UnityPoint ACO’s Mission to Drive Post-Acute Care Success

For accountable care organizations (ACOs), being able to successfully develop and engage post-acute care (PAC) networks has become a core priority when it comes to controlling costs and improving care quality. As noted in a 2018 research paper from Kaufman, Hall & Associates, and published by the Healthcare Financial Management Association (HFMA), “Medicare is the nation’s largest single purchaser of post-acute care services, spending nearly $60.3 billion in 2015, according to a June 2017 report by the Medicare Payment Advisory Commission (MedPAC). For the federal government, post-acute care represents a major savings opportunity, largely due to the high average margins in most post-acute care settings, spending growth in this area, and variation in care patterns cited by MedPAC.”

The researchers added, “The Institute of Medicine has attributed 73 percent of overall Medicare geographical spending variances to post-acute care utilization variation. Such variation is associated with increased costs and lower quality and outcomes.”

Indeed, while efforts to improve the overall value of post-acute care “generally have not been effective,” bundled and episode-based payment models “are starting to eliminate traditional silos among ambulatory, inpatient, and post-acute care settings, thereby reducing problematic care transitions between settings and improving cost, service, and quality dimensions across all settings,” the researchers stated.

Earlier this year, 20 ACO executives from across the country convened at a roundtable organized by healthcare technology company PatientPing to share ideas on how to develop and engage preferred post-acute networks. One such ACO that participated in the roundtable was the West Des Moines, Ia.-based UnityPoint Accountable Care, a participant in the Centers for Medicare & Medicaid Services’ (CMS’) Next Generation ACO Model. For the leaders of the ACO—which in Next Gen performance year 2017, achieved an overall quality score exceeding 93 percent and shared savings of nearly $11.5 million—its work in developing preferred post-acute networks goes back several years.

In the initial days of ACOs, the post-acute management of patients was top of mind for most organizational leaders, and that led to early savings for many, notes Pamela Halvorson, lead executive for ACO operations at UnityPoint Accountable Care. “But we took a more measured approach in that we first looked at how to set minimum criteria for our skilled nursing facilities [SNFs] that would help them stand out as the [optimal] choice for patients so that patients had informed [information] about which [places] were best suited to care for them after they were discharged from the hospital. That work took place for almost three years as we refined those criteria and developed methods in which to help those individual facilities [be] seen as preferred or optimal partners for patients when they were discharged,” says Halvorson.

That process of setting the criteria for the skilled nursing facilities was a collaborative one that included the high-performing SNF leaders being engaged from the beginning, Halvorson recalls. What came from those robust conversations was a network of set criteria and standardized process for preferred facilities that UnityPoint executives believed should be the same regardless of their location. Some of that criteria, as outlined by Chris Butters, manager of network development for post-acute care services at UnityPoint Accountable Care, has included:

That SNFs have the capability to admit patients seven days a week, with a “safe after hours option.” The acute care setting understands the challenges of trying to admit patients in certain off-peak hours, but for those SNFs, the intent was to work around patients’ timeframes to ensure they could safely transition when most appropriate, Butters notes.
Honing in on rehospitalizations, as UnityPoint leaders saw this as a key quality metric that also has been made a priority by CMS, which tracks avoidable rehospitalizations for both hospitals and SNFs
Setting metrics around length-of-stay, and making sure that patients were not in the SNF for any longer than was reasonably necessary, and that they had a safe transition home when they were ready to go
Ensuring that SNFs must have at least a three-star rating, based on CMS’ star rating system for such facilities
Having enough registered nurses (RNs) on staff for a certain time period was important so they’d be well-equipped for the patient admissions that needed to be done after normal business hours, as well as ensuring that RNs were available to handle more clinically complex patients
Requiring that SNFs be linked back to UnityPoint’s electronic health record (EHR) so they could obtain necessary patient information in an easy and quick manner
That SNFs self-report data that may not be publicly reported, such as certain facility or patient experience program results that come from a CMS contract but are not made public
Ensuring that SNFs have a plan in place to have healthcare provider rounding on a regular basis to help with medication reconciliation, orders, and reducing rehospitalizations and avoidable ED visits out of the SNF

This set of criteria is tracked by UnityPoint on a quarterly basis and has generated tangible results since data started to be tracked in January 2016, its leaders attest. For one, the average length-of-stay across the network was previously at 26 days with a cost of more than $9,000 per stay. Further, UnityPoint’s hospital readmission rate from its SNFs was at 16 percent at that time.

But within one year, Butters reports, the network’s length-of stay was reduced by two days, which dropped the average cost of a patient’s stay down to $8,700, all while dropping the system’s hospital readmission rate as well. “Some of that had to do with the relationships that were developed between the acute and post-acute care settings. We have teams of nurses and administrative staff, and some are meeting weekly, some monthly, and some quarterly. That opens a line of communication, as SNFs feel like they have better levels of communication with their acute care partners to discuss admits that may have been challenging, or things to change for future admits,” Butters says,

And, the data continues to get better, he adds. As of December 2018, UnityPoint’s average length-of-stay has dropped to 19 days, with the average cost-of-stay at $7,500. “But our readmission rate has stayed flat at 11 percent, despite the fact that we are continuing to reduce our length- and cost-of-stays,” Butters attests.

SNFs’ Future—in the Context of ACOs

In theory, the ACO concept should lead to the kind of coordinated care that will bend the cost curve in U.S. healthcare. One way ACOs have been able to reap savings is by reducing skilled nursing facilities’ length-of-stays—like in the case of UnityPoint—or in some cases, removing them from the picture altogether. But because of the criteria set forth by the ACO, SNFs can feel pressured to discharge patients in a tight window to meet length-of-stay goals. In one study published last year, which included 70 interviews with staff in 25 SNFs in eight U.S. cities, several SNF leaders reported that ACOs they were affiliated with would set strict length-of-stay targets that placed increased burdens on the post-acute care provider, according to an analysis of the research in Skilled Nursing News.

What’s more, one SNF leader told the publication in a recent anonymous interview that while SNFs have intended to partner with ACOs to keep referral volumes at least at the level they previously were—and hopefully gain market share by improving relationships—in reality, “ACOs have turned out to be, from the perspective of the SNF provider, a complete, utter failure. Patient outcomes have not improved. There is absolutely zero evidence that patient outcomes are any better or any worse,” according to the SNF executive in that piece.

When probed on this issue, UnityPoint executives acknowledge that a key goal is driving down length-of-stays, but insist they are not trying to take business away from SNFs. Halvorson explains that historically, utilization in skilled nursing facilities has been driven by the therapy needed after a major orthopedic surgery at a hospital. But now, since many orthopedic surgeries are being done on an outpatient basis, the level of care required at an SNF is not as medically necessary as it was 15 years ago, she says. Despite that, Halvorson, continues, for SNFs partnering with UnityPoint, due to the criteria set forth by the ACO, these facilities “have raised their capacity for care, and the complexity of the care they can provide, and I think they’re going to do very well.”

Butters additionally points to a benefit enhancement waiver in the Next Gen program that allows a Medicare beneficiary to be covered for SNF services when admitted to the facility without a three-day qualifying inpatient hospital stay. “So, we are also impacting our hospital bottom line, as we’re oftentimes transferring patients away from hospitals to our SNF partners with the aim to get the patient the right care in the right spot,” he says.

Further speaking to the core goal of getting patients the right care in the right location, Butters notes that UnityPoint’s patient choice materials specifically highlight the organization’s preferred provider network “so they can see the SNFs that are partnering closely with us for improved transitions of care. And they can also see all the other SNFs available to them within the regions they live. That’s one way we have attempted to ensure that patients are going to the best facility for the best outcome,” Butters contends.

Halvorson adds that SNFs are partners with the ACO in taking on financial risk for patients, and are thus dually rewarded when they hit quality and cost metrics. She notes that those SNFs working closely with UnityPoint have been receptive to this risk-sharing agreement. “They have welcomed the opportunity to begin to receive rewards for the work they have been doing with us. I think that was the biggest takeaway—that the SNFs were understanding this proposition of value in such a way that they were willing to enter into risk arrangements.”