Transitions of Care: The Importance of Post-Acute Continuum Relationships

Source: CMSA Today


The summer has come to a close quickly after such a wonderful CMSA Annual Conference & Expo in Chicago. Each year, this event allows me to network and learn from peers on innovative ways to tackle the intricate supply and demand relationships within our organization.

As a director of care management at an academic medical center and level 1 trauma center, there is a constant balancing act of meeting, prioritizing and balancing the supply of available acute beds with the multiple placement requests from the emergency room, transfer center, direct admits and surgical patients. The overwhelming theme in those discussions is the need to partner and build relationships with the post-acute continuum (i.e., home health, skilled nursing facilities, long-term acute care hospitals and rehabilitation hospitals). Case management is often aligned and/or intertwined with revenue capture and discharge planning, but the central focus should be care progression. All of the above functions are focused on transitioning the patient out of the acute care hospital setting. My experiences at a number of academic medical centers and other healthcare organizations have solidified the critical need to build solid and effective relationships with the post-acute continuum.

My success as a director of care management is dependent on building relationships that allow the vertical silo mentality to be converted to a horizontal continuum approach. The days of “owning” the patient as “our patient” are gone. We must acknowledge that effective, efficient and individualized care is not episodic. Successful organizations understand that patient satisfaction, staff engagement and penalties for poor quality outcomes all play a critical role in how a healthcare network is evaluated. Any adverse outcomes should be reviewed from a quality and process improvement perspective to see where the gap in service could have been improved, without pointing the finger on an individual or organization.

A successful relationship includes holding regularly scheduled partner meetings to review what went well, explore what the opportunities were and determine how to improve the patient experience and outcomes. Establishing quarterly meetings with all post-acute partnerships also allows for the entire continuum to review trends and promote ways to improve interdisciplinary and collaborative practice. A successful initiative, in my opinion, is the establishment of a dedicated organizational role for post-acute relationships. This leadership role should focus on discharge planning and post-acute continuum of care relationships.

Patients, families, employers and payers are looking for the organizations that are focused on providing quality of care across the continuum. Competition within our healthcare delivery system will continue to escalate and will focus on outcomes across the continuum. Pointing fingers at component healthcare access or transition points will no longer be an effective strategy to reduce blame for patient outcomes — whether clinical or financial. We can no longer wait to collaborate.

As a seasoned case management leader, I spend a significant amount of my time educating the executive leaders on the different levels of post-acute care. In addition, it is extremely important to differentiate and teach the different levels of care with residents, fellows and attending physicians, extenders, case managers and other disciplines. Many times, it is very apparent that our clinicians are not fully aware of the continuum of care and appropriate options for the patients who are being treated within the acute hospital setting. Often, the focus is on the task of discharging the patient quickly because of the need for acute care beds. Instead, we must continually assess whether keeping a patient at the short-term acute level of care is the right level of care. Delaying a transition to the appropriate level of care reduces our opportunity to provide care at the right time and at the right place. Generally, the post-acute continuum has the capacity to accept appropriate patients.

Our healthcare delivery system is developing and implementing a number of outcome measures and pay-for-performance measures across the continuum of care. Many, if not all, U.S. healthcare organizations will have a vested interested in developing partnerships that are collaborative and are value-added. Successful organizations will accelerate partnerships and relationship building with all similarly aligned organizations and providers across the continuum of care.    ■

Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN

President (2018-2020), Case Management Society of America

Dr. Alejandro is the Director of Case Management at UC Irvine Health, Orange County’s only Level 1 Trauma and Burn Center.