Tackling the ‘patient choice paradox’ of post-acute care selection
It's a familiar quandary -- one that healthcare organizations have faced for as long as hospitals have existed. Once a patient is ready for discharge, where does she go next to receive the most appropriate care to complete her recovery – and how does she go about making such an important decision?
In an era when providers are being consistently pressed to improve outcomes while reducing costs, the answer to this question has arguably never been so important.
Research reinforces the important role that such decisions can have on both outcomes and costs. Case in point – 2013 Institute of Medicine research found that 73 percent of variations in Medicare spending were due to cost variations in post-acute services such as skilled nursing and inpatient rehabilitation, home healthcare and long-term acute care. Interestingly, emerging payment and service delivery models, which in part aim to protect patient choice when it comes to post-acute care options – have in many ways placed a spotlight on this age-old challenge for patients, caregivers and providers alike.
Post-acute care: It shouldn't be a gamble
Let's consider the current industry dynamics at play. Hospitals are being pushed by payers to reduce lengths of stay while preventing avoidable and costly re-hospitalizations. As a result, patients and their caregivers have increasingly less time to make important post-acute care decisions. Hospital-based clinicians find themselves faced with a paradoxical challenge. They want (and need) to drive the best outcomes for their patients. Yet Medicare's patient choice requirements force them to leave important post-acute care decisions solely to patients or caregivers, who usually are not prepared for this challenge.
Further exacerbating this situation is the lack of time and information available to make these decisions. The majority of patients know relatively little about the differences between available post-acute care options. In many cases, they're simply handed an alphabetical list of several dozen facilities to consider for their post-acute care needs. This places patients in a particularly stressful position, especially given that they are repeatedly told that being an informed patient is essential to their role in ensuring a positive outcome.
Research shows that for these care-related decisions, most patients want data on quality and costs, yet they often have no idea where to look. When they do find information, they sometimes question its accuracy, and rarely do they feel they have the knowledge to translate that information into the best decision for themselves or their loved ones.
And therein lies the paradox. If patients are expected to choose which type of post-acute facility will best fit their needs, they need quality data. But in most cases, the data either is not available or not credible. And even when the data are available and understandable, research indicates that many patients prefer that clinicians make post-acute care decisions on their behalf. Despite all of these realities, patient choice requirements ironically still result in decisions that may be less optimal and force patients into a post-acute care gamble.
So, what's the path forward?
If we truly want patients to play an active role in improving outcomes and driving down costs, then providers, insurers and policymakers need to work together to start tackling this patient-choice paradox. Here are a few places to start:
1. Evolve toward an "informed patient choice" model. The reality is that while Medicare Fee for Service agreements do prioritize – and require – patient choice, these regulations do not preclude providers from helping patients make more informed choices. Indeed, in our experience working with patients and caregivers alike, the majority feel that it's at best unfair and overwhelming, and at worst detrimental, to expect them to make post-acute care decisions – with no or little healthcare experience, information, data or perspective to guide them. While patients deserve the right to choose where they receive care, they also deserve objective, credible data to help them make the most informed decisions.
2. Initiate post-acute care discussions as far "upstream" in a patient's healthcare journey as possible. All too often, hospitals don't start talking with caregivers and patients about the need to make post-acute care choices until those decisions need to be made immediately – often in a matter of days – or in some cases, hours. This approach leaves patients and caregivers, who are already under significant stress from a serious health event, feeling surprised, caught off-guard and time-crunched to make costly, and usually life-impacting care decisions. What they need, in addition to information, is time. Time to review their finances to determine what kind of care they can afford. Time to gain a better understanding of what kinds of care their insurance will cover. Often, they also need time to make phone calls or personal visits to facilities to educate themselves about the atmosphere that will best fit their needs. More time is needed, particularly considering that all these steps usually need to happen while caregivers are also managing the stress of maintaining families, other responsibilities, and full-time jobs.
We can, and must, do better. We need to move away from prompting these decisions strictly on an immediate, 'need to know' basis. We need to initiate these discussions as early as possible in the patient's healthcare journey, so they are more fully aware of (and can start educating themselves about) the range of health outcomes that are likely, based on their unique situation. These discussions also need to go beyond exploring just 'the next step' in a patient's episode of care. By using tools like evidence-based assessments, predictive analytics and advance care planning, we can help patients develop a more longitudinal perspective, so they can understand and better prepare for the next several steps in their healthcare journey.
3. Standardize and share quality and cost information to enable the most informed post-acute care choices. This is no small challenge, considering that the healthcare industry is only beginning to define what 'quality' looks like in a post-acute care setting. By standardizing select patient data collected from long-term care hospitals, skilled nursing facilities, home health agencies and inpatient rehabilitation facilities, the 2014 IMPACT Act, once fully rolled out, is intended to be a step in the right direction. A key goal of this act is to enable interoperability and access to longitudinal information in a way that makes it easier to facilitate coordinated care, improved outcomes and overall quality comparisons. However, as administrators of CMS have acknowledged, this standardization will be a process that will need to be honed over time. As this effort evolves, a next step will be to collect and analyze data to tell us which types of patients, at which phases in their healthcare journeys, recovering from which procedures, are the most likely to do well in each different post-acute setting. And which providers, in each setting, offer the highest quality care to fit each patient's unique needs.
4. Develop clinical decision support technology that provides actionable data to predict needs and optimize post-acute care
The availability of quality and cost data will not, in and of itself, help patients make more informed post-acute care choices. We also need to develop clinical decision support technologies that leverage this data to help predict each patient's unique risks, needs and best post-acute care options, based on each unique healthcare situation.
The technologies that will be most successful at accomplishing that goal will be those that enable the collection and analysis of data on core quality and health resource utilization records, and provide predictive modeling based on real patient outcomes and experiences. In order to be truly patient-centered, these technologies will need to capture data that impacts patient episode success – metrics such as lengths of stay, self-care, mobility and functional status – not just Medicare Star Ratings. They'll also need to provide the kind of information that can help caregivers plan and align expectations across an episode of care. The most useful clinical decision technologies will also focus on patients' needs and goals, utilization and outcomes, and they'll use a common language, across healthcare settings to enable longitudinal tracking and the ability to monitor quality across post-acute care sites. Perhaps most critically, the developers of these technologies will also need to understand that technology can never replace clinical judgment. That means they'll need to leave considerable room for clinical decision making.
By analyzing available data and making it actionable, emerging technologies can empower providers to offer patients and caregivers the kind of objective information that can truly place patients in the informed driver's seat of their own care.
5. Identify and share best practices to develop preferred post-acute care networks. As the industry awaits standardized cost and quality data that will be made available by the IMPACT Act, some leading health systems are already developing high performing post-acute care networks. These forward-thinking providers understand that when patients are offered reliable, consistent, fact-based and unbiased data from a trustworthy source, they're far more likely to make the care decisions that lead to better outcomes. And they're betting that, armed with this information, their patients are far more likely to experience higher satisfaction too. Although these networks can ultimately help reduce healthcare costs by empowering patients to make more informed post-acute care decisions, they can still be time-consuming and costly to develop. Providers would accelerate their progress by collaborating with industry experts, consultants and other healthcare entities to identify and share best practices in preferred post-acute care network development – this will help drive the widespread dissemination of resources that support patient and caregiver decision making.
While value-based care initiatives have made strides when it comes to improving patient outcomes while driving down costs, more needs to be done to position patients and caregivers, in collaboration with their healthcare team, to make smarter, more informed choices about the sometimes costly, often confusing and always critical post-acute care journey. The reality is that post-acute care has a significant impact on both patient outcomes and cost – and we cannot afford to continue to subject patients to post-acute care decisions that are the luck of the draw.
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Brian Fuller serves as vice president of Value-Based Care for navihealth, a Cardinal Health company, which partners with health plans, health systems, physicians and post-acute providers to manage the entire continuum of post-acute care.
Mary Naylor is a health services researcher who collaborates with health care organizations to promote the use of evidence-based best practices to improve the health and outcomes of at-risk chronically ill adults and their family caregivers.
Brian Fuller serves as naviHealth's Vice President for Value-Based Care, responsible for forging partnerships with providers across the healthcare continuum to improve care transitions, better manage post-acute care quality and utilization and enable success under a variety of new value-based care and alternative payment initiatives. In addition, Brian is considered a national expert on post-acute care focused on improving post-acute integration, network development and operations to better meet the goals of acute care hospitals/health systems and ACOs. Most recently he served as Vice President at Avalere Health and prior to that, Brian spent eight years as a senior strategy executive for Brooks Health System as their Vice President of New Business Development and Planning.
Mary D. Naylor, Ph.D., RN, FAAN, is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. She is the architect of the Transitional Care Model, a care management approach proven in multiple studies to improve health and quality of life and reduce healthcare costs among chronically ill older adults and their caregivers. Dr. Naylor was elected to the National Academy of Medicine (NAM) in 2005; she is a member of NAMs Leadership Consortium on Value & Science-Driven Health Care and co-chairs the Care Culture and Decision-making Innovation Collaborative. Dr. Naylor also is a member of the RAND Health Board of Advisors and the Agency for Healthcare Research and Quality National Advisory Council. In 2016, she completed her six year term as a member of the Medicare Payment Advisory Commission.
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