Why We Need to Integrate Post-Acute Care

In post-acute care, it’s always been in everyone’s best interests to provide quality care, reduce costs and ensure patient satisfaction. Today, it also makes financial sense, to make sure reimbursements are appropriate and avoid penalties. There are things we must do in order to achieve these goals.

Embrace Each Other’s Skill Sets

For example, before a patient is discharged, hospital and pharmacy staff reconcile their medications. However, when home health performs medication reconciliation, we can look at the meds they received at the hospital, plus the ones in their home from before their hospital stay and the new prescriptions they filled on the way home. If there’s a potential for dangerous med interactions, home health care med-rec can keep the patient from landing back in the hospital. The pharmacy and the hospital may have done a good job, but they didn’t have access to the other two sets of meds. We need to embrace the most appropriate ways to provide care.

Invest in Innovation

Another example is a patient who goes from a hospital to inpatient rehab in a skilled nursing facility (SNF), then home healthcare. If the patient has an exacerbation while receiving home healthcare, traditionally home health would call the physician, and the physician would send the patient back to the hospital. But if the home health provider has the technology to note the inpatient rehab facility episode on the patient’s chart, and if its nurses have the tools to communicate the situation effectively to the physician, the patient might be returned to the SNF. There, the patient would have familiar caregivers, less anxiety, lower risk for infection and lower copays. The hospital wouldn’t face an unreimbursed rehospitalization. The physician and the home health company would keep their rehospitalization rates low and maintain good relationships with the SNF and hospital. And the SNF would gain a patient.

Rising to the Challenge of Change

There are significant barriers to making these kinds of changes. Innovation is expensive. Reimbursements are being squeezed. Some 8,500 of the 12,600 home healthcare companies in the U.S. do less than $2 million in revenue a year. They lack resources to invest in innovation, technology or systems.
Larger health systems will also need to devote resources to their home health and hospice services. New partnerships could bring operational, clinical and financial success to the entire hospital system, acute and post-acute.
There are financial ramifications if we don’t embrace a healthcare world void of silos. It’s as though a two-way street has changed to one-way: We must embrace change to get where we’re going.

—William Deary, CEO of Great Lakes Caring Home Health & Hospice, is a member of the Integrated Healthcare Delivery Advisory Board.