There is broad recognition that post acute care providers are vital to an effective healthcare delivery system that coordinates care for better outcomes and reductions in avoidable readmissions. The imperitive of Accountable Care is that Primary Care and acute, hospital-based care must coordinate with post-acute care providers to form "ecosystems." These ecosystems will serve as collaboratives that
- Practice evidenced based medicine
- Share both the financial risks and rewards of delivering better outcomes
- Manage chronic conditions proactively
- Support the elderly through Aging in Place and other programs
- Lower the total cost of care.
In the video below, Mary St. Pierre, VP of Regulatory Affairs for the National Association for Home Care and Hospice (NAHC) discusses how clinicians and home care agencies can help to reduce hospitalizations and improve the quality of care for older adults. Click here to view St. Pierr's discusion.
In a related article titled Preventing Rehospitalization: Home Care to the Rescue, Mary Champ explains that "Medicare is going to penalize hospitals that have high readmission rates. Take it to the next step: hospitals are going to be held accountable for what happens once their patients are home." Medicare patients who are re-admitted within 30 days of their discharge will now have a profoundly negative impact on the hospital's finances. "What used to be considered more revenue, inpatient admissions, is going to cost hospitals money starting October 2012, when a Medicare patient is readmitted in less than 30 days," explains Champ.
Further, "Preventing rehospitalization is nothing new for home care agencies. We’ve been held accountable for a while now." Champ adds, "...hospitals will see greater value in improving communication with their home care partners now that their bottom line will be impacted. Making home care services a part of the rule not the exception in discharge planning would seem to be a logical step to address this problem."