The significant role that post-acute care plays in bundled payments makes it crucial for hospitals to identify providers that perform the best and enter into agreements with them to establish a high-performing post-acute network, according to John W. Malone, MOD, vice president at Novia Strategies, a national healthcare consulting firm.

Malone recommends that case management be part of an executive team that chooses providers with which to collaborate.

Case managers should assess the post-acute providers to which the hospital refers patients and determine which ones historically take the highest number of patients, have the highest quality scores, appropriate nurse-to-patient ratio, best readmission rates, and other quality measures, and work with the administration to develop preferred provider relationships with those who come out on top, suggests Graham A. Brown, MPH, CRC, vice president and practice lead for population health and bundled payments for GE Healthcare Camden Group.

Close working relationships with post-acute providers are crucial for hospitals to succeed in today’s healthcare environment, adds Brittany Cunningham, MSN, RN, CSSBB, director of episodes of care for Vanderbilt Medical Center in Nashville, TN. “The stronger a hospital’s relationship with post-acute providers, the more successful the bundled payment initiative will be,” Cunningham says.

Hospitals have known for a long time that many of the problems with transitions from acute care to post-acute care stem from lack of communication between providers, Malone says. Building relationships with post-acute providers is extremely important, but it takes more than that. The kind of collaboration that is needed between providers often doesn’t exist and has to be developed, he adds.

“Succeeding under a bundled payment arrangement means taking the silos that exist in healthcare and breaking them down. Since hospitals are at risk financially, even when patients are in a post-acute setting they need to be able to provide clinical oversight and measure quality and cost outcomes throughout the 90-day time frame of the bundle,” Malone says.

Bundled payments require a different operating model and a different type of relationship with post-acute providers, Brown adds. “The partners need a data exchange so the hospital case manager can know what is happening with the patient in the skilled nursing facility or home health and so that post-acute providers can know what happened during the hospital stay,” he says.

Arrangements with partners in the post-acute network must include very clear measures and metrics so hospitals will know what is happening after patients are discharged, Cunningham says.

Hospitals should work with post-acute providers to establish performance measures and use them to monitor the performance of their partners, adds Deirdre Baggot, PhD, MBA, RN, principal at ECG Management Consultants and expert panel reviewer for the Bundled Payment for Care Improvement Initiative.

She suggests using measures that include major drivers of costs, such as complication rates, length of stay, and readmissions, and getting the data as close to real time as possible. Other measures, such as patient experience of care, use of ancillary services, and physician utilization, are secondary to the financial effect of the bundle but should be tracked nevertheless, she adds.

Collect and analyze data to show providers and post-acute care partners how their performance stacks up against their peers. Include length of stay, costs, readmissions, readmission penalties, and other pertinent data, Brown suggests. CMS provides hospitals participating in bundled payments with claims data. “Case managers can use this data to show whether a facility or a physician is an outlier,” he says.

When it’s time for patients covered by a bundled payment arrangement to go to a post-acute provider, the ideal situation is for patients to be treated by a provider that has contracted to be part of the bundle and has an excellent track record for patient care, Malone says.

However, both the Balanced Budget Act of 1997 and Conditions of Participation (COPs) for hospitals, among other sources, guarantee patients the right to freedom of choice, points out Elizabeth Hogue, Esq., a Washington, DC-based attorney specializing in healthcare.

“Many patients, however, do not yet know enough about post-acute services and providers to be able to make choices,” she adds.

Hogue reports that in the final rule on the Comprehensive Care for Joint Replacement payment model, CMS stated: “Hospitals, if desired, may recommend ‘preferred provider,’ that is, high-quality post-acute providers/suppliers with whom they have relationships (either financial and/or clinical) for the purpose of improving quality, efficiency, or continuity of care.”

“At the end of the day, hospitals need to honor the ability of patients to choose, but at the same time they can tell patients which providers they have partnered with to manage quality, coordinate care, and track the care plan for the entire 90-day episode of care,” Brown adds.

Brown also suggests that when surgeons meet with patients, they give patients the names of post-acute providers the hospital partners with and give patients objective data to support the quality of care.

Sentara Health System divides its list of post-acute facilities into blocks based on algorithms, their quality and safety indicators, and whether they are partners in the bundled payment project, according to Teresa Gonzalvo, RN, BSN, MPH, CPHQ, ACM, vice president for care coordination for Sentara Healthcare with headquarters in Norfolk, VA.

“We don’t indicate the reasons the facilities are divided that way but if patients ask questions about format, the care manager can tell them the hospital has a relationship with providers in a particular block. The hospital can’t steer patients to a particular provider, but we can give them the information that we have a relationship with a post-acute provider,” she says.