitional care shared services at Luminis Health. “So as we design the care of the future, we have to think about how we create a frictionless environment, so that it makes sense for patients and reduces barriers for the system.”

Reimagining the role of the liaison

If providers have more tools to capture and share their reputation and skills with patients and case managers alike, then they don’t need liaisons to be their marketing reps. If hospitals commit to an open marketplace dedicated to transparency and data instead of old habits and familiar patterns of referrals, then all stakeholders can benefit.

Liaisons can transition from marketers into full-time patient advocates. They can add value by identifying gaps in care transitions so patients don’t have unexpected returns to the hospital. They have more time to evaluate the more complex patients and make sure they meet the criteria for admission. There are good clinical reasons to see patients in person before they move home or to a nursing facility. And stronger bedside connections can go a long way toward comforting patients and their families, forging trust, and building reputations as caring providers.