3 Steps for ACOs to Build Effective Post-Acute Care Networks


Guidelines from the real-world experiences of ACO leaders.

Climbing up steps

Accountable care organizations (ACOs) are increasingly realizing that they must establish post-acute care networks of preferred providers in order to control costs and maintain quality of care for their post-discharge patients.

When it comes to optimizing networks of post-acute care providers-which include skilled nursing facilities (SNFs), long-term acute care hospitals, inpatient rehabilitation facilities, home health care, and hospice and palliative care-the healthcare industry has lots of room for improvement.

Related: Do MSSP ACOs Result In Improved Outcomes And Lower Costs?

More than 40% of Medicare beneficiaries receive post-acute care after a hospital discharge, which cost Medicare more than $60 billion in 2015. Additionally, 73% of overall Medicare geographical spending variance can be attributed to post-acute care utilization variation, according to the Institutes of Medicine. This variation is associated with increased costs and lower quality and outcomes.

To establish a strong post-acute care network that improves care coordination, ACOs should follow these three steps, gleaned from the real-world experiences of ACO leaders who gathered at a roundtable meeting organized by PatientPing, a technology company that enables real-time health information connectivity and coordination of care.

1. Perform a network evaluation 

A data-driven network evaluation will help ACOs identify patterns of current post-acute resource utilization and any gaps in their existing networks. The primary goal of post-acute care coordination is to place patients in the lowest-cost setting that is appropriate for their conditions. A network evaluation will help ACOs determine to what extent they are fulfilling that objective.

“We began by assessing our highest-volume SNFs and looking at their star ratings, length of stay, and readmission rates,” says Ann Marie Niemer, systems director of preferred provider network with AMITA Health, a faith-based health system delivering care to nearly 6.6 million residents in Chicago and its surrounding suburbs. “From here, we selected a preferred network of 14 SNFs, which has since been expanded to 30.”

2. Maintain engagement with preferred providers 

To facilitate better collaboration with post-acute providers, it is critical that ACO leaders prioritize engagement and open communication with their partners. Consider creating a list of guidelines, which explain to providers best practices and expectations around patient experience and care plan development, for example.

“Build trust with your preferred network by holding each other accountable; follow up quickly on any issues that they may be having and build relationships,” says Niemer. “One way we do this is by holding preferred provider meetings, which gather our SNFs together to discuss and review expectations and performances.”

Niemer adds: “Care coordination technology helps us stay connected with our post-acutes, monitor our ACO patient populations, and reduce the time and effort required of our staff to determine where patients are going to receive care. Over the last few years, we’ve been able to decrease our length of stay by nine days, and our readmission rates are down 12% to 13%.”

3. Make it easy for patients to access your network

Unless they’ve had previous experience with post-acute care, most patients and caregivers will be unsure of their best options for obtaining that care. ACOs should endeavor to make it easy for patients to connect with preferred providers by performing outreach and giving patients lists, maps and other tools to aid in decision-making.

“Our organization relies heavily on our primary care physicians, including advanced practice providers, to make phone calls to caregivers or family members on patients who were admitted to a hospital or SNF and help coordinate their post-acute stay at one of our preferred facilities,” says Ewa Matuszewski, CEO of MedNetOne Health Solution, the first physician-based organization in Michigan to actively pursue and contract with community agency organizations to provide access to a broad network of community care services.

While the steps to establishing a preferred network may at first be time- and resource-intensive, ACOs that complete the journey are likely to be rewarded with happier, healthier patients and more manageable costs.

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