The Centers for Medicare & Medicaid Services (CMS) “Pathways to Success” rule for Accountable Care Organizations (ACOs) has five goals: accountability, competition, engagement, integrity, and quality, all aimed at improving patient care. But as today’s ACOs assume more down-side risk, and seek to regain their equilibrium from the upheaval of the COVID-19 pandemic, they must adopt a sixth objective – increasing shared savings in their network.
Where do ACOs go to find those additional savings? Each part of their network is already focused on providing the highest quality patient care while keeping costs to a minimum. However, are the ACOs keeping close eyes on their patients as they move through the network, particularly from acute to post-acute care (PAC) settings? After all, the ACO remains responsible for the outcomes for those patients, and thus the shared savings, no matter where the patients are being treated or rehabilitated.
Accessing and using current patient data generated during PAC stays is one way in which ACOs can track what’s happening to their patients in real-time. By doing that, information needed to improve care is revealed in a timely manner…and shared savings can grow.
Before we look at the four ways this data transparency can boost ACO shared savings, let’s step back and examine why this clarity into the post-acute component of an ACO is so important.
How are Patients Doing in the Here and Now?
The post-acute network is the highest cost segment in an ACO. Within that network, skilled nursing facilities (SNFs) account for nearly half of all PAC costs. So it makes sense that they also present the greatest opportunity for ACOs to reduce costs and increase shared savings. These facilities often cope with the fewest resources and limited medical skills. They, and their ACOs, tend to use predictive analytics to evaluate patient trends and outcomes. Unfortunately, those analyses are usually based on outdated and static data, and calculate trends based on industry standards.
But PACs have a massive amount of frequently generated patient information right at their fingertips, residing in their patients’ electronic health records (EHRs). For the post-acute facilities, and their ACOs, this EHR data offers a clear view into how patients are doing in the moment. Here are just some of the benefits it offers:
- Facility and network trends can be identified and addressed early, without waiting three months to assess claims data
- Strong PAC performers can be quickly recognized, and their best practices shared within the network
- Root cause analyses of outcomes can be performed when everyone still remembers what happened and why
- Good constructs and communications can be formed to help patients better transition to other segments of the ACO network
With fully transparent post-acute patient data, the PACs and ACOs both have greater control of outcomes. This is where the increase in shared savings is realized: from better risk stratification, improved clinical performance, reduced acute readmissions, and shorter lengths of stay (LOS).
- Using Data to ID At-Risk Patients Improves Resource Management
Risk stratification is a major tenet of efficient care management. Patients at the highest risk tend to need the greatest amount of resources. Sharing live clinical data from PAC EHRs enables ACOs and their PAC partners to look at pain scores, vital signs, and pulse ox, as well as pre- and post-admit and readmit histories, to readily understand what’s happening to each person and what is driving their clinical risk. They can then deploy the right resources at the right time based on each patient’s risk level.
ACOs and their PAC networks achieve greater shared savings when staffing and supplies are efficiently delegated to their most vulnerable patients. These can range from telehealth sessions with hospital nurse case managers to the ACOs providing PACs with additional scales to monitor patients with congestive heart failure. Data transparency helps the facility and the network more rapidly identify subtle clinical signs that could lead to a hospital readmission or a poor outcome for the patient, making it easier to avoid unnecessary care costs.
- Consistent, Data-Driven Clinical Performance Leads to Efficient Care
The creation, deployment, and management of standards of care are vital to the success of an ACO. When post-acute networks collaborate with their ACO to establish clinical pathways by care type, they produce a beneficial day-to-day guide for each patient. Sharing PAC EHR data enables the network to outline necessary functional activities, medications, treatments, and education for each patient throughout her or his stay.
Education in the PAC setting is such an important piece of care that is often overlooked. Not surprisingly, most patients absorb less than 50 percent of the information they’re given in the hospital. When acute care facilities share that education with their PAC partners, the post-acute provider can reinforce the patients’ understanding and create a more consistent care journey. Working together, PACs and ACOs also can increase the odds of better clinical outcomes and shared savings by:
- Setting interim goals
- Targeting a discharge date and creating a discharge plan
- Coordinating care goals with patients and families
- Knowing the level of rehabilitation patients can tolerate
- Reducing Readmissions Starts with Fundamental Information and Collaboration
Historically, most patient transitions from acute to post-acute care consist of the transfer of the patient, a stack of paperwork, and little or no report. This is the first place where data can begin to affect a PAC network’s readmission rate. When an ACO hospital ensures that the patient is completely stable before transfer, and provides basic data and a medication list for each patient before arrival to a post-acute facility, it lays a foundation for reducing rehospitalization.
With each readmission costing $14,800, ideal readmission rates are five-to-seven percent. With the majority of post-acute care provided by certified nursing assistants (CNAs) and non-licensed personnel, ACOs must offer data-based acute care guidance on how cases should move forward and not return to acute status. Data transparency is complemented by other initiatives aimed at reducing readmissions including:
- Conducting testing and treatment in PAC facilities rather than the ER
- Bringing in specialists to identify key indicators
- Leveraging telehealth between acute and post-acute facilities to manage emerging issues
- Transparent Data Keeps Lengths of Stay Manageable and Cost-Effective
A post-acute patient stay should be in the 10-to-15-day range, despite the Medicare average of 26 days. The network saves $600 for every day that a patient’s stay is shortened. When ACOs access and evaluate their PAC network’s patient data, a length-of-stay analysis contributes to greater shared savings, too. The right data helps determine current and desired functional states, when patients might be ready to move to the level of care, and what the network expects patients to be able to do once they leave post-acute care.
What else promotes shorter LOS? Determining each patient’s next stop in advance. Will that person be living independently or need home care? ACOs can make sure their PAC partners are giving their patients everything they need to succeed when it’s time to make the next transition. PACs and their ACOs should regularly discuss all new PAC patients as well as any patients whose stay has exceeded 15 days. Families are another important component of the length-of- stay conversation. The patient’s status, the need for spouse or other caregiver respite or training, and the allowable versus necessary LOS must all be considered.
PACs Appreciate ACO Support – and a Share in the Savings They Create
ACOs might think that their post-acute network knows its own business, and would not welcome ACO involvement in patients’ PAC care. In fact, PACs appreciate ACO guidance and resources that lead to better patient results – and lower PAC costs. Seeing the value of post-acute patient data can enable ACOs and PACs to develop a trusted partnership that puts patient responsiveness and care first.
When such a partnership is established, ACOs can reward their post-acute network with financial incentives from their improved shared savings. If the PACs are doing a great job driving patient outcomes, financial motivation keeps them focused and engaged in the overall success of the ACO.
ACOs now provide healthcare to 32 million Americans, reflecting the industry’s move towards value-based care. By taking advantage of data transparency with their PAC networks, ACOs are making that care model – along with additional shared savings – a reality.
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