Older patients with complex care needs often require a diverse array of services to treat major health episodes, manage chronic disease, and maintain independent, healthy living. While many patients receive care in the physician’s office or inpatient hospital settings, a variety of other settings are available to patients who need certain specialized follow-up care. This care is provided in different settings, for example, long-term acute-care hospitals (LTACHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and at home through home health agencies (HHAs). Collectively these services are described as post-acute care (PAC) and they support patients who require ongoing medical management, therapeutic, rehabilitative or skilled nursing care.
PAC facilities require systems that promote seamless coordination across the care continuum. Many hospitals and health systems have connected PAC facilities, most often inpatient rehabilitation facilities and home health agencies. However, the hospital or health system may not have the capacity to admit all post-acute patients or meet different care needs. Thus, hospitals and health systems may need to extend its preferred network or collaborate with care coordinating entities to ensure access for all patients.
Both healthcare providers and patients stand to gain from the increased emphasis on care coordination. Fragmented care and miscommunication result from poor transitions of patients from one care setting to another. Poor patient transitions increase risks for medication errors, missed appointments with primary care and specialists in the outpatient setting, duplication of resources, and increased cost related to health care services. Integrated PAC models ensure that patients, especially the chronically ill, receive the right care at the right time, while avoiding unnecessary duplication of services and preventing medical and other errors. Mistakes may occur during intake, gaps in patient education, processes for initial assessment, care planning, discharge planning, or post-discharge follow-up. Inconsistent care continuity and poor patient understanding of self-care needs can lead to hospital readmission and increased financial burden to the healthcare system.
Chronic Care Management (CCM) and Transitional Care Management (TCM) partnerships can extend PAC coordination for chronically ill older patients. Care Managers can effectively boost post-acute care management, patient outcomes, and caregiver satisfaction by supporting care coordination efforts. They can serve as transitional care mangers helping integrate case management, special diets, social counseling, routine monitoring, physical therapy and skilled nursing services.
Providers of post-acute care play an important role in providing high quality care for patients in lower cost settings. Those providers who can demonstrate their ability to move the needle on costs and quality and raise their value within healthcare. The shift from a fee-for-service model to value-based reimbursement model creates opportunities for post-acute coordination resulting in better quality care for individual patients. Partnerships with CCM and TCM Care Managers can help bring focus to post-acute care management, chronic health care services, and transitional care models that take patients from hospitals to an array of PAC facilities.
Written by Joseph F. West, ScD on Tuesday, 03 January 2017. Posted in Integrated Care Coordination, Post-Acute Care, TCM, CCM