This post is sponsored by CareCentrix.
Efforts to improve value in health care have focused heavily on hospital care, but post-acute care (PAC) is costly and involves inconsistent outcomes, and patients may not be directed to the setting that is best for them. PAC optimization is an important method to improve the quality, cost and experience of health care, but it requires a new way of defining episodes of care plus data tools that allow for a personalized approach to care decisions. SmartBrief spoke with CareCentrix Chief Medical Officer Dr. Michael Cantor to learn more.
How do ongoing efforts to reduce length of hospitalization influence utilization of skilled nursing facilities?
Over the past 15 years, as hospital length of stay (LOS) has declined, we’ve seen an associated increase in skilled nursing facility (SNF) utilization, and spending on SNF care has risen substantially. In an effort to control this spending and improve value, many payers and at-risk provider organizations are now looking to more tightly manage SNF admissions and explore whether patients can be managed at home instead.
What are the care and cost implications of SNF utilization? When is it good for patients, and when is it not?
SNF utilization is good for many patients, but admission to an inpatient setting like a SNF must be based on the clinical needs of each patient. This decision depends on the patient’s ability to care for themselves and recover from a medical illness or surgery, as well as their rehabilitation needs.
Variability in SNF utilization suggests there may be patients who can be managed at home instead. For example, Medicare data shows wide variation in SNF use after hip replacement, and this variation is not explained by differences in patients’ clinical needs. In these cases, patient assessments focused on postoperative functional status should guide decisions about whether patients need rehabilitation in a SNF or at home.
This kind of need-based decision making can save money while improving care. Analysis of the Medicare Shared Savings Program Accountable Care Organization model found that the ACOs that saved money reduced SNF utilization. Using home-based rehabilitation and support instead of SNF care can reduce costs, limit risk of complications and improve patient experience.
Please describe the concept of “home to home” time and why it’s important to patients and payers.
Hospital LOS is the metric commonly used to measure resource use for acute illnesses. A recent New England Journal of Medicine article1 contends that a more meaningful measure is “home to home” time, which includes the length of all inpatient care, including stays in hospitals, SNFs and other inpatient rehabilitation settings.
From the patient’s perspective, this metric accounts for what matters: time away from the familiar and often comforting home environment, regardless of where care is provided. For payers -- who cover the bills for the entire acute episode of illness, including hospital, SNF and other inpatient settings -- “home to home” time is a more comprehensive and accurate way of understanding the length and cost of acute illness care. For some illnesses, post-acute care rehabilitation accounts for the majority of an acute episode’s costs.
When is home the right place for patient care and recovery, and what support systems are necessary?
The level of support needed depends on the patient’s strength and functional status. Some will need nursing or physical therapy visits, while others will also need home health aides or access to transportation to doctor’s visits and to get medications and food. Family caregivers play a prominent and often critical role in making sure the patient gets coordinated care, transportation, food and medications, so when patients live alone and don’t have caregivers, home may not be the best place for them.
New technologies that allow for remote monitoring of patients, video communication with providers and administration of medications in the home will make it easier for some patients to get treatment at home rather than at an acute care hospital or SNF.
What tools are available for directing patients to the right setting?
New tools use big data and predictive analytics to identify the best path of care for a discharged patient. CareCentrix uses these tools to determine not only whether a patient needs a SNF stay or home health services, but also to evaluate the best provider for that care by accounting for data from past cases involving similar patients. This type of personalized, objective determination of the best path for a specific patient is far more effective than relying on reputation or access to select a SNF or home health agency. Of course, it is not a substitute for clinical judgment, but a helpful adjunct that can lead to better outcomes.
Dr. Michael Cantor is a geriatrician with over 20 years’ experience in designing and implementing population health and quality improvement programs for health plans and healthcare providers. He is currently Chief Medical Officer for CareCentrix, a home care and post-acute care benefits management company.
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1. Barnett ML, Grabowski DC, Mehrotra A. Home-to-Home Time - Measuring What Matters to Patients and Payers. N Engl J Med. 2017 Jul 6;377(1):4-6.