JAMDA xxx (2016) 1e2

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Letter to the Editor

“Post-Acute Care 2.0” Regarding Burke RE, Whitfield EA, Hittle D, et al. Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes. To the Editor: The useful analysis of Burke et al1 prompts us to describe how we are using such insights to develop a next-generation model of readmission reduction. The broader domain of long-term care continues to pose stubborn challenges,2 but post-acute settings offer multiple conspicuous opportunities for improving quality, decreasing costs, and preventing unnecessary patient and family suffering. Readmissions are the leading indicator of our successes and failures in post-acute care. Burke et al1 highlight several key issues, including timing of hospital discharge, patient selection for level of care and therapies, the care processes in place before and shortly after discharge, and timing of clinician visits. The California Association of Long Term Care Medicine has extensive previous experience teaching Quality Assurance Performance Improvement implementation3 and combining the INTERACT program4 with intensive interprofessional training followed by one-to-one mentoring of staff. Reports about this structured mentoring approach are beginning to appear.5 We are now building on this experience in developing PostAcute Care 2.0 (PACare 2.0), which widens our scope to include the entire post-acute ecosystem. This is the same lens through which a community’s delivery systems view the post-acute continuum, including skilled nursing facilities (SNFs), home health, palliative care, hospice, primary care, specialist care, home-based primary care, and community-based services. Adding a layer of care coordination staff to span this ecosystem can help but is costly. Standardizing communication and care processes across settings will get more directly to the heart of the problem. Burke et al1 point out vulnerabilities leading to readmissions from SNFs, but analysis of internal managed care data available to us reveals that the number of patients readmitting after discharge from their SNF stay, while still within the 30-day post-acute period, is similar to the number readmitting during their SNF stay, even though the post-skilled period is shorter. Most of these readmissions represent failed SNF-to-home discharges, which call into question the adequacy of coordination between the SNF and follow-up care providers. PACare 2.0 focuses attention on that transition in particular, as well as optimized integration of home health and community-based services either directly following http://dx.doi.org/10.1016/j.jamda.2016.01.009 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

hospital admission or following the SNF stay.6 Attention to SNFs in isolation from the ecosystem’s other elements will have limited impact. PACare 2.0 also takes a unique approach to improving postacute care by bringing together rival delivery systems to share best practices and standardize care processes across the community. Such an approach has been used in California by the Right Care Initiative, a multi-stakeholder, public-private collaboration focused on cardiovascular health.7 The Right Care Initiative’s “University of Best Practices” approach in San Diego and Sacramento8 goes beyond familiar collaborative peer learning models by engaging all major delivery systems within a single metropolitan community in multiyear improvement efforts. Burke et al1 describe several specific financial incentives apparently at play in their 2003e2009 dataset. That description is beginning to look quaint to many of us, at least in California, who already live in a value-based world. Public and private accountable care arrangements abound, in addition to baseline managed care penetration. Multiple hospital systems are now enrolled in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement initiative,9 with upside/downside risks for 90day episodes of care for fee-for-service Medicare patients. Nearly all provider organizations either bear risk themselves or depend for market share on others who do. Partnership has become imperative.10,11 In sum, PACare 2.0 is likely to succeed because of the following new levers for change:  Significant new financial incentives for hospitals, medical groups, and post-acute providers.  Deployment of new measurement tools (eg, real-time 30-day and 90-day readmission data with covariates available for fee-for-service and managed care populations).  A focus on readmissions as the emotional hook for staff, not merely as a leading indicator for cost and quality: each unplanned readmission is a failure of our delivery system.  Collective engagement of the community’s large delivery systems as drivers of practice change, supported by a multistakeholder community coalition.  New models and measures of interprofessional and interorganizational coordination, such as relational coordination.12,13 PACare 2.0 will take advantage of insights from the nowextensive literature on readmissions, but as Burke et al1 point out, we still need prediction models for who will do well and who will not, with what type of care. Those prediction models should be made publically available. Approaching post-acute care as a community ecosystem, with real-time data, will accelerate development of new care processes and standards to the benefit of patients, families, payers, and postacute staff.

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Letter to the Editor / JAMDA xxx (2016) 1e2

References 1. Burke RE, Whitfield EA, Hittle D, et al. Hospital readmission from post-acute care facilities: Risk factors, timing, and outcomes. J Am Med Dir Assoc; 2015 Dec 20; pii: S1525-8610(15)00705-7. http://10.1016/j.jamda.2015.11.005. [Epub ahead of print]. 2. Kane RL, Kane RA. The long view of long-term care: Our personal take on progress, pitfalls, and possibilities. J Am Geriatr Soc 2015;63:2400e2406. 3. Bakerjian D, Zisberg A. Applying the advancing excellence in America’s nursing homes circle of success to improving and sustaining quality. Geriatr Nurs 2013; 34:402e411. 4. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc 2011;59:745e753. 5. Chodosh J, Price RM, Cadogan MP, et al. A practice improvement education program using a mentored approach to improve nursing facility depression care-preliminary data. J Am Geriatr Soc 2015;63:2395e2399. 6. Institute of Medicine. The Future of Home health Care: Workshop Summary. Washington, DC: National Academies Press; 2015. 7. Rodriguez HP, Ivey SL, Raffetto BJ, et al. As good as it gets? Managing risks of cardiovascular disease in California’s top-performing physician organizations. Jt Comm J Qual Patient Saf 2014;40:148e158. 8. Right Care Initiative. Available at: http://rightcare.berkeley.edu. Accessed December 24, 2015. 9. Centers for Medicare and Medicaid Services. Bundled payments for care improvement (BPCI) initiative: General information. Available at: https:// innovation.cms.gov/initiatives/bundled-payments. Accessed December 24, 2015. 10. Maly MB, Lawrence S, Jordan MK, et al. Prioritizing partners across the continuum. J Am Med Dir Assoc 2012;13:811e816. 11. Lage DE, Rusinak D, Carr D, et al. Creating a network of high-quality skilled nursing facilities: Preliminary data on the postacute care quality

improvement experiences of an accountable care organization. J Am Geriatr Soc 2015;63:804e808. 12. Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: A ninehospital study of surgical patients. Med Care 2000;38:807e819. 13. Rundall TG, Wu FM, Lewis VA, et al. Contributions of relational coordination to care management in accountable care organizations: Views of managerial and clinical leaders. Health Care Manage Rev; 2015 May 14; [Epub ahead of print].

Terry E. Hill, MD Hill Physicians Medical Group San Ramon, California Dan Osterweil, MD California Association of Long Term Care Medicine Los Angeles, California SCAN Health Plan, Long Beach California Debra Bakerjian, PhD, APRN, FAAN, FAANP Betty Irene Moore School of Nursing UC Davis Health System Sacramento, California Albert Lam, MD Palo Alto Medical Foundation Palo Alto, California

"Post-Acute Care 2.0" Regarding Burke RE, Whitfield EA, Hittle D, et al. Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes.

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