Accountable care organizations continue to fine-tune their post-acute care strategies. Gloria Rey, PA-C, M.P.H., director of post-acute care at Michigan-based Henry Ford Health’s Populance subsidiary, recently spoke at the NAACOS fall meeting about her health system’s approach involving wrap-around services.
(For more details about Populace, see our January 2025 interview with its president, Christopher Stanley, M.D., M.B.A., the former chief population health officer at Sutter Health.)
Rey said Henry Ford Health, a large integrated health system, owns two home health care agencies and two hospices, but doesn’t own any long-term care or skilled nursing facilities. It does have a clinically integrated network, an insurance company called Health Alliance Plan (HAP) and the Populance population health subsidiary.
Within Populance, Rey explained, they have an ambulatory case management team, a transition-of-care team, a diabetes care connection team. These clinical teams are dedicated to making sure that value-based contract patients are taken care of once they leave the four walls of Henry Ford’s 13 hospitals. She described a mulit-pronged post-acute care strategy.
“A big one is our care delivery for our patients in our value-based contracts going into skilled nursing facilities,” Rey said. “We have a whole team that's dedicated to our ACO and HAP Medicare Advantage, as well as some other lives for patients that are discharged from any hospital within Michigan into any skilled nursing facility. We have three specialists, one manager, and seven case managers who are working with our skilled nursing facilities and with our patients and their family members to ensure that we're transitioning them appropriately to their next level of care,” she said.
She noted that because Henry Ford is a large integrated system, it has resources that the SNFs may not have in order to transition those patients appropriately to their next level of care. “We have conference calls that are set up with the SNFs,” Rey said. “We also call patients and family members to assess what is going on with that patient in the home. We don't have any authorization to cut their time in that skilled nursing facility, but skilled nursing facility days is incredibly important for us,” she said. “Obviously, from a cost perspective, we know that can drive up your post-acute care costs, so we work with families and the skilled nursing facility teams to start doing discharge planning on the day of admission, and we ensure we put resources in place. We call the patient at least one or two times after they've discharged from the skilled nursing facility to ensure that those wrap-around services that we thought we put in place are actually working.”
They can also use a mobile integrated health team or advanced home health care model to help the caregivers who might be overwhelmed because they took a family member home and don’t know how to care for them, she said.
She described several goals her team is working on. One is to ensure that they are reducing that SNF length of stay. “We want to make sure that we're making those appointments for patients to follow up with their PCP, because we know that when they do they are less likely to readmit,” Rey said. “We really want to make sure we reduce our readmissions for this patient population.”
Rey said when they look at their ACO population and compare the full population to those who were touched by somebody on the Populace team, they see an average days reduced by about three days. “When we extrapolate that number out and we take three days by $500 a day at around $1,500 a patient, we know that we have approximately a $3.1 million savings for our ACO in 2024 just by being able to have that wrap-around care for them and make sure that they have that reduction in length of stay.”
Second, Rey said, they want to know if in their efforts to reduce length of stay, are they increasing their readmission rate? “In this case, when we look at that claims-based data, we are not,” she said. “We still see that reduction in readmissions for those patients that have been touched by somebody on our team compared to the general population.
Extrapolating that data out, we see approximately $1.3 million savings for our ACO. By having this team in place, it has exceptionally improved the experience of our patients. It improves their perception of Henry Ford Health in general. They see that wrap-around, they see the calls, and it really helps them come back to the organization to reduce leakage for the organization as well.”
Another focus is network management. She stressed that it's not just about building a scorecard or making sure you have good relationships, or have that scripting with your case management. "It is really about having that full wrap-around service to ensure that your post-acute network is being used, and you're holding your skilled nursing facilities or other networks accountable for it as well.”
Populance has program managers who are responsible for certain levels of care. It has skilled nursing facility, home health care and hospice post-acute networks.
“We have meetings with them involving a variety of different levels of care,” Rey explained. “We have our value council meeting, which is really high executive level, that talks about how the whole enterprise is doing and the new things that are coming out. But we also have 12 individual local post-acute meetings that are being run on a quarterly basis. We are essentially in front of our post-acute network every two months, minimally, talking to them about their outcomes, what's going on with them, what they can expect from us, what we expect from them, and new programs that we're putting in place.”
She adds that they also meet with their case management partners on a monthly basis to find out what's going on with them. Where are those referrals going? Why are they having barriers? What kind of scripting are they using? “Based on those meetings, we're developing programs to ensure that we're improving that transition of care not only for our post-acute patients, but really working with our partners as a hospital to try to improve their length of stay and their metrics as well.”
