Unity Health Network has taken a progressive approach to create and execute an effective Post Acute Care strategy. Doing so provides our organization with three main benefits: to ensure our patients have access to the post-acute care capacity needed; to ensure successful participation with value-based payment models; and to keep post-acute care patients who do need readmission, within our continuum of care.

The first step was to develop a network of partnerships with preferred post-acute care providers. These providers offer a continuum of post-acute care services (skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, hospice care) that ensure appropriate geographic coverage, high-quality care and strong patient experience, and efficient use of resources.

Partners are selected based on evaluation against carefully developed criteria, with a heavy emphasis on quality performance and cost management, as well as willingness to accept hospital/system input into post-acute care standards and protocols. STAR ratings and LOS in post-acute settings, as well as readmission rates to acute care, are also among criteria commonly considered.

Once selected, Unity Health Network’s Quality Improvement committee reevaluates the preferred post-acute partners’ quality and outcomes data on a quarterly basis to ensure the organization is still within the parameters of the preferred network status.

With 30-plus home health agencies, skilled nursing facilities, and other post-acute care organizations in the Unity Health Network market area, some of the objective quality measures, such as Star ratings, do not always reflect true quality or value. We also take into consideration data around actual patient outcomes in as real time as possible, as one of the biggest challenges with reviewing claims data is the difficulty of talking about events that happened 10 to 18 months ago. Partnerships are also assessed by reputational insight and interpersonal/staff collaborative support.

We are always looking to align with facilities and home health agencies that do a good job of managing patients with certain diagnoses while improving quality, reducing length of stay, reducing readmissions, and enhancing patient experience.

In addition to simply creating a network of preferred providers, Unity Health network’s Post Acute Care strategy also includes a number of tactics to help us reach quality and value goals, including transition coaching programs, medication reconciliation programs, and involvement in collaboratives of post-acute care organizations that meet regularly to create functional care programs that help patients transition home and stay there. Unity Health Network also continues to develop new initiatives focused on the post-acute care environment, such as working to share clinical information with regional hospital ERs to provide better care and avoid duplicate testing and reduce potential avoidable admissions.