Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands

Medicare's proposed payment rates and quality programs for skilled nursing facilities (SNFs) for 2017 and beyond solidify post-acute care's (PAC) partnership in the transformation of healthcare delivery.

Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient careónot just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Pre-publication discount on Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider DemandsPost-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient's journey through the network continuumódrilling down to improve the quality of the transition from acute to post-acute care.

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In this 25-page resource, Julia Portale, vice president of community services, Jewish Senior Services, and Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration, St. Vincent's Health Partners, describe how their two institutions have aligned around clinical standards to improve patient careódespite separate parent companies, health IT platforms, and other challenges.

In this dual venture, St. Vincent's Health Partners (SVHP), a participant in Model 2 of the CMS Bundled Payments for Care Improvement (BPCI) initiative spanning the acute and post-acute settings, created a post-acute care network of SNFs to streamline patients' movement through its clinically integrated network.

As a vetted SVHP network member, Jewish Senior Services, a post-acute care provider holding a 5-star rating in skilled nursing from CMS, contributes to a partnership that identifies potential problems across the patient care continuum and crafts cross-boundary solutions.

This special reports highlights the benefits that resulted when SVHP and JSS reacted to the industry's paradigm shift and opted to collaborate instead of compete in the post-acute care space, placing patients' needs above their organizations'.

Ms. Portale and Ms. Swedberg cover the following points:

  • Background on the St. Vincentís Health Partners Network and its motivation for aligning for change in an era of healthcare transformation;
  • Organization, tools and strategies of SVHP's cross-functional cross-boundary Transitions Leadership Group and how the group is breaking down care silos;
  • The role of the CMS BPCI initiative as a springboard to network development and collaboration;
  • Development of the SVHP best practice-based Care Transitions Playbook documenting more than 140 possible transitions for patients traveling from one setting to another;
  • Protocols driving SVHP network success;
  • Perspectives from SVHP Network member Jewish Senior Services, from the viewpoint of home care, rehab facility, and skilled nursing facility;
  • Opportunities to standardize common acute to post-acute care pathways;
  • The challenges of collaboration with organizations that may in certain scenarios also be competitors;
  • Prioritizing patients' needs even when delivering the most appropriate care might cannibalize an organization's own services;
  • The value of networks and flexibility in a post-acute care world;
And much more.

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