Clinical Pathways

What happens after discharge?

jhc-sept16-cvrJHC readers may be familiar with clinical pathways in the hospital – that is, well-researched, well-documented paths to providing care that result in optimum outcomes. But what about clinical pathways for patients following their hospital stay? When should that patient be discharged? And to what kind of facility, or perhaps home? For how long? And then what?

These are significant questions for payers, providers and distributors, as reimbursement methods change and post-acute-care costs continue to rise.

Post-acute spending is estimated to exceed $200 billion per year and is growing at approximately 6 percent annually, according to Cardinal Health. Proper discharge planning and post-acute care coordination reduces overall cost and variance in the healthcare system, which is important to providers and health plans participating in value-based payment models, including bundled-payment initiatives, the company says.

That’s one reason that naviHealth Inc., a Cardinal Health company, recently acquired Curaspan Health Group Inc., a provider of care transition tools for hospitals and post-acute-care providers.

Cardinal Health isn’t new to post-acute care. In 2013, for example, the company acquired AssuraMed, a provider of medical supplies to patients in the home. The company continues to operate through two separate businesses: Edgepark, a mail-order, direct-to-home provider of disposable medical supplies; and Independence Medical, a wholesale medical supplies distributor providing services to home health agencies, providers, retailers, and home medical equipment customers.

In August 2015, Cardinal Health acquired a majority stake in naviHealth, a Nashville, Tenn.-based company that manages the post-acute-care segment of the care continuum for health plans, health systems and providers. naviHealth uses evidence-based protocols and technology to help optimize care plans and align all stakeholders, including providers and patients, according to Cardinal Health. At the time of the acquisition, naviHealth served 2 million health plan members and more than 75 hospitals and physician groups.

Four months later, in December 2015, naviHealth acquired RightCare Solutions, a healthcare decision support software service provider specializing in hospital discharge planning software and readmissions management. RightCare’s software is powered by evidence-based decision-support technology developed in conjunction with the University of Pennsylvania School of Nursing, according to the company. RightCare licenses its software to hospitals and health systems to assess patients for post-acute care needs, determine risk of readmission, and coordinate patient discharges to post-acute care providers. The company also licenses its software to post-acute-care providers, allowing them to automate many of the administrative tasks involved in accepting referrals.

Curaspan, which Cardinal Health acquired in June 2016, is designed to automate transitions of care, create workflow efficiencies, reduce variation and optimize collaboration among providers as patients move from one site or mode of care to another.

The system is installed in more than 600 hospitals and has more than 8,000 post-discharge customers, including skilled nursing facilities, home health agencies, long-term acute-care hospitals, dialysis centers, durable medical equipment distributors, hospice providers, transportation companies and other post-acute-care organizations.

Attacking variation
Approximately four out of 10 Medicare patients – and about a third of all hospitalized patients – require some form of post-acute care, says Clay Richards, CEO of naviHealth. That can take place in skilled nursing facilities, at the home, or in more intensive settings, such as inpatient rehab facilities and long-term acute-care hospitals.

“Often, these patients bounce from one facility to another and back again,” says Richards. “Costs go up and there is no correlation to better outcomes. That’s why post-acute care has become such a focus for the Medicare Payment Advisory Council and the Centers for Medicare & Medicaid Services.

“The challenge is, there is a lot of variation among hospitals and discharge planners as to how a post-discharge plan is determined,” he continues. Some patients are monitored by a primary care physician, but many are not. “If it’s a surgical case, the surgeon is involved,” says Richards. “If it’s a medically complex patient, a hospitalist might be involved. Physician alignment is important, but who that physician is varies by patient. Decisions are based more on practice patterns than clinical effectiveness.”

Perhaps the biggest obstacle in delivering cost-effective, high-quality post-acute care is our current payment system, he says. “Historically, there has been no financial incentive for the hospital to manage the patient after discharge. But you’ve started to see that change, because of value-based purchasing, readmissions penalties and, more important, bundled payment arrangements.

“We’re very good in healthcare in following the money; we adjust pretty well to that. But today, there is still so much financial misalignment. There are few incentives to drive better outcomes cost-effectively.”

Three years ago, the Institute of Medicine reported that if providers could eliminate variance in the post-acute care of Medicare patients, Medicare spending would drop dramatically, says Richard.

naviHealth has strong clinical analytics and clinical decision support tools, to help discharge planners and providers make decisions about an individual patient’s post-acute-care regimen based on a number of factors, including functional status, comorbidities, living situation, etc., says Richards. “Curaspan has the most comprehensive workflow capability across acute- and post-acute-care settings,” he says, that is, 600 hospitals and 8,000 post-acute-care providers.

“Think of Curaspan as pipes connecting hospital and patient to post-acute providers.”

Interoperability: You can’t have a continuum without it

Keeping tabs on patients after their discharge is the key to comprehensive, effective post-acute care. In fact, in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress declared it a national objective to achieve widespread exchange of health information through interoperable certified electronic health record (EHR) technology nationwide by Dec. 31, 2018.

Providers are moving toward interoperability, but their path has been uneven.

National rates of hospitals’ electronically sending, receiving and finding information to and from providers or sources outside their hospital system increased between 2014 and 2015, reports the Office of the National Coordinator for Health Information Technology (ONC), the principal federal entity charged with coordinating nationwide efforts to implement and use advanced health information technology and the electronic exchange of health information.

Some highlights from the ONC report:

  • Hospitals’ rates of electronically exchanging laboratory results, radiology reports, clinical care summaries, or medication lists with ambulatory care providers or hospitals outside their organization doubled since 2008, when 41 percent of all hospitals electronically exchanged health information with outside providers.
  • The percent of hospitals electronically sending, receiving, finding and integrating key clinical information grew between 2014 and 2015, from 23 percent to 26 percent.
  • Forty-six percent of hospitals in 2015 had necessary patient information electronically available from providers or sources outside their systems at the point of care, compared to 41 percent in 2014.
  • About one-third of hospitals (36 percent) reported their providers “rarely” or “never” use patient health information received electronically from outside their hospital system when treating their patients. Fewer than one-fifth (18 percent) of hospitals reported their providers “often” use patient health information received electronically from outside their hospital system when treating their patients. And 35 percent reported their providers “sometimes” use patient health information received electronically from outside their hospital system when treating their patients.
  • Among hospitals that rarely or never used patient health information electronically received from outside their hospital system, 53 percent said the information is not available to view within the EHR; 45 percent indicated that they experienced difficulty integrating the information in the EHR; and 40 percent indicated the information was not always available when needed.

To view the report, “Interoperability among U.S. Non-federal Acute Care Hospitals in 2015,” go to

Safe Transition Home

Los Angeles-based Cedars-Sinai has teamed up with HomeHero, a non-medical homecare provider, to help discharged patients stay on a healthy path and, if possible, avoid readmission.

The joint program, called Safe Transition Home, aims to address transitional care challenges by providing licensed and trained homecare professionals as a post-acute extension of Cedars-Sinai’s healthcare continuum.

HomeHero’s caregivers, referred to as “Heroes,” provide assistance with activities of daily living, such as personal care, housekeeping and medication management. Safe Transition Home covers additional services, including transportation to and from follow-up appointments with the patient’s physicians.

Equipped with a mobile app leveraging Apple’s CareKit platform, the “Heroes” conduct safety checks in the home, record patient health information, monitor social determinants and deliver real-time data back to families and case managers in the hospital.

The program is funded through a combination of private clients and Cedars-Sinai.