Post-acute care has often been a black box for hospital-based physicians and nurses. Traditionally defined as the place where a patient is cared for after a hospital stay, but before they return home, it has become a significant part of a patient’s experience as pressure has increased to reduce hospital lengths of stay and readmissions.

Of particular concern, said Mass General’s Charles Pu, MD, is that post-acute care is a discipline very few physicians have actually trained for. As Medical Director for Care Transitions and Continuum at Partners, Pu spends a lot of time educating his colleagues and thinking about how to deliver post-acute care more efficiently while still providing the highest quality care.

“We need to think of post-acute care as a core part of the care continuum with many options for getting the ‘right patient to the right setting at the right time’ and not just a discharge destination after a patient has been hospitalized,” Pu said. “And one area where Partners has made significant strides is with our skilled nursing facility (SNF) initiatives, the SNF Collaborative and the SNF waiver.”

The change has not been easy, but it is critical for our future. Many of the things we’re doing are meant to safely keep patients out of the hospital while maximizing time in their community and their own homes.

Chuck Pu, MD, Medical Director for Care Transitions and Continuum

The SNF Collaborative, comprised of 59 facilities across Massachusetts, assures providers that their patients, once discharged from a Partners hospital, will be transferred to a SNF which has met specific standards for quality of care. Since the 2013 launch of the program, Medicare patients receiving care at a SNF Collaborative facility have had shorter lengths of stay, at a lower cost, and with a lower rate of hospital readmissions. They’re also more likely to leave the SNF with an appointment with their primary care physician scheduled within a week.

A waiver of long-standing Medicare rules, negotiated as part of Partners population health management initiative, is also helping to make sure that Medicare patients who only need skilled nursing care don’t have to be admitted first to a hospital in order to qualify for their Medicare post-acute benefit. For many years, Medicare has required a 3-day inpatient hospitalization before a patient could be transferred to a SNF. Pu said, “In the old days, a patient would go to the ER, and if they couldn’t go home right away and needed skilled nursing care, we would have to admit them first for several days at a cost of thousands of dollars per day before they could go to the SNF.” According to Pu, the SNF waiver allows certain patients to be admitted directly to skilled nursing facilities so they can get the care they truly need.

“With the SNF Collaborative and waiver, we’re redefining appropriate, safe, alternative care pathways from what hospital-centered care used to be. In addition to providing more rehabilitative services, high quality SNFs are now increasingly able to provide medical treatments that used to be done in smaller community hospitals and at an appropriate cost; a SNF may be just $500 a day compared to $3,500 for a hospital.” The result is the right care at a lower cost.

At Partners, we know these changes require a break from the hospital-centric way in which post-acute care was implemented in the past. But for Pu and other health care professionals who know hospital and post-acute care well, it’s a shift that must happen if we are going to provide the highest quality affordable health care.

“The change has not been easy, but it is critical for our future,” Pu said. “Many of the things we’re doing are meant to safely keep patients out of the hospital while maximizing time in their community and their own homes.”

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Topics: Affordability, Patient Experience, Innovation

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