Bundled payment programs require effective care coordination encompassing the hospitalization and the post-discharge recovery period. Within this care coordination process, selecting the ‘next site of care’ after hospital discharge is a crucial element in the provision of high value patient care. Why? When looking at large data sets representing aggregate spending, the cost of post-acute care can rival that of the initial inpatient stay.(1) For many bundles, total 90-day episode spending for a patient discharged to a skilled nursing facility can be more than two times that of a patient discharged to home.(2)
Care At the Right Location
In many hospitals, the next site of care may be determined without input from the attending physician or other important team members. Therapists may document “recommend SNF” or a case manager may have a brief conversation with the patient and his/her family to arrive at this important decision.
Success in a transformed, value-based healthcare system will require a paradigm shift that elevates the importance of this decision. The new paradigm envisions the next site of care discussion occurring in a team-based environment using a checklist and validated decision support.
What are the factors the hospital team, patient, and family must consider when selecting the best next site of care? Based on an expert analysis of the evidence, Remedy Partners has identified the domains that impact the quality of post-acute care and created CARL (Care At the Right Location), a decision support tool that proposes the next site of care for a patient.* The following domains should be evaluated and discussed by the clinicians, patient, and family:
- Can the patient perform activities of daily living?
- Can the patient ambulate?
- How is the patient’s cognition?
The first two criteria can be qualified by whether the patient is independent, in need of assistance, or fully dependent in each area. Cognition can be rated as oriented, forgetful, or disoriented.
- If the patient needs it, is a caregiver who is capable and reliable available?
- If so, is s/he available 24 hours a day or less than 24 hours a day?
- Based on inpatient evaluation, does the patient require PT, OT, and/or ST?
- How much and for how long?
Skilled Nursing Needs
- What, if anything, does the patient require in this area? For example, a new PEG tube, wound care, IV therapies, etc.
Although the CARL assessment by design does not include a formal rating of the home environment, the hospital team should include this topic in discussions about next site of care. A number of tools, such as the ‘Safe At Home Checklist’, can be used to assess the home environment.
The Crucial Conversation
Reviewing and assessing each of these domains is important. Then a conversation with the team, the caregiver, and the patient reviewing these factors and how they impact the selection of a next site of care is crucial. Once the domains have been assessed and this conversation is held, and ideally not before, a decision is made about the next site of care.
The CARL tool uses a decision support algorithm to propose a next site of care. This CARL recommendation should inform the crucial conversation. For some patients who might otherwise go to a facility, a home recovery may be possible with advanced planning. For those who go to a post-acute facility, setting expectations for the length of stay in the facility should be part of the discussion. Ultimately, the goal is a safe transition and getting the patient home as soon as possible.
Care Redesign – Improving Quality and Affordability
At its core, bundled payment programs are about care redesign, or improving quality while lowering costs. Optimizing the next site of care decision in a deliberate, collaborative way is one of the most powerful ways to achieve better care at lower costs.
The CARL tool has gone through an evaluation utilizing clinical and claims data with nearly 1600 patients who completed an episode in the Medicare bundled payment program during Q2 and Q3 of 2014. In the evaluation, compared to what was observed, the CARL tool recommended that a larger share of patients be discharged to home and to home with a home health agency (an increase of 19% and 11%, respectively). Conversely, CARL recommended 26% fewer patients discharged to post-acute care facilities. The next phase of the evaluation looked at the potential effect of sending more patients home. Would this result in more hospital readmissions? We derived the answer by creating risk adjusted logistic regression models to predict 90-day readmission rates for patients discharged to home, to home with a home health agency, and to a post-acute facility. We found that, compared to observed 90-day readmission rates, predicted readmission rates were not significantly different.(3)
- Mechanic R. N Engl J Med 2014; 370:692-694.
- All Remedy Partners Phase I Providers (600+) Oct 2013 – March 2014.
- CARL Scientific Report. February 2016.