Post-Acute Care: What to Know and How Hospitalists Can Improve Care-Slides

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This presentation by Dr. Robert E. Burke highlights the critical importance of post-acute care (PAC) for hospitalists and strategies to improve patient outcomes. Post-acute care, often involving skilled nursing facilities (SNFs), home health care, or inpatient rehab, plays a growing role in managing older adults after hospitalization. Hospitalists must understand PAC to address hospital gridlock caused by patients awaiting SNF placement and to enable smoother discharge planning.<br /><br />Key challenges in SNFs include limited advanced medical capabilities, understaffing (often high nurse-to-patient ratios), frequent staff turnover, and financial constraints. These factors impact the quality of care and patient outcomes, with only about 65% of SNF patients successfully returning home within 100 days post-discharge.<br /><br />Hospitalists can improve PAC outcomes by enhancing decision-making on discharge timing and patient placement, using tools like Medicare Compare for selecting high-quality SNFs, and partnering with SNFs through shared clinical resources, data exchange, and quality improvement (QI) programs. Examples of effective hospital-SNF partnerships feature shared geriatricians, joint meetings, shared electronic medical records, and coordinated medication review.<br /><br />Policy changes such as accountable care organizations (ACOs), bundled payments, and value-based purchasing are reshaping PAC by incentivizing quality and cost-effectiveness. However, hospitalists need to incorporate prognostication to inform discharge decisions, avoid inappropriate long-term acute care hospital (LTACH) use, and consider home health care as a viable alternative to SNFs in many cases.<br /><br />Dr. Burke summarizes eight practical takeaways: bring resources to support SNFs, engage humbly in partnerships, use data effectively, build sustainable QI frameworks, select providers wisely, prognosticate thoughtfully, consider delaying discharge by a day if possible, and leverage value-based purchasing to motivate leadership.<br /><br />Overall, hospitalists’ active involvement and collaboration with PAC providers, informed by data and supported by evolving policies, can improve the quality, efficiency, and patient-centeredness of post-acute care.

Keywords

post-acute care

hospitalists

skilled nursing facilities

discharge planning

patient outcomes

quality improvement

accountable care organizations

value-based purchasing

home health care

long-term acute care hospital