Beyond Acute Care: The Time Has Come

Today’s hospitals and health systems need a strategy for comprehensive care across the continuum that seamlessly coordinates the consumer healthcare journey. This requires deploying a solution that supports the transition from inpatient acute care to a full array of post-acute and care-at-home services – backed by integrated workflows and effective collaboration.

This was the overarching message from panelists during an America’s Essential Hospitals (AEH) webinar, “Advancing a ‘Beyond Acute Care’ Strategy to Solve Operational Challenges” — part of a three-part series, “Mitigating Financial and Operational Care Delivery Challenges for Essential Hospitals” – moderated by Guidehouse Partner Donna Cameron, a clinical transformation leader with four decades of experience.

The session featured on-the-ground insights from Dr. Lisa Harris, CEO of Eskenazi Health, and Vernon Pertelle, a management consultant with two decades of healthcare experience who has implemented Palomar Health’s transition care management program and supported the Centers for Medicare & Medicaid Services (CMS) waiver approval process and implementation plan for its Acute Hospital Care at Home program.

Solving Capacity and Throughput Challenges

Acute bed capacity challenges motivated Eskenazi Health to build and deploy a more thoughtful beyond-acute strategy. “Our capacity issues existed before the COVID-19 pandemic,” said Dr. Harris, “but 18% of patients we’ve seen in the past four years are new to the system. We’ve seen inpatient days, specialty care, and primary care at record-breaking volumes month after month as the health and economic consequences of the pandemic hit the patients we care for the hardest.”

While the Eskenazi Health campus was built with expansion in mind, as leaders worked to solve their capacity challenges, they wanted a solution that would avoid significant capital investment in bricks and mortar. The biggest driver of their capacity challenges wasn’t the few individuals who were staying in the hospital for a significant period of time. Instead, it was the many patients staying in acute care for one to three additional days, for whom improved multidisciplinary coordination and streamlined discharge planning for post-acute venues of care could lead to a timelier discharge when they were medically ready.

Through the process of assessing how patients were transitioning from acute care, Eskenazi Health recognized the need to develop a post-acute collaborative with skilled nursing facilities and home health agencies in the community.

“It was an opportunity to meet our expectations for quality, patient experience, and cost while also creating and adhering to more standardized workflows related to care progression and discharge planning,” Dr. Harris added. “That’s how we entered into this post-acute strategy.”

Palomar Health was not only struggling with similar capacity challenges during the pandemic, but as a designated federal medical station it needed to be a resource for all the regional facilities surrounding the hospital within a 30-mile radius.

“With the CMS waiver available, we decided that we would build a strategy that included providing acute care beyond the walls of the hospital,” said Pertelle, who previously led home health and home care community outreach projects as the Home Health director for Palomar Health.

“We defined our service area, community resources, and linkage with other organizations in our communities to mitigate the challenges. That helped us when we embarked on the interview process with our state licensing agency on how we could not only provide acute care in real time at the same level of care… but also address any emergencies, monitor those patients, and mitigate any issues," said Pertelle.

Pertelle mentioned the importance of learning from other leaders and organizations who have successfully deployed similar programs. Doing so allowed them to think creatively about designing their processes and workflows to enable high-quality acute care in the home.

The organization prioritized the patient experience while program planning and continues to do so as they develop their post-acute care at home model. Part of Palomar Health's inclusion criteria is patient willingness to participate in their own care — something that’s preferable inside a hospital but essential when care is happening inside the patient’s home.

“Patients love being in their homes and hate being in a hospital — but if you don’t provide the same level of care and service, that can work against you,” said Pertelle.

“We knew that if this was going to be a long-term sustainable program, we had to incorporate all the mechanisms to ensure an overall exceptional patient experience. So, it wasn’t just about the quality but also how the patient felt. Did they feel like they were getting less than what they would typically get?”

Pertelle shared that some of the many initial challenges involved concerns over medication safety, visitors coming into patient homes, physician telemedicine credentialing, quality assurance, and critical event management. Palomar Health’s commitment to involving key stakeholders from the outset was crucial to their success, including executives, medical, and home health staff, and all regional EMS facilities.

“Having gone through the process with CMS to answer all the questions that Guidehouse helped us prepare for, we already had the model and just needed to build the algorithm and communication frameworks,” Partelle said.

“And then it was a matter of getting everyone in the organization involved in operations in the acute setting to know it’s not home health, it’s acute care. It was very challenging and uncomfortable in some cases with some folks not being able to control what they typically control. So, we built a unique team [with acute care competencies] for consistency, continuity, and quality.”

Eliminating Siloes and Coordinating Care

Both Dr. Harris and Pertelle highlighted the importance of eliminating care delivery siloes. “We lacked horizontal coordination across all these independently high-functioning and deeply committed teams,” said Dr. Harris. Eskenazi Health leadership focused on getting their teams aligned around the same performance improvement metrics and creating efficiencies where they could.

Pertelle highlighted the importance of an engaged leadership team working to get stakeholders on the same page, which required significant education.

“When you are talking about essentially building a new hospital outside of the traditional hospital, we were novices. So, one thing that we realized early was the need to educate every single individual.”

Leaders at both Palomar Health and Eskenazi Health have realized that through better coordination of in-hospital and at-home care delivery, they can apply learnings to their respective operations to achieve improvements within the walls of their hospitals and reduce capacity pressures at the same time.

At Eskenazi Health, special rapid-improvement teams have worked across in-hospital and home-based care to address diabetic foot ulcers — resulting in mean length of stay reductions for that condition from 12 days to 1.9 days. And when it comes to nutrition, the hospital’s new care at home efforts complement its existing medically tailored meal approach.

In Palomar Health’s case, having its own skilled nursing facility, certified home health agency, and home care and community outreach efforts already in place made it easier to coordinate care transitions. The organization built a network of outside services, including vendors providing telemedicine, remote patient monitoring, and respiratory therapy, and created integrated systems for communication and handoffs from acute to post-acute to skilled nursing.

“We looked at these partnerships based on what we needed to do to further the care continuum to prevent recidivism and readmissions, and it became a very effective model that we have in place today,” Pertelle said.

Tailoring Beyond Acute Care Strategy

Between both organizations, one theme is consistent: There is no “one-size fits all” approach to shifting historical paradigms to eliminate care delivery siloes and successfully deploy beyond acute care strategies. Designing a tailored beyond acute care strategy requires:

• Clear understanding of clinical and operational challenges, including capacity for and access to acute care, clinical outcomes, patient experience, avoidable healthcare utilization, financial health, capital expense avoidance, market differentiation, strategic growth, and/or care model innovation
• Robust qualitative and quantitative current state assessment to avoid assumptions and identify true root causes for disconnected care
• Compelling beyond-acute care business case representing the comprehensive system-level impact

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