LeadingAge Magazine · November/December 2012 • Volume 02 • Number 06

The Time is Now for Partnering With Hospitals and Health Systems

November 15, 2012 | by Gregg Loughman and Kathryn Peisert

Not-for-profit hospitals and health systems are seeing their world change dramatically, and are gaining a better appreciation of the role of quality post-acute and long-term care. Now is the time for you to learn to speak their language and build partnerships.

For insight into what hospitals look for in partnership with post-acute and long-term care providers, LeadingAge magazine asked governance consultant and hospital insider Gregg Loughman, vice president of The Governance Institute, to explain.

Not-for-profit hospital executives and board members are becoming aware of the important role that nursing homes, home health agencies, assisted living centers, and other providers are playing in their future as they move from volume- to value-based reimbursement models.

One out of five Americans discharged from hospitals are being readmitted within 30 days—and as many as 76 percent of these readmissions are preventable. According to 2009 Medicare data, over half of readmitted patients received no care or follow-up in the 30 days after hospitalization only (Jencks, Williams and Coleman in The New England Journal of Medicine.) As the delivery of care is transformed to be more customer-centric and focus on wellness, prevention and population health management, the ability to ensure quality, effectiveness and efficiency across the entire care continuum will be essential for hospitals to achieve their mission.

The Governance Institute works with more than 1,000 not-for-profit hospital and system boards across the U.S., educating executives and board members on best practices for governing health care resources and strategies to thrive in our dynamic health care market. So what is grabbing the attention of hospital executives and board members? Reductions in reimbursement, reimbursement penalties for poor performance on outcomes measures, increasing pressure from payers to assume risk for their members while reducing the cost of care, and the coming influx of newly insured patients through health exchanges and Medicare. These challenges to revenue make it increasingly difficult for not-for-profit hospitals to fulfill their mission and, in some cases, retain their not-for-profit status.

Reduced payments and penalties have drawn criticism for a number of reasons—for example, they don’t take special circumstances into account. “While hospitals feel these new developments are somewhat unfair, at the same time they have all accepted that we are now in a new world, where they will be held at least partly accountable for what happens after the patient leaves the hospital,” Robert M. Wachter, M.D., associate chair of the Department of Medicine at the University of California, San Francisco, told The Governance Institute recently. “Bundled payments, accountable care organizations and readmission penalties are ways of readjusting hospital incentives and altering what hospitals do at many levels.”

Post-acute care plays a fundamental role in the continuum of care, and there is great opportunity for collaboration with hospitals to improve transitions, reduce costs and manage populations. “There is a strong correlation between 30-day readmission rates and nursing home stays,” according to Mark Aspenson and Sunil Hazaray of Avery Telehealth. “When the quality of nursing home care or care from home health agencies does not meet a patient’s needs … these factors drive rates of both admission and readmission. Inadequate care after discharge is often a result of a lack of care coordination (e.g., the hospital may fail to share a list of the medications prescribed to a patient upon discharge …).”

Hospitals and health systems are developing strategies to reduce 30-day readmission rates and avoid Medicare penalties. Initiatives being implemented in hospitals include:

  • Establishing performance indicators focusing on a patient’s ability to transfer to another care setting (including daily assessments from nursing and physical therapy)
  • Focusing on groups of patients at highest risk of readmission based on severity of illness or chronic conditions
  • Looking at data showing which post-acute settings their readmitted patients came from to identify trends
  • Improving patient communication and education on medication and other issues prior to discharge, including how to look for early warning signs
  • Improving transfer forms and communication to support smooth transitions and consistency between care settings (including “road maps” for post-discharge care)
  • Forming collaborations with post-acute providers to look at problem cases together and explore what happened and find ways to prevent reoccurrence

Communication breakdowns (or lack of communication altogether) are too common in care transitions. Completing all the steps necessary to discharge a patient requires the efforts of many different resources within and outside the hospital (and thus, many handoffs where information can be forgotten or lost if there is no standardized process or checklist to follow).

Physicians, nurses, case managers, physical therapists, unit assistants, diagnostic imaging services and lab technicians are key players in this process. In addition, ambulance services, skilled nursing facilities, rehabilitation centers and outpatient services can further influence a timely and effective discharge (Johnson and Capasso in the Journal of Healthcare Management). Smoother transitions play an important role in improving patient satisfaction, which is now linked to hospital reimbursement. Increasing reimbursement by achieving higher quality outcomes is a strategy that meets the competing needs not-for-profit hospitals face: providing care for all members of a community regardless of ability to pay while improving revenue to protect the future of the hospital. Proactive hospitals and systems have taken simple steps to alleviate these issues, including:

  • Faxing needed medications to the pharmacy the day before discharge so they will be on hand when the patient arrives at the post-acute care setting
  • Providing a written prescription for pain medications before the patient leaves the hospital
  • Having the hospital physician contact the post-acute physician who will be responsible for the patient and, when possible, informing the post-acute physician in advance that the patient is being discharged
  • Ensuring that all staff involved in the discharge/transfer process (including nurses and social workers) stop the process if they see a problem or have any concerns

Hospital executives and board members are awakening to the greater need for collaboration and partnership. Hospitalists in the post-acute setting play a valuable role in reducing readmissions—post-acute hospitalists who have access to acute-care provider databases can ease care transitions once the patient arrives at the post-acute facility, by having real-time, complete information about the patient’s condition. (“Post-acute hospitalists” is a new term referring to physicians specializing in hospital-based medicine, who are leaving hospitals and moving to nursing homes to base their care delivery in this setting.) Some post-acute hospitalists meet with their patients’ acute providers to further discuss their cases. The following are additional ways post-acute providers can be proactive in collaborating with hospitals:

  • Proactively share your organization’s data on quality of care and patient satisfaction, and let hospitals know why you offer a safe place for their patients to receive high-quality, appropriate care from experienced, qualified staff (i.e., how do your services stand apart from others?).
  • Frame the discussion by providing hospitals specific information on how you can help them reduce costs by reducing readmissions.
  • Offer to share/combine data and work together to identify populations in the community that are most at-risk for multiple hospitalizations/readmissions if they do not receive proper post-acute and/or home care. Develop a joint action plan with the hospital to address these patients’ needs.
  • Form a care-transition team with the help of hospital leadership that includes interdisciplinary staff from both the hospital and post-acute provider. Charge this team with developing standardized discharge and communication protocols for each organization.

These programs can positively impact hospital clinical quality, patient satisfaction and the bottom line, setting the stage for an advantageous partnership. Having these programs in place and being able to tie them to the important goals and strategies of your local hospitals is not enough. It is essential for post-acute providers to have access to reliable, actionable data reporting on patient satisfaction and quality of care—and open communication channels with hospitals to share this data. As the old saying reads, “In God We Trust; all others bring data.”

Not-for-profit hospitals and health systems are seeing their world change and their ability to fulfill their mission come into question. Learning to speak their language and quantifying the impact you can have on their business and while helping them fulfill their mission will improve your business and the delivery of customer-centric care across the continuum in the communities you serve.