How to Build an Accountable Post-Acute Network

Quality of care and teamwork across the care continuum have taken on a new level of importance as a variety of structures, from ACOs to readmission rates, force outcomes-based financial accountability on hospitals and health systems. 

Post-acute care organizations and the quality of care patients receive there have become such important issues to inpatient-focused organizations that they’re keeping score.

At least, that’s the tactic Altamonte Springs, Florida–based Adventist Health System is using.

Beth Weagraff, corporate vice president of post-acute strategy and implementation, says developing a scoring system for skilled nursing facilities and home health companies used by the 46-hospital, nine-state health system helps focus Adventist on the fact that it’s on a path toward delivering “holistic” care that includes patient interactions with inpatient, outpatient, post-acute, and the physician office.

“We see holistic care as our differentiator, but we recognize that if we’re going to expand the network and improve the product, we’re never going to have enough post-acute assets to do that ourselves,” she says.

Yet among its nine states and 82,000 employees, Adventist does own significant such assets. While following patient choice protocols, the system refers patients to both owned and non-owned post-acute providers, in varying volumes, depending on the city, state, or region where it has a presence.

That means it needed a fair way to recommend options for where patients should continue their care following an inpatient discharge, which is where Weagraff and her colleagues sought help to develop a survey and scoring system to refine and incentivize post-acute network partners.

Quantifying quality and cooperation

In late 2016, Adventist began to work with a consultant to begin to construct a framework that incorporated quantitative and qualitative metrics to rank post-acute partners in a way that was agnostic as to whether the partner was an Adventist-owned asset.

CMS star ratings are among the data points, as are individual partners’ readmission rates and variation and improvement on patient outcomes. Scoring well on these criteria qualified that organization for a site visit for further evaluation.

What constitutes “scoring well,” varies from market to market depending on the supply of potential partners, says Weagraff. For example, in Texas, where thousands of home health care agencies exist, thousands were screened off the eventual recommended list, but in rural markets in Florida, not many were eliminated at this stage.

“Once we kind of weed them out through quantitative criteria, a trained team goes out and conducts site visits for those that are still in the running,” she says.

Questionnaire prior to visit

A work group that spans all Adventist markets developed a questionnaire that helped score providers on a set of variables, such as new patient capacity, administrative staff, clinical staff, capabilities, types of technology, the organization’s willingness to partner, and other categories.

The questionnaire totals 35-40 questions, and a few are market-specific, such as hurricane readiness in Florida.

“It’s been an evolution, but it provides a broader picture of their approach to patient care that you don’t get in overall star ratings,” says Casey Silver, Adventist’s director of business development for post-acute care.

The questionnaire results help the work group measure actual quality, which is paired with the perception of quality as evidenced by the site visit.

“We’re enabling and providing tool set to sustain the network,” says Weagraff. “Casey works with them to model the criteria for the network so that we can continue to build the relationship with partners over the long haul.”

During the site visit, the team focuses on putting together collaborative forums at the local level with designated post-acute leaders in the region, to evaluate over time how post-acute providers are performing in quality outcomes and in responsiveness.

“Those are the key components of what deployment looks like,” Weagraff says.

Adventist has completed the first two processes in three Florida regions: South, Central, and North; and it will roll out all 12 networks by the end of 2018. During the next two years, Adventist teams will help focus them on collaboration with Adventist hospitals.

Earn referrals

Weagraff says post-acute partners have been eager to try to compete for inclusion in the network.

“Key is going to be how we sustain and continue to evolve the network,” she says. “We’ve gotten very good engagement so far. It’s been good dialogue.”

Weagraff says that in developing such a system, one can’t assume what a team of Adventist care managers (it employs more than 2,000 of them), region to region, knows about how to deal with patient choice on post-acute providers. Patients can choose to continue their care wherever they like, regardless of any survey, ranking system or quality scores, and Adventist managers provide patients a full list of providers, not just the ones that score well enough to be in its preferred provider network. But they also spend a lot of time and effort to educate care managers about the importance of these choices.

They also make use of vast amounts of data in the ranking system. NaviHealth, a data management and clinical decision support company, helps educate Adventist care managers on utilizing such data.

In training care managers, Weagraff says, “what became important was to set legal boundaries first. Here are the guardrails. What’s been interesting is in some cases you can have collisions between physicians and the patient.”

That said, the focus has been on forming the network.

“We know how we’re going to measure it,” she says. “Providers have to understand they’ve got to earn referrals based on responsiveness, delivering on strong outcomes, CMS measures, ensuring patients are happy with their experience and that they are responding quickly to our requests to send patients.”

She says for other health systems, ensuring that owned post-acute assets are performing at the top of their game is important because of the agnostic nature of the network.

Also, health systems should “be open to forging relationships with post-acute providers that you may not have known were in the market,” she says.  

Having a consulting firm with experience in setting up such networks provides objectivity, she says, adding that while Navigant is no longer involved in the program, the firm helped set up a framework and helped Adventist avoid internal politics in the process.

“We’re on a journey to provide top-decile performance, so sometimes you need someone else to provide industry best practices,” she says. “They’ve worked with 40 health systems. If they get it set up, you can sustain it. That way if we ask them to come back and validate, it keeps their objectivity as well.