Center Guides Patients through Post-Acute Care Maze

The post-acute care (PAC) continuum traditionally has been structured in silos, with each service run as a separate entity and little communication between hospitals and skilled nursing facilities (SNFs), hospice, home healthcare and others.

As healthcare moves from a focus on volume to one of value, the approach to post-acute care (PAC) needs to change, says Eiran Z. Gorodeski, MD, MPH, FACC. In response to that need, Cleveland Clinic opened its Center for Connected Care in early 2013, says Dr. Gorodeski, who is Director of the Center.

“The goal of our Center for Connected Care is to keep our patients connected to the highest quality of care as they transition from the hospital to home or a post-acute care facility,” Dr. Gorodeski explains. The Center, which includes more than 500 multispecialty caregivers providing daily care to approximately 3,500 patients, brings together all of Cleveland Clinic’s home and transitional care services, such as:

• home care
• hospice
• mobile primary care physician group practice
• home infusion pharmacyGeriatrics Center Guides Patients through Post-Acute Care Maze
• home respiratory therapy
• facility-based physician group practices —
  • clinical staff are embedded at twelve area SNFs
  • clinical staff are embedded at Select Specialty Hospital-Cleveland Fairhill to provide long term acute care to patients discharged from our health system
• home palliative medicine and
• emerging transitional care programs

The brave new world of value-based post-acute care

“Value-based healthcare is exciting because this is a brave new world where post-acute care is more important than ever,” Dr. Gorodeski says. “The way we view post-acute care within the Center for Connected Care is at a high level. We’re interested in bringing together the entire menu of PAC for patients in a holistic and integrated way.”

He adds: “Through our Center, we strive to provide a full continuum of care so that patients can recover from illnesses or injuries in the best location for their individual needs, with Cleveland Clinic caregivers at their side.”

Helping patients through the PAC maze

Traditionally, when patients leave the hospital, they “enter a complex and potentially dangerous maze,” Dr. Gorodeski says, that can include discharge to a SNF for short-term care, then to home with home healthcare, then rehospitalization and discharge again — this time to long-term acute care (LTAC) — and ultimately into hospice.

“The patient in this example just experienced five different venues and services along the post-acute care continuum, and what happens during that time can be highly variable — the quality of care, how the entities communicate, and the cost,” he says.

The Center for Connected Care’s goal is to reduce variability through an integrated, standardized approach — and to carefully guide the patient through the PAC maze. “Our goal is to coordinate care in a seamless manner, to achieve better outcomes, increase patient satisfaction and reduce costs,” Dr. Gorodeski says. “We’ve thought carefully about how the dots are connected and how they work together in order to develop this progressive model for post-acute care. Within the center, the leaders of each of the PAC areas work together on a daily basis to ensure continuity and integration.”

He adds: “It’s important to innovate and operationalize care as the healthcare system changes and to stay a step ahead. There’s no book you can read to tell you what the post-acute care continuum will look like tomorrow, let alone in the next 10 years.”

Improving quality while reducing costs

While quality of care is always the highest priority, providers operating in an environment in which reimbursement mechanisms for PAC are eroding must be more cognizant than ever of cost considerations.

“In today’s value-based healthcare environment, where we follow patients indefinitely with the goal of reducing costs during their entire lives, metrics such as hospital utilization rates and the cost of post-acute care are more important than ever,” Dr. Gorodeski says.

Traditional home healthcare reimbursement rates are dropping and hospice requirements are tightening, he says. “We now have a huge opportunity to standardize post-acute care, demonstrate better outcomes for populations, reduce costs, and achieve a financial win while also improving quality.”

Luke Kim, MD, staff in the Center for Geriatric Medicine, says that geriatric patients benefit greatly from the Center’s resources. “We are able to care for patients in whatever setting they call ‘home’ in the post-acute phase. Because our systems are technologically and administratively connected, we can allow patients to recover from illnesses or injuries without adding the additional stress and worry of disconnected care.”