What level of integration makes for a successful post-acute care network? Antonio Rodriguez, M.D., medical director of the continuing care network for UNC Health Alliance in North Carolina, recently described a decision-making framework for healthcare systems that are taking their first steps in building post-acute care networks.
Rodriguez, a family medicine physician, was speaking at the spring NAACOS conference last week. First, he gave some background on his organization. UNC Health is tied to the University of North Carolina School of Medicine. It is the safety net hospital network for North Carolina, and has a presence in all 100 counties of the state and delivers care across 14 hospitals. UNC Health Alliance is the clinically integrated network arm of UNC Health, which brings together 6,400 providers, 25 percent of whom are primary care providers, roughly 30 percent of whom are independent providers.
UNC Health also houses a population health division, as well as the skilled nursing facility (SNF) preferred network, which holds affiliate agreements with 20 skilled nursing affiliates and five home health affiliates. “We have two performance tiers for our skilled nursing partners, and our primary intervention in the space is embedded care management,” he explained. Its care managers also serve as quality improvement advocates, he added.
UNC Health is responsible for roughly 250,000 covered lives, about 40 percent of which carry downside risk. UNC Health recently transitioned from Next Gen ACO to MSSP Enhanced, and continues to expand the breadth of its Medicare Advantage contract base year over year.
The first step health systems should take, Rodriquez says, is to assess their landscape. You have to measure your baseline and have a deep understanding of the current state of your post-acute space. “This is really a data aggregation-heavy phase of development,” he said. “You have to understand readmissions from the space, you have to understand length of stay, the percentage of patients that are successfully being discharged to the home environment. You must also understand the volume drivers. Are these medical admissions? Are they surgical admissions and post-operative patients? Then go down to disease granularity.”
When you know your current state, you can ask what is the gap between that current state and your perceived optimal performance? “Once you can answer that question, I think you've come to a fundamental inflection point,” he said, “which is what is the level of integration that I need between my healthcare system and my post-acute care space to close that gap?”
Rodriguez pointed to some research that suggests that if your market is heterogeneous from area to area, you can't apply a one-size-fits-all solution; you have to customize. In terms of variables to look at to customize, the research suggests one is the level of embeddedness, and the other is environmental uncertainty. “Level of embeddedness is simply the sum total of your informal processes across that post-acute space. First-name basis relationships, right? Our care manager can call their social worker. The sum total of all of those informal relationships are what creates a high degree of embeddedness.”
The pandemic is a great example of a highly uncertain environment, Rodriguez added. It has caused lots of dynamic change within the space. Larger health systems likely have a combination of high uncertainty and low embeddedness. They probably don't have a lot of those first-name-basis relationships. “In that case, you may need to have a bigger intervention to bridge that gap,” he said, so you may need a tighter degree of integration leading up to potentially buying into the space or at least some firm partnerships in the space.” In contrast, a much smaller healthcare system can maintain those informal relationships, and if they are functioning in a fairly small environment post-acute wise, they may get away with less formal partnerships, and affiliate agreements may be sufficient to bridge that gap.
The next step, Rodriguez said, is looking internally at the health system. What are the processes that bring patients into the post-acute space? You should engage all of the stakeholders — inpatient care management teams, care managers, ambulatory providers — who work with a lot of patients going to post-acute care and gain a fundamental understanding of how they operate from a workflow standpoint, but also understanding the culture. What are their perceptions about their relationships with the post-acute space? You can do a root cause analyses to identify what the barriers are — from their standpoint — that are contributing to dysfunction, or need for optimization. “That should naturally bring you to a place where you can identify your primary objectives for this space, and come up with core metrics and KPIs,” he said.
The third step is writing affiliate agreement. “If you've done your first two steps effectively, you should have a concrete understanding of what your affiliate agreement with these post-acute providers needs to contain,” Rodriguez said. “One caution is that when you write your affiliate agreement, it is from the perspective of the healthcare system. Don't forget the value proposition to your post-acute partners, because it is tempting to make this just from the internal side. But if there is no value proposition that is enduring and compelling for your post-acute partners, it's not going to last very long, and the whole thing will fall apart.”
Finally, Rodriguez notes that one of the most fundamental steps in developing your network is identifying your data sources. “We've heard over and over again that data really drives function in the space. It gives you visibility; it helps you to understand your performance. But it also really drives quality improvement in the space,” he said, adding that data needs tend to evolve over time.
“For us, at the beginning, we were satisfied with lagging claims data — that works really well for process improvement at the beginning, but we evolved over time. And it is very likely that as you become more sophisticated in your ability to understand the spectrum of patient care, particularly in your own EMR, you'll get to a point where visibility in your post-acute space lags behind your internal abilities to understand patients when they're in your hospital systems,” he explained. “You've come to a place where you start to ask for more granular clinical data at the patient level, and more real-time data to provide actionable quality improvement work moving forward. I'd argue probably the end stage of all of that is predictive analytics — being able to accurately predict what's going to happen to those patients in the space before it happens.”
How do you enhance utilization after you have created this robust network and aligned everyone? Rodriguez said use your data to help make a compelling argument. “This is not a subjective conversation. Adequate reports geared towards the specific stakeholders will help you to have that conversation,” he said. “And I consider patients a major stakeholder, too. We're not just talking about representatives of the healthcare system, or within the post-acute space. Your patients are consumers of this data as well. Talk about your outcomes at a level that a patient and family member can understand.”