Health Plan Executives Discuss the Integral Role Post-Acute Providers Play in the Future of Health Plans

November 15, 2023 | Written by: Real Time Medical Systems

Health plans continue to face challenges as they assume responsibility for care that extends beyond the walls of their network’s facilities, specifically, in post-acute care (PAC). In 2021, Medicare spent $28.5 billion on skilled nursing facilities (SNFs) – representing a significant percentage of member care coming in at an extremely high cost.

So, just how important is it for health plans to partner and build a post-acute network? More significant than you would think.

Real Time recently sat down with a group of health plan executives to learn more about the challenges and successes they face in achieving value-based outcomes with post-acute partners. Also included in the discussions were the strategies, tools, and tactics health plans are encountering as they develop high-performing post-acute networks.

Here are some of the key takeaways from the sessions.


Post-Acute Care – The Benefits of Re-Evaluation for Health Plans

We wanted to understand how post-acute care currently fits in with health plans strategic goals and if this care setting is significant enough to not only invest in, but to help drive better member outcomes and decrease overall costs. Some of the responses we heard included, “while it may not hold the same weight as Medicare, there is an opportunity to identify best practices for quality care within SNFs.” Other executives felt that being able to identify high quality providers within post-acute facilities, so members are cared for appropriately and are having positive outcomes that decrease readmissions is vital. Additionally, ensuring appropriate length of stay (LOS) and safe care transitions (long-term facility, home, etc.).

A segment of the health plan executives stated the post-acute segment is definitely a focus for them, linking to Medicare with the transitions of care measures and the impact on 5-Stars ratings – something they’re always striving to improve on within this metric. Some noted that they are at the point where a lot of their facilities have made the switch and are now looking for additional areas to increase efficiency in that transition. Beyond transitioning from in-patient rehab to SNF and from SNF to home, executives are looking more at the finer details of ways to improve this process. While the participants don’t have preferred provider networks currently, they do have contracts with non-member providers for value-based payment arrangements.


Managing Members in the Post-Acute Care Setting

During our sessions, we asked participants who we’re not currently partnering with a post-acute network, how their member’s care is being managed and at what level are they being within this setting. Responses varied, with some executives focusing on ensuring that post-acute providers understand their role and the value they bring in longitudinal care management. It is an area that health plan executives are thinking of in terms of Accountable Care Organizations (ACOs), and advance primary care models with financial risk for providers. For some, it’s a multifaceted approach, lacking a large provider population shouldering the majority of the risk for PAC. Therefore, it is dependent on their desire to be either in or out of scope for the utilization management (UM) review and really a blended interaction between case management and UM programs. Others noted, providers in the value-based payment arrangements are being assessed on their performance to drive total cost of care, and reaching out after discharge is a way to improve that, while incorporating specific Quality Measures (QMs) targeting outreach post-discharge.

A few participants are challenged with locating a SNF that is able to take a complicated member, spending a lot of time and effort making those coordination’s. Some are doing automated care coordination to try to leverage overlays for electronic records to facilitate better insights and analytics – treating the member with the right level of care, in the right setting, and using data to drive those type of actions.  Whereas other participants have already invested in a care coordination tool, providing a 360 degree view of their member – building in the appropriate workflows to successfully manage the care continuum. Some contributors already have facilities, making the communication easier while working from the same workflows. Alternatively, we found that many participants were just starting to have the discussions and begin the groundwork within the post-acute setting. Verifying that although the communication is present and the data is available, there are still resource limitations.


Assessing Post-Acute Network Performance

For members in a post-acute setting, we asked our participants how they were assessing their care providers performance. Some responses we heard were that they don’t have providers tracking and score carding currently, but it’s something their trying to develop more in depth to driver better outcomes and overall performance. What they are also looking is are the providers adhering to the specified LOS, are they being readmitted from PAC, and are they in the right care setting. Others do have measures being tracked on a specific level: follow-up within 5 days of discharge, readmissions, and medication reconciliations to name a few. We also discovered that a few have value-based programming for their SNFs, however, it is fairly new. With a focus on quality of care, they’re looking at what they can do with home care and ensuring their members are in the right setting, at the right time.

Also noted during our discussions in relation to the SNF value-based program, there are two key metrics being looked at and measured on – LOS and readmissions. Participants are trying to get better financial analytics and metrics to truly understand total cost of care at the granularity that it needs to be. It’s also important to not only look at it as a whole but breaking that down into population health types. Allowing providers to understand by case type, age, and other comorbid conditions on how they needed to address or adjust their plan of care with those members. Furthermore, health plan executives are looking to ensure care providers adhere to standards of care in the post-acute arena and helping to improve outcomes across the network. Early identification and treatment is crucial, but it’s also about making sure the treatment being provided is accurate, while following through on the plan of care.


Post-Acute Care Collaboration – Areas of Opportunity

To close our discussions, we wanted to understand the current areas of opportunity participants see with their post-acute partners. The quality of care that members are receiving, within the appropriate setting was the fundamental opportunity for all participants. Ensuring the appropriate level of care is being provided is critical. When members are at a point where they can be safely transitioned to the next care setting, it is integral for providers to be confident in supporting that transition successfully. We also heard that transitions of care was important and having those warm hand offs to and from the SNF are essential to successful patient outcomes. Additionally, setting the right expectations for how long a member is going to be in a post-acute setting, and effectively communicating the discharge plan. Also noted was being able to have clinical line of sight into their members care during their post-acute care journey and preventing the admissions back to acute settings is vital to a member’s outcomes.

Another big area of opportunity is ensuring the members have the necessary resources upon discharge. There is a big gap that is continually seen with many of the participant’s members, especially through readmissions – driving up additional LOS and costs. Leading to, another big area of opportunity is with appropriately managing LOS, understanding what is best for the member, and what can be treated in place in the post-acute facility instead of being readmitted to the hospital.


Utilize Data Analytics to Promote Relationships with Post-Acute Providers

As we wrapped up our discussions, we heard the pieces are there to begin building post-acute networks, but with more coordination and collaboration – especially on leveraging interoperability and data sharing across differing systems. “It’s really about being able to pull the right information at the right time, and having the right tools, data transparency, in the right hands that enables those relationships to be successful and improve member care and outcomes,” stated one executive.

Obtaining key clinical insights, at the time they are occurring can really make an impact on care outcomes in post-acute care – which seemed to be the consistent theme during our discussions. With Real Time’s Interventional Analytics solution, health plans can look at any member, at any time, and understand exactly where they are in the post-acute care continuum. By accessing live member information pulled directly from the SNF EHR, health plan providers can see critical structured data including vital signs and demographics, as well as essential unstructured data such as keywords within progress/nursing notes. With this live data and analysis, health plan providers can significantly improve member care and outcomes, while strengthening their post-acute partners to decrease costs.

To learn more about the ways Real Time can help, contact us today.

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