Hospitals and health systems can improve patient experiences post-discharge in part by paying attention to population health management, according to Jonathan Jaffery, MD, senior vice president and chief population health officer, UW Health. Jaffery met with WHA’s Post-Acute Work Group at its third meeting April 21 to provide some insights into managing post-acute care.
Although alternative payment models and readmission penalties are driving hospitals and health systems to pay attention to post-acute care, focusing on population health can provide necessary information to improve post-discharge patient outcomes and control costs across the care continuum, according to Jaffery. Incorporating a population health perspective into post-acute care starts with examining data on the patient population served by hospital or health system, including where patients live, analyzing the social determinants of health for the overall patient population, and how those factors may affect length of stay, readmission rates, and successful post-acute care outcomes.
Work Group members located in rural areas of Wisconsin noted it is more difficult to examine population health because they lack a critical mass of people in their area on which to gather data. This, coupled with a scarcity of post-acute providers, creates unique issues for some rural providers in managing post-acute care. In many rural areas, improving the social determinants of health is an important factor for successful post-discharge patient outcomes.
Jaffery also emphasized the need to create good post-acute care partnerships, both formal and informal, to improve patient outcomes when discharged to a post-acute setting. Systems of care are still evolving and are not currently optimized to provide patients with the best support. Jaffery noted that both large and small hospitals and health systems are still figuring out the best ways to provide this care and create good handoffs of patients to post-acute settings.
Another issue that affects transition planning for post-acute care is the interoperability of electronic health records (EHR). Not all hospitals, systems and post-acute care providers have the resources to implement an EHR platform that enables universal sharing of information on patients that could enhance transition planning. The Work Group agreed on the importance of developing cost-effective alternatives for sharing essential patient information in real time, which will improve planning for post-acute care.
Some patients may remain in the hospital long after they are ready to be discharged because of the difficulty in locating a post-acute provider that can meet the patient’s needs. The Work Group discussed the need to develop specialized post-acute care options for these patients. Because not all post-acute providers can meet every specialized care need, it may be necessary to create regional, specialized post-acute options to care for complex patients.
The Work Group will meet again in June and continue to identify areas that can improve post-acute care.