Post-acute care (PAC) providers are critical partners in the transition toward a more integrated, value-based delivery system, panelists said at a May 1 special AHA Annual meeting briefing.

Panelists described the new partnerships emerging between hospitals and PAC providers and the regulatory thicket that stands in the way of getting patients the best possible care across the care continuum.

“Remove the regulations and give us the freedom to design the care that gives the best patient value,” said Lynn Jones, president of Christiana Care Health System’s Visiting Nurse Association (VNA) in Wilmington, Del., the state’s largest home health agency.

He talked about innovative approaches to coordinating care, such as Christiana Care’s Care Link project – part of the Centers for Medicare & Medicaid Services’ Bundled Payments for Care Improvement initiative. Care Link’s team of nurses, case managers, social workers, pharmacists and physicians provide comprehensive care from pre-surgery through 90 days after hospital discharge. Care Link also treats patients throughout Delaware supporting Christiana Care’s Accountable Care Organization.

In its first year, Care Link supported more than 2,500 90-day bundled-payment Medicare patients. Fewer than 9% needed to be readmitted within 90 days of leaving the hospital, compared to 18% during the baseline period before Care Link management.

Collaboration with PAC providers helps hospitals get patients to the right PAC setting; gets patients home faster; reduces readmissions; achieves an appropriate length of stay and improves efficiencies and clinical care and outcomes, said David Chernow, president and CEO of Mechanicsburg, Pa.-based Select Medical, a health care organization that owns long-term acute care and inpatient rehabilitation hospitals, as well as occupational health and physical therapy clinics. 

Select Medical recently launched a telemedicine service with Cleveland Clinics' clinical care physicians to expand specialty services to long-term care hospital patients in Avon, Ohio.

“We will clearly need regulatory relief in the future” to continue designing post-acute care innovations, Chernow said. 

Peter Mantegazza, president of Birmingham, Ala.-based rehab provider HealthSouth’s northeast operations, described the clinical collaboration between Barnabas Community Medical Center and HealthSouth Rehabilitation Hospital in Toms River, N.J. HealthSouth specializes in treating patients recovering from stroke, brain injury, multiple trauma, orthopedic injuries and surgery, neurological disorders, amputations and other debilitating conditions.

“We recognized the need to tear down silos to drive coordinated, efficient outcomes and reduce transfers back to acute care,” he said, adding that the “move to value-based payments needs patient-focused collaboration with post-acute care.”