Reducing Avoidable Days in Your Hospital: Finding Post Acute Care Beds

One of the greatest challenges in caring for the chronically ill that are in your hospital is quickly finding the appropriate post-acute care facility for your patients.  With 42 percent of all Medicare patients being discharged to some post-acute care facility, and hospitals trying to manage costs in a flat-revenue environment this manual, time consuming match-making is both risky and expensive.  

Consider today’s hospital or health plan case manager, who is trying to transition the patient to the right facility. Given the short length of hospital stays, the discharge care planning process must be tightly managed and efficient. Securing a post acute care bed is a time consuming process that involves the transmission of demographic and a lot of clinical documentation. That information provides the facility with a snapshot of the patient’s current and emerging care needs. This helps the facility determine if they can meet the patient’s needs and address bed availability. At times, case managers are faced with surprises. These are patients who are expected to discharge home; a day before or on the day of discharge, placement is needed. The potential for avoidable hospital days with no additional hospital compensation is a reality.

Secondly, the number of post acute care facilities is great, with specialty and regional variation.  According to Medicare, payments to the more than 29,000 PAC providers totaled $59 billion in 2013, more than doubling since 2001. There is certainly some irony here, as Medicare is closely watching utilization and length of stay per condition in hospitals, yet the post-acute care spend is doubling.  This is troubling since cost and quality are not highly correlated in this corner of healthcare.  According to Jonathon Blum, Director at CMS testifying in front of the House Ways and Means Committee’s Subcommittee of Health, found that “40 percent of all variation in Medicare spending is explained by variation in the utilization of post-acute care services.

What is your case manager doing to manage these transitions today?  Probably the case manager has a list of community facilities that have, on an unmeasured basis, been easy to work with and accommodating.  This list is probably photocopied, written on, and placed on a clipboard or in a folder.  The case manager starts calling facilities on the list, and frequently, will be bounced around while waiting to communicate with the admissions coordinator, put on hold, or sent to voicemail.  

The case manager needs not only to find a bed, but ensure that the appropriate health care modalities are available.  There is a very slim chance that there is electronic integration between the facility and the hospital for secure conveyance of the patient’s medical records so a full clinical assessment can be made by the receiving facility.  Faxing of information is the traditional secure approach.

After leaving a round of messages, the case manager goes back to their long list of other duties, and waits for a call back from the facility.  There’s a very good chance if a facility does call back, the case manager misses the call as they are busy.  Then, there is the patient’s right to choice in the selection of the facility.  The care manager must let the patient be the ultimate arbiter of whether or not they go to the facility where beds may be available.  The patient might have had a bad experience, or heard someone they knew had a bad experience at the facility and may not want to go.  If that’s the case, then the case manager must start over to find alternate arrangements. Should the process not be timely, there is the potential for uncompensated avoidable hospital days.

What is the cost for this manual, suboptimal hand-off?  For our purposes, an avoidable day is considered an inpatient stay longer than Medicare or other payers will pay for, based on the patient's diagnosis and current clinical status. While statistics relating to avoidable days of hospitalization are elusive, given no standardized definition, with the numerous issues listed above, it’s reasonable to assume that 20% of Medicare patient days are avoidable, and 40% of these are due to inability to secure a bed in a timely fashion.  The average national compensation for an inpatient is $1200, and the average national occupancy rate 64%, the estimated average cost to a 500 bed hospital:

(500 beds * 360 bed days per year * $1200/ day average Medicare inpatient payment * 64% average national occupancy rate) 40% Medicare/Medicaid payer mix * 20% overage on Medicare days * 40% attributable to difficulty finding beds * = $4.4M in lost revenues per annum

This lost hospital revenue is likely understated since it does not include factors related to care quality and patient satisfaction.  What patient wants to spend an unnecessary day in the hospital?

Hospitals work hard to transition the patient out in a timely fashion. Variation in cost and quality of post acute facilities mean that Medicare costs have ballooned in the post-acute space, while readmissions have barely budged.  The difficulty in managing these costs and outcomes  of post-acute care services is at the core of bundled payment initiatives.  Soon, the hospital will no longer be able to end their responsibility simply by finding a bed for the patient in a timely fashion.  They will need to ensure the patient goes to a high quality facility, able to best meet the patient’s clinical needs, at a reasonable cost. Hospitals will need to communicate with both the patient and the facility in order to avoid readmissions and absorb additional costs further downstream.

What can a health system do?

  • Create tighter collaborative relationships with the post-acute care facilities with high patient outcomes in the area. Formalize the contracting process, and create SLAs so that your network of extended care providers take patients in a uniform consistent fashion.
  • Start the transition process sooner.  Some clinical conditions all but guarantee post- acute care facility needs, like lower extremity joint replacement. Securing the SNF reservation can begin when surgery is scheduled.
  • Give case managers the systems they need for the timely electronic transfer of clinical information to the extended care providers (full-disclosure, this is Axial’s business, and we can help).
  • Follow the patient’s progress.  As part of the contracting process, stipulate that extended care providers send back key pieces of clinical information that helps identify patients that are at risk post discharge.  Allowing for the coordination of additional care and service to minimize a readmission.

Health systems are increasingly the risk-bearers in these complex cases.  Managing the patient doesn’t end with the discharge, or even with the follow-up call after the discharge.  It’s time to do a complete assessment of your health system’s hand-offs to post-acute care providers.