Drive Better Outcomes From Your ACO Post-Acute Care Networks

With smartphones attached at the hip, apps that manage nearly every aspect of our lives, and social media feeds that keep us up-to-date, we may be connected 24/7, but real relationships still matter in business and in life.

The key to any successful relationship requires that both parties prioritize transparency, trust, engagement, and collaboration. As Helen Keller said, “Alone we can do so little; together we can do so much.” And nothing could be further from the truth when it comes to the partnership between Accountable Care Organizations (ACOs) and their post-acute care networks.

With the shift towards value-based care, the number of ACOs has grown exponentially, now covering 32 million Americans. Building strong post-acute care networks has never been more vital to their success, or more challenging.

Accountable Care Organizations: Laser-Focused on Skilled Nursing Facilities

Although primary care was initially a priority for ACOs, today most are focused on building post-acute care networks, providing quality care across the continuum, and finding the best ways to control and maintain their costs.

While post-acute care networks can be made up of several types of settings, a majority of the spending occurs in skilled nursing facilities (SNFs). According to a December 2018 report by The Commonwealth Fund, SNFs accounted for 54 percent of all post-acute care spending in 2015, followed by home health (33%) and inpatient rehabilitation facilities (13%). Though average expenses per patient in a SNF can be four times greater than average costs for that individual receiving paid care in the community, SNFs still maintain lower readmission rates than any other post-acute care setting. In fact, a March 2019 study in JAMA found that patients who received home health care were 5.6 percentage points more likely to be re-admitted into the hospital within 30 days than patients receiving care in a SNF.

As a result of high costs and spending variations in post-acute care, ACOs looking for ways to control their costs, and get their patients to the right SNF, at the right level of care and at the right time to meet their patients’ needs.

How ACOS Can Build Strong SNF Preferred Networks

As ACOS look to build effective relationships with their SNF networks, they should focus on 3 key areas.

1. Use the right data and analytics

Although many ACOs use claims data, this data is anywhere between 90 and 180 days old, and it’s not an effective way to make decisions in real-time. For example, the data may not have the clinical benchmarks they’re looking for, and it’s not inclusive of the actual patient risk or hospital readmission.

A more effective method is to use interventional analytics, which allows ACOs to capture live data and obtain direct line of sight within the SNF for their members so they can respond, communicate and make decisions based on the clinical record, and change the course of care to improve patient outcomes.

With interventional analytics, ACOs can work with their SNF partners to determine which patients are at higher risk for hospital readmissions and collaborate to intervene immediately.

2. Prioritize patient engagement

Studies show a lack of patient engagement is associated with increased re-admission rates. It’s important therefore, for ACOs and SNFs to have standardized education around disease states and offer consistent messaging across all levels of care.

3. Collaborate using the same platform

Data transparency and care coordination between ACOs and SNFs are crucial to lower readmission rates, but both parties should work from the same data platform. Doing so promotes effective dialog and strong partnerships to manage care and drive outcomes.

Real Time Medical Systems is the only company that offers an interventional analytics platform, which extracts nursing home data directly from most EHRs and generates live alerts and dashboards, allowing ACOs and SNFs to work from the same data.

Through CARD, Real Time’s patent-pending, patient acuity monitoring system, clinical teams receive a readmission risk score for every patient based on an algorithm that looks at the number of data points in the EHR. This allows ACOs to reduce readmission rates by 50% and successfully manage length of stay, 6 to 9 months after implementation. To learn more, contact us today.

Contributing Author

Phyllis Wojtusik, RN Executive Vice President, Health System Solutions

With over thirty-five years of health care experience in acute care, ambulatory care, and post-acute care, Phyllis has 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.

E. [email protected] P. 443.859.7120