April 30, 2015

Connecting the Dots from Hospital to Home or Post-Acute Care

Center ensures continuity during patient transitions

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The post-acute care 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.

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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 created its Center for Connected Care, 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,” he explains. The center, which recently celebrated its second anniversary and 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 pharmacy
  • Home respiratory therapy
  • Facility-based physician group practices ‒ clinical staff are embedded at eight area SNFs
  • Home palliative medicine
  • Emerging transitional care programs

“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 are 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. For example, a hospitalized patient may be discharged to a SNF for short-term care, then to home with home healthcare, only to be readmitted to the hospital and discharged again ‒ this time to long-term acute care ‒ and ultimately into hospice.

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“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 guide the patient through the PAC maze carefully. “We’re striving to coordinate care in a seamless manner, to achieve better outcomes, to increase patient satisfaction and to 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.

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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.”

Refer a patient to the Center for Connected Care by calling 855.REFER.123.
Why should your patients choose the Center for Connected Care?
› PEACE OF MIND. Even after they are discharged from Cleveland Clinic, your patients can rest assured that our experts still will be at their side every day, overseeing their recovery.
› COORDINATED CARE. We will work with their other physicians, surgeons and specialists to continue their care and keep their healthcare team updated on their progress. Their transitional care will be recorded in the same electronic medical record used by their other Cleveland Clinic doctors.
› INDUSTRY LEADERSHIP. Continuing the care of our patients outside of our facilities is an innovative healthcare concept. Cleveland Clinic is an industry leader in developing this novel system of care.
› ONE OF AMERICA’S TOP 4 HOSPITALS. Cleveland Clinic’s Center for Connected Care provides the same excellent care that patients would receive anywhere else at Cleveland Clinic.

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