Sharing patient data and making extensive use of analytics is crucial for providers looking to achieve success in the post-acute care market.

That’s particularly true for organizations that want to perform well in a value-based care environment, contends James Giordano, national director of population health management and value-based care for Kurt Salmon, a large management and strategy consulting firm.

As providers focus on strategic network development for the new healthcare environment, they’ve typically poured resources into optimizing hospitals, with little thought to the providers who care for patients before or after an acute care encounter. But care outside the hospital is rising in importance now, says Giordano, who led a session on post-acute care at Health Data Management’s Best Practices in Value-based Care conference in Dallas.

“Most attention has been focused around achieving acute care enterprise scale and the primary care physician role as gatekeepers,” he says. “But to manage that expense, you need to have efficient post acute care. The ability to achieve the best network performance is really the mover here. It’s a critical success factor, which includes having an enabling value-based care foundation that includes clinical analytics and a strong IT infrastructure.”

Analytics undergird efforts at Jordan Health Services, according to Scott Herman, its chief executive officer. The large home care agency provides in home care to patients in Texas, Oklahoma, Louisiana and Texarkana, Ark., including personal care services, home management, pediatric services, skilled care and hospice. It has 17,000 employees and more than 3.4 million patient visits, which it’s used as the basis for predictive analytics.

Scott Herman

It’s created the Synergy Program to anticipate the care needs of its patients, Herman says. For example, it looks at changes in activities in daily living that it believes are leading indicators of problems patients will encounter in their health levels.

Non-clinical staff who support patients in the home are able to use an app with a hand-held device to assess them with six yes or no questions, which Jordan Health research has shown to be predictors of changes in patient health conditions. These simple assessments include easy-to-identify patient issues, such as changes in skin conditions or ambulation.

The app alerts professional caregivers of patients who are experiencing changes in observable physical conditions, enabling them to work with the patient or send clinical staff to try and head off medical conditions that might require serious intervention, such as re-hospitalizations.

Jordan Health has collected 21 terabytes of data, and that enables it to conduct analytics on patient descriptions of patients who are most likely to have certain risk factors or die in the next 12 months. For example, 74 year old males who have fallen and have a hip fracture have about a 68 percent chance of falling in the next year, so Jordan Health can use data to pre-identify these patients. It says it found 600 of those patients in its database, and reduced falls among this small population by 48 percent, compared with what would otherwise be expected.

Overall, its reduced hospital readmissions on more than 40,000 of its patients to 6.5 percent, more than a third of the national average.

Post-acute care providers need a new perspective in working with acute care organizations, says George H. Terrazas, president, of the Texas Care Alliance, which represents 12 hospital and healthcare organizations throughout the state. He notes that, just like acute care facilities, post-acute care providers are undergoing a major shift in strategic focus, because their current strategy was built on the premise of maximizing revenues from government and commercial payers, solely on volume of care.

“Payments by Medicare for post-acute care reached $59.4 billion in 2013,” he noted. “That’s not sustainable for our nation, so we have to focus on new models of care. Existing payment models must be modified to enhance value for consumers and reduce payments for payers.”

Re-admission penalties are looming large for hospitals as well, totaling $280 million for 2,213 hospitals in 2015. That points to the need for more formal relationships between hospitals and post-acute care providers to which patients are typically sent for treatment or recovery after hospitalization.

For close partnerships between hospitals and post-acute care providers, sharing of financial risk and data integration are keys for success, Terrazas contends.

Texas Care Alliance organizations are working with a model that uses an RN care coordinator, who follows patients for 30 days after discharge to ensure recovery is going well for individuals. The approach has reduced readmissions by 50 percent, he says. TCA hospitals also are working on a transition program that uses an RN as a care manager who focuses on continuity of care for Medicare patients who are discharged to skilled nursing facilities.

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