Developing Advanced Clinical Pathways for High-Risk Disease Across Your Post-Acute Network

May 11, 2022 | Written by: Phyllis Wojtusik, RN, EVP of Health System Solutions

Every day, 10,000 Baby Boomers reach retirement, and it is estimated that Medicare enrollment will catapult to over 80 million beneficiaries by 2040. According to the National Council on Aging, 80% of older adults have one chronic illness while nearly 70% have two or more.

Drill down further and you’ll see that 40% of Medicare patients hospitalized for injury or illness are discharged to post-acute care (PAC). Unfortunately, up to 25% of them, particularly those with chronic diseases, are readmitted to acute care within 30 days. These conditions are costly with cancer, heart disease, diabetes, obesity, COPD, and kidney disease driving 75% of healthcare spending and readmissions.

These findings demonstrate the critical importance of developing clinical pathways between acute and post-acute providers for chronic disease management and prevention of high-risk readmissions. With more people relying on Medicare and the health system than ever before, are hospitals and Accountable Care Organizations (ACOs) ready to manage this aging population who are living longer, and often with more chronic diseases?


The Importance of Partnering with Post-Acute Network to Standardize Clinical Care

Managing your post-acute patients while driving outcomes by design and sharing your vision is essential for quality outcomes. It is also important to partner with your post-acute network and understand their challenges and obstacles. This partnership is established by collaborating to overcome barriers for the patients’ benefit, being willing to evaluate and improve patient processes, create intentional measurement of progression and outcomes, and sharing those results routinely with the appropriate persons and working together to enhance them.

More often than not, I’ve heard from organizations, “My preferred provider post-acute network knows what they are doing.” While they may be experts in a particular field (i.e., rehab experts), they are not disease management experts, and motivations towards patient care are not always aligned. There could be limited access to data to improve care, limitations to physician intervention or oversight and limited testing. Additionally, patients in PAC have multiple medical comorbidities that impact overall status and care.

Are post-acute providers getting the information they need to adequately care for the patient? For example, only 50% of transfers have nurse to nurse handoffs or only 60% of patients are discharged with PCP appointments. Now, more than ever, it is imperative to establish clinical pathways between acute and post-acute providers. It is crucial determine the standards of care for a population based on disease management principles, with priority interventions for different case types, measurement of outcomes, readmission management, and ensuring smooth transitions of care across health systems.

When identifying case types for clinical pathways, identifying high volume and high-risk case types with moderate volume is crucial. It is not always feasible to have a defined clinical pathway for every condition, for example- some conditions should have clinical protocols for routine management such as diabetes. Moreover, identify five to ten case types across your clinical landscape to provide standardized care aligned with evidenced based best practices that will lead to improved quality of care and patient outcomes. Typical case types include CHF, Sepsis, Pulmonary- Pneumonia/ COPD exacerbation, fractures (hip), and CVA.

National clinical guidelines of care should be followed, and top clinical case types prioritized while making process repeatable. Provide onboarding and goal setting tools, discharge processes and post discharge follow-up information as well.


Define Standards of Care Across Acute and Post-Acute Providers

As hospitals and ACOs try to manage patient outcomes across the continuum of care, collaboration across the post-acute network and adopting standards of care, including medical and functional components, is imperative to not only the success of your ACO’s outcomes, but your patients as well. So, what does a clinical pathway encompass?

During the post-acute stay, timing is of the essence, and it is integral to know the “when” and “what” for the patient’s care such as timing, care transitions, and estimate discharge date. Key evaluations may be identified including routine clinical assessments focused by case types, functional progression, discharge planning, nutrition, and hydration status. Also included within the clinical pathway is routine follow-up or change in condition testing, medication standards, and patient education to enforce consistent practices across your entire network.

Although a clinical pathway may be available, how do you get your post-acute network to implement the pathway? Identifying best practices for different case types and ensuring your post-acute partners incorporate these standards into their regular workflow, is instrumental. Educate, establish accountability on desired outcomes and processes, focus on volume measured in network referrals and continuously measure and communicate!

When gaining buy-in from patients, it’s important to focus on key factors. Provide a thorough overview of the process of the patient specific clinical plan and communicate details of what to expect with potential milestones. Additionally, set expectations for improvement and discharge, provide an individualized patient copy, maintain patient participation throughout the process (i.e., CHF – complete and record daily weights) and reflect on insights you have learned.


Leveraging Live Post-Acute EHR Data

Defining standardized care strategies and leveraging live PAC EHR data can help to identify and prioritize high-risk patients in the post-acute setting Metrics should be used to evaluate results for process review and to confirm that the correct process is being repeated. Accessing live post-acute EHR data and analytics can help ACOs better collaborate with PAC partners to achieve better patient outcomes, maintain standards of care, reduce readmissions, minimize length of stay, and enhance clinical stability.

Utilizing real-time clinical alerts and interventions, helps to identify changes in conditions, manage accordingly across post-acute networks and can be customized by the ACO as needed, ultimately driving the standards of care. In turn, providing a nice opportunity for an acute care setting to partner with their PAC facilities, both working together towards the outcome of the patient.

Learn how Real Time Medical Systems Interventional Analytics is helping ACOs, health providers and hospitals access live clinical data from the post-acute EHR to proactively manage care for chronically ill, high-needs members, reduce readmissions, and impact total cost of care across their acute and post-acute network. Click here to get started!



With over thirty-five years of health care experience in acute care, ambulatory care, and post-acute care, Phyllis Wojtusik has led the development of post-acute networks, participated in the Medicare Shared Savings Program and other value-based contract programs. Prior to joining Real Time Medical Systems, Phyllis led the development of a preferred provider SNF network for PENN Medicine Lancaster General Health. In this network she developed and implemented strategies that reduced total cost of care and readmissions while improving quality measures and patient outcomes. She utilized system approaches, clinical standards, and care management tactics to improve coordination and transition of care while reducing post-acute length of stay in a network of non-owned SNFs. 

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