Post-acute care leaders are navigating a tightening financial and workforce landscape even as new care models expand what’s possible outside the hospital.
Home is becoming the new destination of care and post-acute is being repositioned as a strategic driver for hospitals and health systems, all of which post-acutes leaders are excited about. But despite growth, there are several challenges leaders are facing.
Becker’s asked 23 post-acute care leaders from health systems across the country the same question: What post-acute challenge is keeping you up at night?
The most common challenges leaders highlighted included:
- Reimbursement and funding pressures, including Medicare Advantage denials
- Workforce shortages
- Capacity and patient flow
- Care transitions and coordination
Editor’s note: Responses have been lightly edited for clarity and length.
Matthew Bartels, MD. Professor and Chairman of the Department of Rehabilitation Medicine at Montefiore Einstein (New York City): The greatest challenges and concerns in post-acute care right now are in three domains. First, there is a lack of qualified healthcare providers for post-acute care. This includes nurses, therapists and, most importantly, home health aides to help people who require care and supervision. Workforce challenges due to immigration enforcement and fewer younger people in the workforce are creating a crisis in providing health services in post-acute care settings. The enrollment of family to help care for their relatives, and automation and robotics, may help address this.
Another challenge in post-acute care is the limitation of funds to pay for these services. Medicare and Medicaid provide a majority of the payment for post-acute care. There are many moves to try to limit payments or services, and this is a particularly acute issue as our population is aging, so an increasing number of people may require post-acute services. Automation may help with some of this, as long as the technology is priced in the “consumer device” range and not the “medical device” range.
Finally, we have a lack of coordination of care between health providers, institutions, insurers and regulators that is often dictated not by patient needs, but by the costs of services or consideration of the profits to be made in providing care. This creates an environment where innovation is often limited due to fears about costs or losses of revenue, and leads to a lack of responsiveness that we need in the changing environment of healthcare as we have an aging population and often people who need services but may have limited family support. The lack of coordination is also, in part, a lack of a unified mission and vision for post-acute care in the United States, and could benefit from a policy based on providing the best possible services while maximizing efficiency in an environment where resources are not unlimited. Unfortunately, we have a great deal of inefficiency in the current system that causes existing resources to be spent less efficiently and limits our quality of outcomes.
Patricia Buiocchi, BSN. Chief Operating Officer of Post-Acute Care at MaineHealth (Portland, Maine): The challenge that keeps me up at night is ensuring access keeps pace with demand. We’re serving an aging population with higher acuity needs while navigating workforce shortages, reimbursement pressures and increasing expectations for quality and performance. In Maine, these challenges are amplified by the fact that we are the oldest state in the country, and we’re facing significant capacity constraints across the post-acute continuum. Skilled nursing facilities routinely operate at or near 90% occupancy, available beds continue to decline, and the state lacks long-term acute care hospitals, limiting placement options for medically complex patients. As a result, many patients remain in acute care hospitals long after they are clinically ready for discharge. That is not patient-centered care, and it creates bottlenecks throughout the healthcare system, delaying access for others who need hospital-level care. The stakes have never been higher, because post-acute care now plays a critical role in the success of the entire healthcare system. The organizations that will lead the future are those that can expand access, scale innovative care models, leverage technology intelligently and build strong clinical partnerships while never losing sight of what matters most: delivering exceptional outcomes for patients and families.
Peter Chang, MD. Senior Vice President and Chief Transformation Officer at Tampa (Fla.) General Hospital: The first is the fragmentation in the record systems. Many times, when a patient is discharged from the hospital, do simple things like the medication reconciliation forms get to the post-acute settings? Are they looking at them? Can they see them? What’s the method of transfer? Insight into bed availability in the post-acute space is always a challenge for us: who really has capacity to take patients out of the acute care setting into post-acute care, like inpatient rehab and skilled nursing. Those are the main things. We have a good support network of independently owned assisted living facilities in the area, but some of them are higher quality and some are lower quality. So it’s always kind of a crapshoot on where you get that patient to go for the initial placement. So there’s the information exchange, and then information coming back to us if the patient ever gets admitted or, unfortunately, readmitted. Do we have information coming back to us on the patient’s primary issues and what they’re dealing with? We rarely have insight into that. They just show up on our doorstep, sometimes really sick, and we don’t know exactly what led to that.
The second challenge is the reimbursement structure. One of the things we explored here at Tampa General was SNF to home, but there really isn’t a reimbursement model for that type of care. So we tried to cobble together a couple of things we have. We have home health with rehab, we have home health with some nursing support, we have some chronic care management reimbursement for our ACO patients, and remote patient monitoring would be the fourth realm. If you take all of those and cobble them together, could you actually create something sustainable for skilled nursing at home?
Jane Cipriano. Director of the Post-Acute Service Line at Concord (N.H.) Hospital: While the growth of the program and the ability to add a post-acute care option with the Concord Hospital Health System are one side of the coin, the challenges that healthcare leaders face are the other side. Access to care in rural communities, lack of long-term care placement options, and reimbursement are just a few of many. Collaboration and community connections are important ways to address these challenges and effect positive change for the people in our communities.
Diane Ehn. Vice President of Post-Acute Care for the Froedtert & the Medical College of Wisconsin Health Network (Milwaukee): Workforce shortages remain one of the biggest challenges facing post-acute care providers. Staffing constraints can limit facility capacity and make it more difficult to place patients, particularly those with complex medical needs. At the same time, demand for services continues to grow as the population ages.
Another concern is whether post-acute providers will have the resources to implement new technologies that can enhance care coordination, improve quality and safety, and help address staffing challenges.
Finally, there is a need for payers to expand support for home-based and transitional care services. New reimbursement models and care options will be critical to meeting growing patient demand, reducing placement barriers and ensuring patients receive the right care in the right setting.
Melissa Frias. Interim President and COO, CNE VNA of Care New England, and Executive Director of Kent Hospital at Home, Geriatrics and Palliative Care (Providence, R.I.): The challenge that keeps me up at night is the deepening workforce shortage colliding with the inherent isolation clinicians can experience in the home environment. Field staff navigate complex, acute clinical scenarios without the immediate physical backup available in a traditional hospital ward. Because of this, it is paramount that we build robust operational structures to ensure our front-line clinicians feel fundamentally supported, safe and seamlessly connected to agency resources. Safeguarding our workforce from the emotional and physical strain of isolated clinical decision-making is not just a retention strategy; it is a foundational pillar of clinical safety.
Nathan Goldstein, MD. Chair of the Department of Medicine at Dartmouth Health (Lebanon, N.H.): What keeps me up at night is that healthcare systems have historically done a poor job matching the care we deliver to what patients actually need and prefer. One way we’re addressing that is by building our Vickie French Hospital at Home program, which takes the hospital to patients instead of bringing patients to the hospital. That means our doctors and nurses go to the home, along with medications, labs and monitoring equipment — so patients can receive acute-level care while staying home, surrounded by family. This program has been made possible through a generous donation by Ken French, honoring his late wife Vickie, whose philanthropic vision transformed our ability to deliver care where patients actually want to recover.
Danna Lamont, DNP. Nurse Practitioner Lead for Post-Acute Care Services; Thuan Ong, MD. Medical Director for UW Post-Acute Care Services at Harborview Medical Center; Mengru Wang, MD. Assistant Professor of Division of Gerontology and Geriatric Medicine at UW Medicine (Seattle): The financial pressures in post-acute care and its downstream consequences have always been worrisome, but perhaps never more so now. In the last decade, Washington state has lost approximately 12% of its skilled nursing facilities (SNFs) due to closures. Chronic staffing shortages, higher nominal wages and restrictive immigration policies have led to wage competition and higher operational costs for post-acute care facilities. Reimbursement and revenue are equally challenged by expected reductions in Medicaid funding, ongoing pressures to reduce lengths of stay from Medicare Advantage plans and value-based payment models, and continued decline in the number of fee-for-service Medicare patients. These pressures will negatively impact the access and care that patients receive. The average out-of-pocket cost for a SNF bed is $438 to $532 per day. How do we ensure that the most vulnerable and disadvantaged patients still have access to post-acute care? How do we reduce societal inequities and optimize health outcomes at the patient level within these constraints? Emergency rooms and hospitals will be negatively impacted too, as discharges are slowed and readmissions increase from less-than-ideal discharge plans.
Aashka Mehta. Vice President of Post-Acute Care at Cone Health (Greensboro, N.C.): Staffing. I literally had a call with HR this morning about what we’re doing about staffing. I think we lost a lot of people — I don’t know the full story, but after COVID-19, we lost so many healthcare workers who just opted to leave the field, and that keeps me up at night. We want to maintain facilities that are five-star. We have amazing technology now, we have data, we’re making data-centric decisions — all of that is great, but you still want that nurse by your bed. When you press that call button, you still want somebody to help you. You still want that therapist to walk you from your bed to the bathroom to get your mobility up and going. I wonder, at a statewide and national level, what policies health systems can influence to restart — you know, how back in the day we could get staff from other countries. What can we collectively do? I’d even challenge Becker’s to put something together for next year’s conference to bring political liaisons together to talk about what we could do to influence the national government to ease off on some of these policies so we can get healthcare workers back into the country and do something meaningful. Bedside nurses are definitely where we see the most opportunity. One thing Cone Health also does is take LPNs through a bridge program — LPN to RN — so you’re working with us while going back to school to get your RN, and your livelihood increases as you grow professionally. If we loosen up some policies and get more folks into this country, that opportunity extends to bedside nursing and, I’d say, primary care physicians too.
Katrina Melton. Vice President of Post-Acute and Palliative Care at Sentara Health (Norfolk, Va.): The challenge that concerns me most is the growing impact of social determinants of health on our patients and families. Every day, patients are faced with difficult decisions, whether that means choosing between purchasing medications and paying household expenses, struggling to find timely access to a primary care physician or specialist, or lacking the caregiver support necessary to remain safe and successful at home. I think often about our seniors and how they will continue to afford living independently as the costs of housing, healthcare, transportation and daily necessities continue to rise. While I am incredibly proud of the way our team members partner with community organizations and leverage available resources to support our patients, the need continues to outpace the resources available. One of the greatest challenges in post-acute care today is balancing a patient’s personal goals and desire for independence with the need to ensure their safety and well-being. As reimbursement pressures and ongoing revenue reductions continue across the post-acute landscape, I worry about the long-term sustainability of services that our communities depend on. My concern is not simply for our organizations, but for the patients and families who rely on these services to remain healthy, independent and connected to their communities. Ensuring access to high-quality post-acute care in the years ahead will require innovation, collaboration and a continued commitment to addressing the social and economic barriers.
Nathan Nartey, MD. Medical Director, Rehabilitation at Hospital for Special Care (New Britain, Conn.): A big challenge is ensuring our patients receive the appropriate level of care while navigating increasingly difficult insurance restrictions, particularly with Medicare Advantage plans. Our ultimate goal is to maximize functional independence and recovery for patients. Currently, only those who meet the strict criteria for long-term acute care are admitted, which excludes many patients who could benefit most from these programs. We frequently encounter patients who meet the clinical criteria for acute inpatient rehabilitation but are denied authorization, meaning they cannot access the best path to recovery. Ultimately, these decisions can delay recovery, limit meaningful rehabilitation opportunities, and place additional strain on patients and families, while delaying acute care discharge and the emergency department flow at acute care hospitals. We as a medical community need to continue advocating to be the final decision makers on what level of care patients with devastating injuries and medical disorders receive.
Mara Prandi-Abrams. Patient Flow Administrator at Denver Health (Denver): Probably two things. One is the aging population — the “silver tsunami” — and whether there will be enough facilities, home health agencies, guardians and so on to care for that population as it ages. That worries me. And then there’s our population experiencing homelessness — especially as that population ages, given their high acuity, figuring out what care settings will meet their needs.
Susan Sales. CEO of NYC Health + Hospitals/Gouverneur (New York City): Residents who want to be independent while living here are often a challenge. Any injury that occurs at the nursing home is something we’re very concerned about, and that’s something we have to always be on alert for. What we’re also seeing now is continuing tightening of budgets and reimbursement, which is a continuous challenge with every annual state budget — and when federal budgets are passed, we have to continue to highlight the good work skilled nursing facilities do. Most recently, we’ve seen the impact extend to families living in the community as well, through those changes in reimbursement regulations.
Melissa Seccareccio, MSN, RN. Executive Director of Care Coordination at Southern New Hampshire Health (Nashua, N.H.): The challenge that keeps me up at night is whether patients can access the right support at the right time after they leave the hospital. Across healthcare, we’re caring for an aging population with increasingly complex medical and social needs. However, that population may not have the means to pay for certain services. Many in-home and long-term options are costly and require private pay, and many post-acute providers continue to face an ever-changing reimbursement infrastructure, along with workforce and capacity challenges. We know that a safe transition home or to another care setting, with the right amount of caregiver support, can make all the difference in a patient’s recovery. Ensuring those services are available and well-coordinated remains a top priority.
Mona Siddiqui, MD. Senior Vice President of Home and Community Care at Highmark Health (Pittsburgh): I don’t think I’m going to say anything that folks will be surprised by. Having people who are motivated from a provider perspective to join our teams — and to stay, with good retention — is a real challenge. I think we undersell the importance of what these providers are doing in the home; they’re doing tremendous work caring for these patients and their families. So the challenge is on us to make sure we’re continuing to create a work environment that feels inviting, that has opportunity for professional growth, and where they feel respected and supported. That’s going to continue to be a focus for us — making sure we’re creating a good place for our team members to come to and to stay.
Cathy Smith. Executive Director of Rehab Services at WakeMed Health & Hospitals (Raleigh, N.C.): We’re having to fight to keep the money. Right now, we can provide the care, and it can be excellent care for all the right reasons. But once we’ve completed the care, we’re facing multiple audits in the form of either prepayment or postpayment reviews, where there could be a technical denial that takes that money back for services we’ve already provided to the patient. That puts facilities in a predicament, because we’re fighting technical issues that sometimes have nothing to do with the care or quality of care provided to the patient. That’s another challenge I think we’re facing on a daily basis.
Tim Switaj, MD. Vice President and Chief Population Health Officer at WellSpan Health (York, Pa.): The biggest challenge for us in post-acute care is that there simply is not enough of it. Post-acute care is a high-risk time for a patient, and it can be difficult to place patients in the best care setting for them. The shortage of beds is being driven by high demand, given an aging and increasingly sicker population, coupled with resourcing constraints. Additionally, longer lengths of stay in post-acute facilities are impeding our ability to discharge patients ready to enter post-acute care. The need exists to rethink our determination of appropriateness for post-acute care settings and give stronger consideration to how we can manage patients differently in nonfacility settings.
Regina Tarkovsky, MD. Post-Discharge Acute and Transitional Care Physician Leader at Maimonides Medical Center (New York City): What keeps me up at night is that discharge can create a false sense of completion. From the hospital’s perspective, the acute problem may be stabilized and the patient may be ready to leave. But from the patient’s perspective, that is often when uncertainty really begins. They are going home with new medications, new limitations, new questions and often a family that is trying to absorb all of this at once. I worry about the gap between being medically ready for discharge and actually being ready for recovery, because that is where small problems can become consequential very quickly.
Jennifer Vennare, DNP, RN. President of UPMC at Home and Vice President of Population Health at UPMC (Pittsburgh): What keeps me up at night is the thought of someone feeling overwhelmed or unsupported during healthcare transitions from the hospital to the home. A goal of post-acute care is to make sure patients and families have the support, resources and clinical expertise they need to recover safely and successfully at home.
That’s why continued focus on improving access, care coordination and workforce development are such important priorities. When those pieces come together, we reduce barriers, create a more seamless experience and help people stay healthier, more independent and connected to the care they need in the right setting.
When care transitions are managed thoughtfully and support is available in the home, we can often prevent avoidable hospitalizations, help people maintain their independence and make more thoughtful use of health care resources. Ultimately, that’s better for patients, families and the sustainability of the health care system as a whole.
Beth Villena. Director of the Rehab Hospital at WakeMed Health & Hospitals (Raleigh, N.C.): The biggest thing we’re facing is access to care, and this comes from a variety of different angles. Individuals who need different levels of post-acute care are having to fight battles to access what they need, and there are multiple culprits behind this. Medicare Advantage plans are acting as gatekeepers for services — people who have a qualifying diagnosis to come to inpatient rehab or a skilled nursing facility are being told no, they don’t have that access, while someone with a traditional Medicare plan does. So you’re seeing a disparity there. You’re also seeing it with people who are unfunded and underfunded for services. For example, home health agencies literally can’t afford to provide care to individuals because of the low reimbursement rates they’re getting from some of these companies. So they deny access to care in that situation. They have a contract, and the payer would pay, but the rate of reimbursement is so low that they can’t stay in business taking care of those patients. So we’re seeing patients leave the inpatient rehab hospital with no access to follow-up services, because they can’t get to outpatient rehab and home health isn’t an option for them because of where they live and what other resources they have. To me, that’s a travesty. These are people who have lives ahead of them, and if a small amount of money were invested in them post-accident, post-injury or post-surgery. They could thrive, and instead they’re left with home exercise programs that we can provide for them to do on their own, getting back half the return, if that.
Nataliya Yakovleva. CEO of NYC Health + Hospitals/Coler (New York City): One of the significant challenges facing Coler and other safety-net healthcare providers is the ongoing pressure created by insecurity of Medicaid funding. Medicaid reimbursement usually covers 70% of the cost of care and often does not fully reflect the true cost of providing comprehensive, high-quality care, particularly for our residents with complex medical, behavioral health and long-term care needs. At the same time, residents may require extensive services and support despite having limited or no resources to contribute toward the cost of their care. These financial pressures make it increasingly difficult to sustain the staffing, programs and resources necessary to meet the needs of our residents. As a public healthcare organization, however, our commitment remains steadfast: Every individual deserves compassionate, dignified and equitable care regardless of their ability to pay. Finding sustainable funding solutions and strengthening Medicaid support will be essential to ensuring that we can continue to fulfill this mission while maintaining the quality of care our residents deserve.
