The Complete Guide to Post-Acute Care Coordination and Management

Do you need to improve your post-acute care coordination? Learn more about post-acute care management, including its benefits and how to improve your process.

Healthcare is a complex system, which means it can sometimes fail.

Because patients frequently change facilities or providers, communication errors can occur, causing critical patient information to become lost. This costs the healthcare industry millions of dollars each year and can result in patients receiving subpar care.

May 18, 2022

Healthcare reform has introduced a variety of new payment models designed to improve the quality of care patients receive. This transformation has led to the formation of value-based care (VBC) organizations, including Accountable Care Organizations (ACOs). Value-based systems enhance the quality of care delivered to patients across various providers by holding health systems financially responsible for patients after they are discharged or change providers.

Post-acute care coordination and management are critical now more than ever. But what is post-acute care coordination, why does it matter, and how can we improve post-acute care management?

Before we answer these questions, let’s first start with a definition.

What Is the Difference Between Acute and Post-Acute Care?

Acute care refers to medical services and treatments patients receive on a short-term basis. These treatments address injuries, accidents, and other causes of sudden need for medical attention.

The most common acute care settings include:

  • Emergency Rooms
  • Urgent Care Centers
  • Intensive Care Units

In many cases, patients in acute care settings require constant or significant levels of care. 

Post-acute care (or post-acute management) typically starts after a patient’s discharge from a hospital. Patients who require post-acute care are often still recovering from illnesses, injuries, or surgeries. Their post-acute care could involve long-term services or short-term rehabilitation. 

Some of the most common types of post-acute care include:

  • Skilled Nursing Facilities (SNFs)
  • Inpatient Rehabilitation Facilities (IRFs)
  • Long-Term Care Hospitals (LTCHs)
  • Assisted Living Facilities (ALFs)
  • Home Health (HH)
  • Hospice

What Are the Goals of Post-Acute Care?

Post-acute care’s primary goal is to improve patients’ wellness, independence, and recovery following acute care. Additionally, post-acute care helps reduce the risk of premature admission to long-term care facilities, such as nursing homes, or readmission to the hospital. These services also serve as a bridge between a facility and a patient’s home (i.e. SNF to Home, Hospital to Home, etc.) by assisting in the transition process.
While many at-risk post-acute care patients are senior citizens, patients of all ages can benefit from these services. The type of services and level of care a patient will need depends on their injuries, illness, or medical conditions.

What Is Post-Acute Care Coordination?

Post-acute care coordination is the process of managing a patient’s care after they leave the hospital and return home or enter another facility. This process involves communicating with the patient’s new care team, overseeing the transfer of patient records and documents, and ensuring plans are in place to address any problems that may arise throughout the post-acute care process.
By coordinating a patient’s care in this way, providers can ensure the patient receives the best possible treatment. Post-acute care coordination is beneficial for a variety of reasons, including reducing the likelihood of readmission, improving patient outcomes, and reducing the financial burden on both the healthcare system and the patient.

Common Care Coordination Activities

  • Communicating with patients and post-acute care providers
  • Assessing a patient’s goals and needs
  • Creating a proactive care plan to aid in a patient’s recovery and outcome
  • Connecting patients to additional resources within their communities
  • Helping patients transition to additional post-acute care providers and/or to home
  • Monitoring a patient’s needs and outcomes

Why Does Post-Acute Care Matter? (And How ICS Helps)

As the healthcare system continues the shift to a value-based care model, providers are expanding the depth of services they offer patients after discharge.

Organizations like Integrated Care Solutions (ICS) are crucial to management success because they help implement effective post-acute care coordination, provide analytical insight, track patient outcomes, and help control costs.

5 Reasons Health Systems Should Care About Post-Acute Care Coordination and Management

1. Reduce Avoidable Readmissions
With the previous fee-for-service healthcare model, approximately 20% of Medicare patients were readmitted within 30 days of their initial discharge, costing the U.S. healthcare system billions of dollars each year.

Post-acute care coordination reduces readmission rates. 

ICS helps providers navigate this complex system while automating follow-up care and communication. Additionally, ICS allows providers to assess risk factors and track patient status in real-time. As a result, ICS achieves an average 10% reduction in readmissions for providers.

2. Boost the Quality of Care
Post-acute care coordination and management have the power to improve the quality of care delivered to patients following acute care. Not only does improved care lead to fewer readmissions, but it also improves the patient’s quality of life, reduces premature admission to long-term care facilities, and avoids ineffective and duplicate treatments.

ICS adopts a patient-first approach, resulting in enhanced patient experiences, reduced burden on caregivers, increased patient enrollment in community services, and better transitions to home care.

3. Improve Transitions
Post-acute care management gives patients the best care possible upon discharge and throughout their journey to a permanent care setting, whether a home or a care facility. ICS facilitates a smooth transition by helping providers identify risk factors in their patient’s care, preventing readmissions to hospitals or nursing homes, and coordinating during and after the transition between acute to post-acute care.

4. Enhance Patient Outcomes
Not only does effective post-acute management improve a patient’s quality of life and chronic illness management, but it also helps providers control costs and payment penalties.

Poor communication between providers poses a significant risk to patients and may cause illness, duplicate treatments, poor reconciliation of medicines, and ultimately, increased readmissions.

5. Increase Profitability
To control costs and increase profitability, providers need effective post-acute care coordination that tracks patient outcomes, navigates transitions efficiently, and follows post-acute care best practices. ICS provides a high-tech, high-touch approach to post-acute care management that drives measurable results for value-based care organizations. Our partners have averaged a 20%+ reduction in the total cost of care.

How to Improve Your Post-Acute Care Processes and Build Meaningful Relationships with Patients

Effective post-acute care coordination begins with strong communication between providers, patients, and post-acute facilities. This is the foundation of any quality healthcare program.

The key to successful post-acute care management is implementing a comprehensive technological platform to ensure patients don’t fall into the high-risk category. Technology ultimately fosters communication and collaboration between providers in order to best care for patients. At ICS, Care+ provides a robust dashboard of analytics and real-time reporting tools to track patient records and implement effective post-acute care solutions for better patient outcomes.

Optimizing Your Post-Acute Care Coordination with Integrated Care Solutions

As we go forward in an age of value-based healthcare, proper post-acute care management is critical in reducing avoidable readmissions, improving profitability, and enhancing patient experiences and outcomes. Integrated Care Solutions delivers measurable results and unique, personalized solutions using a high-tech, high-touch approach.  

Are you ready for exceptional post-acute care coordination solutions? Speak to an expert to learn more about how we improve patient outcomes.

ICS accelerates the transformation to value-based care for ACOs, providers, and payers, delivering ongoing care coordination, consulting, and expertise in data-driven processes necessary to achieve quality care and financial success.


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