Challenges in post-acute care
For people with complex health needs, especially if they are dealing with multiple chronic health conditions, that require longer-term care out of the hospital pose many challenges. When patients are moved from hospitals to a post-acute care facility, a post-acute care facility could be:
- Skilled Nursing Facility
- Home Health Agency
- Inpatient Rehab Facility
- Long-term Acute Care Hospital
Often, patients and care can become siloed with poor feedback loop between the hospital, primary care providers and the post-acute care facility. With the lack of homogenous and data-driven care, there is lack of adequate feedback regarding patient conditions and when to intervene. This often leads to large number of patients relapsing within 30 days of discharge from hospitals - Medicare patient readmission rate is ~20% within 30 days of discharge.Lack of effective care coordination, early intervention, and consistent care can exacerbate patient conditions leading to readmission.
What can Healthcare Organization Do?
Currently, CMS bundled payments are incentivizing Providers to target patient improvements in 30,60 and 90 days after episode or hospital stay. Since the onus of care improvement is not on a single organization but all Providers involved, the Providers must work in tandem to obtain the best value for the care provided. Thus implying reduction in inefficiencies, improvements in care coordination, and reducing cost of care. When the Providers are provided bundled payments, the adjusted fixed payment will cover the episode-related care services CMS believes should cost, any overages are the burden of the Providers or particular Provider. The CMS model has influenced private Payers to embrace bundled payment approach as well with growing popularity. For Providers involved in bundled payments, being impactful and efficient is the key.
Improving care quality and coordination requires access to timely meaningful information, effective patient engagement & communication, and the ability of clinicians/caregivers across the healthcare system to see critical information. This implies shared situational awareness amongst all caregivers with critical health-related data. EHR patient portals have opened new possibilities for patients to interact with clinicians and communicate with them in-between visits. However, patient portals are not effective for (near) real-time patient feedback and to monitor patient health status.
To improve patient outcomes and reduce readmissions,having accurate patient data is vital to recognize shifts in health trends. Telehealth capabilities such as remote patient monitoring and mobile health enable clinical teams to monitor patient health beyond vitals. With affordable options, patient’s can report symptoms, vitals data, and communicate with clinical teams all from single platform. This is a paradigm shift for healthcare – not only can readmissions be reduced, but low cost advanced technology can be used.
CMS’s BCPI (Bundled Payments for Care Improvements) Advanced, introduced end of last year includes 29 inpatient clinical episodes and 3 outpatient episodes. While BCPI is voluntary, it is a great opportunity for organizations to improve care and reduce cost. The BCPI Advanced episode beings at the day of the patient admission to the hospital or the day of the surgical procedure and continues for 90 days. Payments are adjusted for care quality and regional expenses. The care quality component has 7 separate measure, three of them:(1) All-cause Hospital Readmission Measure, (2) Advance Care Plan, and the (3) CMS Patient Safety Indicators will be required for all clinical episodes. The precedence of care improvement and coordination presents a great opportunity to use telehealth technology for patient care. Recent study have shown savings and improvement in patient outcomes by using telehealth technologies. Telehealth technologies can also be used for: (1) Risk stratification, (2) Remote symptom diagnosis, and (3) Monitoring and timely interventions. Additionally, it can allow Providers to schedule home visits (Physical therapy, Nurse follow-up, etc.) when needed and at the patients convenience. In fact, a study of bundled payments for comprehensive care for joint replacement (CJR) found on average $2,750 in savings per patient.
For healthcare organizations, there is strong incentive to improve care quality, coordination, reduce readmission, and improve earnings. Considering that telehealth technology is becoming more accessible and affordable and CMS is introducing more reimbursement options, the time to act is now.
DocToDoor is a custom branded Telehealth solution designed to empower physicians to manage care through the entire care continuum for post-visit, chronic care, and post-op recovery. We are empowering physicians with user-centric remote patient monitoring & engagement and telemedicine platform to manage and care for patients through the entire breadth of patient-provider relationship.