Because the post-acute care sector more and more transitions to a value-driven supply system, nursing services (SNFs) ought to contemplate taking part in an Accountable Care Group (ACO) to not solely assist obtain optimum outcomes, but additionally to uniformly enhance affected person care pathways. Constructing a clinically sturdy continuum of care entails long-term acute and post-acute care hospitals and suppliers working successfully collectively. Whereas solely a small share of sufferers require care in post-acute settings, this quantity is rising, with referrals to nursing services (SNFs) rising by greater than 10% over the previous two years. These sufferers additionally typically require essentially the most complicated and dear care, accounting for practically $60 billion in annual Medicare spending, placing them at greater threat for readmission as a result of they typically endure from a number of power situations and have the best want for ongoing care from physicians and specialists.

Accountable care organizations are designed to place sufferers on the middle of care to assist them navigate a posh healthcare system—notably by getting further assist managing power ailments. These coordinated care efforts offered by ACOs assist be sure that chronically unwell sufferers obtain the appropriate care on the proper time, with the aim of avoiding pointless duplication of companies, stopping hospitalizations and worsening of situations, and stopping medical errors. ACOs additionally place monetary duty on suppliers in hopes of bettering affected person administration and decreasing pointless spending, all with the affected person and their journey on the forefront of those efforts.

However SNFs have been reluctant to take part in ACOs. In accordance with a white paper printed by the American Well being Care Affiliation and Nationwide Middle for Assisted Residing (AHCA/NCAL) and the Nationwide Affiliation of ACOs (NAACOS), fewer than 2,000 SNFs actively take part in ACOs, which is about 10 p.c of SNFs nationwide. Even then, that share is concentrated in a small variety of ACOs, leaving 70 p.c with no SNF illustration. A nationwide ACO survey discovered that greater than half of ACOs had no formal relationship with SNFs, however the majority of ACOs are forming most well-liked SNF networks to enhance collaboration amongst sufferers, suppliers and facility employees, and to deal with the expansion and variability in well being care spending on this space.

However that dynamic might quickly change because the Hospital Readmissions Discount Program continues to penalize SNFs with greater readmission charges and withhold Medicare reimbursements from services. As extra SNFs are penalized and extra sufferers are referred to house care, becoming a member of an ACO could also be a strategic answer to enhance care coordination, organizational objectives, and affected person outcomes total.

Improved care coordination made simpler by expertise and knowledge

A fragile steadiness between expertise and human sources will guarantee seamless transitions of take care of complicated and chronically unwell sufferers from hospitals to nursing houses to house, decreasing fragmentation and bettering total high quality of care. By leaning on real-time knowledge and predictive analytics, built-in digital well being information (EHRs), telehealth companies, data-driven efficiency metrics, and patient-centered care plans normally, the well being system will see improved care coordination that encourages energetic affected person engagement in their very own well being journey, particularly when care could be tailor-made to their particular person situation, elevated adherence to remedy plans, and improved well being outcomes, which actively help the ACO’s objectives of high quality care and price discount. These outcomes and improved coordination are vital for ACOs, who profit from improved affected person outcomes and satisfaction—key metrics in shared financial savings calculations—whereas making certain the collaboration between ACOs and post-acute services that develops the foundational relationship that drives improved outcomes.

• Actual-time knowledge and predictive analytics: By leveraging real-time knowledge from distant affected person monitoring after which making use of superior analytics, ACOs and SNFs can higher coordinate care, enabling them to make extra knowledgeable scientific care selections that in the end forestall readmissions or worsening situations. Predictive analytics and historic knowledge can be utilized to foretell potential well being issues or sufferers in danger and proactively intervene earlier than they escalate, decreasing emergency room visits and hospital readmissions.
• Knowledge-driven efficiency measurements: Actual-time knowledge may also inform monitoring and reporting, giving ACOs the insights wanted to repeatedly enhance care processes and partnerships. These knowledge and different expertise instruments used to tell a affected person’s care journey allow proactive well being administration and well timed interventions that forestall expensive problems and emergency care that may erode shared financial savings and price sufferers their lives.
• Built-in Digital Well being Information: Moreover, improved expertise and knowledge sharing, notably in terms of EHRs, ensures that each one suppliers on the affected person’s care staff have entry to essentially the most up-to-date, complete medical historical past to assist forestall medical errors and enhance the standard of care throughout suppliers. Such a integration that technological developments present permits for seamless data sharing and continuity of care in some of the complicated areas of healthcare, the place gaps and silos of data could be detrimental to sufferers.
• Growth of telehealth companies: By leaning on expertise and knowledge to enhance continuity of care, we are able to concurrently develop entry to telehealth companies, which might present steady affected person monitoring and help for complicated situations, particularly in areas that want it most, similar to rural or underserved communities. Telehealth can facilitate common check-ins, treatment administration, and well timed interventions for sufferers with out the necessity for in-person visits or monitoring. This eases the burden on a supplier’s or facility’s restricted employees and permits them to see and deal with high-priority points whereas nonetheless offering high quality care in every single place.

How ACOs and SNFs can collaborate successfully sooner or later

Whereas ACOs are nonetheless working to extend the speed of engagement of long-term or post-acute care suppliers, most are presently creating networks of high-performing SNFs to make sure that well being techniques can refer sufferers to services that present the very best care obtainable. This strategic improvement is vital to sustaining management over the standard of care presently offered throughout settings, additional rising the potential for shared financial savings.

As ACOs and long-term or post-acute care services proceed to boost knowledge sharing and analytics by means of expertise help, the subsequent steps to strengthen a robust relationship between these entities ought to give attention to establishing complete integration protocols, strengthening affected person engagement initiatives, and monitoring and adjusting care methods. On the identical time, coaching and help for suppliers and employees needs to be expanded to align with ACO objectives and protocols, fostering a tradition of steady enchancment round patient-centered care.

These subsequent steps construct on a robust foundational relationship between entities, which in flip will likely be simpler in bettering affected person care, decreasing prices, and bettering total healthcare outcomes. This not solely advantages sufferers, but additionally contributes to the sustainability and effectivity of the healthcare system as a complete.

Picture: everythingpossible, Getty Photographs

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