Fitting the pieces together: Why is choosing quality post-acute care so hard?

Stephanie Jackson | | October 11, 2017

Have you ever tried putting together a 1,000-piece jigsaw puzzle with all the pieces facing upside-down? Do you think you could do it? How about if you have five other people at the table, jostling for space, elbowing one another, rearranging the pieces you had just organized, each with their own agenda and strategy for getting to the complete picture? And what if none of those people was talking to each other? Picture this scene and you have some idea what it’s like to come up with a quality post-acute care plan for patients.

When patients are admitted to the hospital, it can be scary for them and their loved ones. All they want is to get better. Dealing with a health crisis can be overwhelming, even before you add the pressures of thinking about what will happen after the patient leaves, who will pay for it, and what their quality of care will be like. Many patients and families can only focus on the moment of the acute health crisis.

According to a 2015 report, “Report to the Congress: Medicare Payment Policy,” from the Medicare Payment Advisory Commission,1 about three million Medicare beneficiaries are hospitalized for a serious condition and then discharged to a post-acute setting in the US each year. As case managers, we know that in addition to providing the immediate care each of those patients need, there are healthcare workers behind the scenes, gathering at the table to put the pieces of post-acute care and discharge together from the moment the patient walks through the door. Stakeholders include the case manager, the patient, his or her family, the entire care team, and even the payers. Due to the complexities of many discharges, sometimes it seems like each person involved has his own cluster of puzzle pieces and is trying to put the whole picture together without being able to look at what anyone else is working on.

Mary, a sweet, 70-year-old lady who was living independently before her stroke, wants to return home and live life the way it was prior to her event. Her sister Lisa wants her in a rehab facility close to where Lisa lives so she can visit and help out. Mary’s daughter Susan, who has two kids and a full-time job, is sick with worry about how the family will afford the care Mary needs. On the healthcare side, physicians are feeling pressure to discharge as quickly as possible to keep the “revolving door” open and empty the bed for the next patient who needs it; CMS is imposing limits on both how long Mary can stay and penalties if she is readmitted (often a result of being discharged too soon); and case managers are scrambling to find the post-acute care options that are amenable to everyone involved, but more importantly, offer the highest quality of care for Mary’s individual needs. In this tense situation, it’s easy to forget what the final image will look like—a tranquil scene where everything fits just right.

Oftentimes, it feels like there are just too many moving parts to keep track of. Post-acute care options are abundant: skilled nursing facilities, physical and occupational therapy, nurses to administer medications, equipment providers, home health care, and more. How does Mary’s case manager or family know which facilities are best for stroke recovery, which ones have the best doctors, the lowest readmission rates, and the best quality outcomes? How can anyone decide how all these disconnected pieces fit together?

For many years, the responsibility fell squarely on the shoulders of the case manager—it became his or her job to flip all the puzzle pieces over, separate and organize them, and direct everyone at the table to work towards a complete picture. This challenging task involved researching facilities for every individual patient, acting as a liaison between all stakeholders, and making decisions that meet everyone’s best interests.

FierceHealthcare reports that in September 2016, expert panelists at the California Associations of Physicians Group (CAPG) Colloquium recommended four steps healthcare teams can take2 to make this task more manageable:

  • Order an evaluation to explore the possibility of home health
  • When discussing next site of care, ask, “Why not home?” to ensure the topic is broached
  • Consider palliative care options, which may best be administered at home
  • Communicate closely during handoff to a post-acute care facility (or with home caregivers) for high-risk patients

To take these and other steps in the right direction, healthcare teams need the right tools and data to make the best decisions. A July 2016 article in Hospital & Health Networks, titled “Why Post-Acute Care Partners Are Critical to Hospitals' Future,”3 notes that hospital executives “lack the formal mechanisms that might enable direct control of post-acute care, so they must establish relationships, processes and infrastructure to achieve coordination and control with trusted post-acute care partners.”

Fortunately, recent technology has provided the processes and infrastructure required, making the task of choosing post-acute care more manageable. What is needed is a robust database that both the clinical care team and the patient and family members can access to make sense of the choices available. Such a comprehensive database—with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information—is the only way to get everyone working together to build the complete picture.

Sometimes it can be hard to remember that everyone involved is building the same puzzle and working to the same end goal—the best possible care for the patient. With the right tools, together we can create a finished picture that we can be proud of, with pieces that interlock in precisely the right way.


About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination.