The key to navigating the challenges of bundled payments and access to quality healthcare is managing the interprofessional care coordination, care redesign and improving communication and accountability across the continuum of care.

Interprofessional Care Coordination: Transition from the hospital to the clinically appropriate next site of care (Home Selfcare, Home Outpatient Care or HomeHealth, Subacute – Skilled Nursing Facility, Inpatient Rehabilitation Center or Long Term Acute Care Hospital) is a decision that must be made collaboratively by the patient/family and the clinical team. Patients recover best in their familiar environment and in most cases that is their home – residential or congregate setting. The team including our dedicated physicians, nursing, therapy and other support staff assess and identify needs and risk factors so they can order and send out the requisite referrals to providers and other support personnel. Here at Holy Cross Health, our model allows easier access to our clinical and support teams for our Advanced Payment Model Population (BPCI-A, ACO & CJR) which is led by our Population Health Nurses (PHNs) who assist our patients/families navigate our complex healthcare system. Our PHNs and other members of our care management team focus on transition management with an emphasis on proactive patient management this includes early identification of patient needs while in the post-acute setting and addressing barrier(s) to care, some of which are socially influenced.

Care Redesign: The heart of care redesign has cultural underpinnings and very early in our process of redesigning care we identified the need to change our approach and terminology when our patients were leaving the hospital. We started to socialize the term transition among our colleagues with a focus on moving from discharge to a transition process. Standardizing care delivery using evidenced based best practices across healthcare settings – hospital, subacute and home – helps to improve quality of care and success for the patient and the healthcare system. Engaging providers (physician/surgeon/nurse/therapist) in a model that supports standard work and being able to demonstrate the value add and resultant benefits to patients, providers and healthcare system presents its own challenges. Healthcare systems participating in these risk model programs also need to be agile so they can respond to the programmatic changes from Medicare.

From a programmatic perspective, I have found the three-day waiver in BPCI-Advanced to be misaligned with the objectives of the initiative. The waiver could potentially help avoid readmission during days 3 through 90, unfortunately it can only be used within the first 30 days after discharge. There is already a provision that allows Skilled Nursing Facility admission during this period once the patient meets the qualifying 3 midnight stay while an inpatient so this waiver does not provide any benefit to program participants.

Communication and Accountability Across the Continuum of Care: At Holy Cross Health, we call this “transitioning the patient.” It’s more than just a discharge, it’s a warm hand off to additional healthcare providers that are part of the continuum of care. Transition conveys more compassion, which aligns with the Holy Cross Health mission and core values that include reverence, stewardship and integrity. In BPCI your reimbursement is not just for the acute admission, it covers the post-acute care costs as well. Our financial responsibility for the patient continues beyond the hospital walls and for a period of 90 days after their hospitalization or their outpatient procedure. Collaborating with our Community Partners including other Hospital Systems, Skilled Nursing Facilities, Home Health Agencies helps to facilitate the ease of information sharing that allows for continuity of care. It promotes communication between providers and with providers and patients and their families.

An important element in healthcare that does not get the necessary attention is that of advanced directives and their importance in guiding healthcare decisions that support honoring a patient’s wishes when they can no longer speak for themselves. A person-centered approach to healthcare promotes educating patients on the importance of documenting their wishes and sharing this document with their healthcare providers. Its importance was reinforced when CMS introduced Advanced Care Planning as one of the quality measures of the BPCI-A program. Patients can identify a healthcare surrogate or proxy if they are unable to document a plan at that time. I have observed that many healthcare surrogates feel conflicted when the advanced directives do not clearly state a patient’s wishes. We recommend that these discussions pertaining to advanced directives take place in advance so there are no questions and there is no confusion should a health episode arise. Palliative care and hospice care services are also not appropriately utilized. It makes sense to have access early for chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) or End Stage Renal Disease (ESRD) so teams that are experienced in helping to manage chronic conditions can assist in helping to improve a patient’s quality of life.