Connecting Post-Acute Care: Collaboration for Performance Improvement Across Networks

Connecting Post-Acute Care: Collaboration for Performance Improvement Across Networks

For complex and frail patients, the transition from acute to post-acute care (PAC) is a critical point in their care journey. But inconsistency in the quality of care, inadequate communication and a lack of visibility and patient tracking lead to a number of issues, including patients returning to acute care, suboptimal use of services and higher costs. To address the challenges presented by PAC transitions, Southwestern Health Resources (SWHR) launched an initiative to improve operational and clinical performance among the post-acute providers in its network.

The problem

Transitions from acute to post-acute care are the most vulnerable and costly points in the care journey for complex and frail patients. This is a universal challenge in healthcare that affects not only patient satisfaction, but also total cost of care, operational performance and clinical quality. The care patients receive in post-acute settings influences their satisfaction with their acute care experience, as patients tend to perceive the two as a single experience. 

Masked nurse assisting masked patient in walker

The opportunity

Post-acute care accounts for 97% of all Medicare spending. By improving operational performance and clinical quality, post-acute facilities' spend can be reduced and outcomes improved for the most complex patients. These improvements can also help raise patient satisfaction rates for both acute and post-acute care providers.

The solution

In a unique initiative, SWHR employed technology, data and education to improve overall performance for providers across North Texas. The goal was a seamless patient experience, appropriate utilization of beds and services, and continuous performance improvement that lowered the total cost of care.


The results

The initiative succeeded by reducing the per member, per year total cost of post-acute care by an estimated $6 million. It also helped reduce patient returns to acute care across all post-acute facilities. This model lowers the total cost of care for high-acuity and complex patients and can be replicated by clinically integrated networks seeking to create value by improving patient outcomes and experience.