Looking Beyond the 4 Walls of the Hospital to Reduce Readmissions: The Value of Post-Acute Care Hospitalists

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Health reform measures are leading hospitals to focus more and more on the space beyond the physical hospital facility into post-acute and preventive areas. CMS' Readmissions Reduction Program, which lowers hospitals' Medicare payments for certain preventable readmissions, is resulting in hospital initiatives to improve discharge planning and follow-up with patients post-discharge. Partnering with post-acute care providers to ensure patients continue to recover post-discharge presents a significant opportunity to improve patients' health and reduce readmissions.

Dr. Jerry Wilborn is national medical director for post-acute care services at IPC The Hospitalist Company.Hospitalists in the post-acute care setting

Increasingly, hospitals recognize a variety of benefits when post-acute facilities add hospitalists to their staff. These physicians become medical directors at the post-acute care facilities and visit the patients several times a week to monitor their health and prevent readmissions. The frequency with which hospitalists staff the post-acute care facilities will vary depending on the patient census and acuity, but a good guideline is at least three times a week, according to Jerry Wilborn, MD, national medical director for post-acute care services at IPC The Hospitalist Company.


A post-acute care hospitalist arrangement can benefit all three parties: The patient benefits because he or she gets healthier; the post-acute care provider benefits because it retains the patient; and the hospital benefits from reduced readmissions.

Hospitalists at post-acute care facilities fill a gap in post-acute care, according to Dr. Wilborn. "Hospitals and physicians need to truly understand that patients in the post-acute setting are sick. Not only are these people really sick, but there are very few support systems in the post-acute space to get them better," he says. For example, nursing homes typically do not have imaging equipment such as MRIs, and they tend to have few physicians on staff. Placing hospitalists in these post-acute care facilities brings medical expertise and continuity to patients' care that can provide the support needed to keep patients out of the hospital.

A continuum of care needs continuity

Hospitalists in post-acute care settings can be physicians at a hospital who visit patients post-discharge in addition to their hospital duties, or, more commonly, hospitalists whose sole role is caring for patients in the post-acute setting. In both cases, there is a benefit to having an established relationship between the post-acute care hospitalists and the hospital, according to Dr. Wilborn. A hospitalist group that staffs for both hospitals and post-acute care facilities can facilitate communication between the two groups, which is critical when managing patient transitions, he says.

The post-acute care hospitalist should contact the hospital for additional medical information about the discharged patient, since the patient's hospital chart does not carry over in full to the post-acute care setting. Knowing specifics about the patient's medical history can mean the difference between a continuous stay at a post-acute facility and a readmission. For example, Dr. Wilborn says a patient at a skilled nursing facility may have obstructive sleep apnea but may not be compliant with his or her continuous positive airway pressure machine. If the patient has low oxygen levels at night and the post-acute care hospitalist is aware of the patient's history, the physician can quickly treat the patient. If the hospitalist was not aware of this information, however, the facility would likely have sent the patient back to the hospital, resulting in a preventable readmission.

Building relationships with post-acute care providers
Simply placing hospitalists in a post-acute care facility without first forming a relationship with the facility and its providers is not a strategy for success. Hospitalists have to work with post-acute providers to discuss patient care and how they can partner to prevent readmissions.

To build a relationship with post-acute care providers, hospitalists should educate the nurses at the post-acute care facilities, according to Dr. Wilborn. "Our back office support has been tremendously helpful. We bring resources to these facilities, not just in terms of providers, but in compliance initiatives, to make sure we're dong what we should be doing. We have training programs as it relates to federal and state regulations. It's a huge educational initiative," he says.

In addition to educating the post-acute care provider, hospitals should educate themselves about the post-acute care facilities in the community. Dr. Wilborn likens discharging a patient to a post-acute care facility to referring a patient to a specialist — one should recommend a provider that has a history of delivering quality care. "When in the hospital, a physician may [recommend] 'Dr. Smith' as a pulmonologist because he does a good job. It's no different when you're sending very sick and chronically ill patients to a nursing facility," he says. He suggests collecting information on what the readmission rates are for each post-acute care provider and then starting a dialogue about hospitalist staffing with facilities that have the lowest rates.  

More Articles on Hospital Readmissions:

Study: No High Readmissions for Early-Discharge Colorectal Surgery Patients With Enhanced Recovery Pathway
20 Statistics on Hospital Readmissions

Study: Safety-Net Hospitals Hurt Most by Readmission Penalties

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