Skilled Nursing, Post-Acute Providers Must Embrace ‘Death of Dogma’ to Survive Shift to Episodic Care

As payers and hospital networks increasingly treat skilled nursing facilities as just one stop along an overall episode of care, operators in the space have received a variety of messages about how to survive: Bring data, get to know referral partners’ problems, demonstrate your worth.

But a leader at a major Philadelphia-area hospital network took that advice a step further this week, calling on providers up and down the spectrum to use new data insights as a weapon to destroy their preconceived notions about acute and post-acute care.

“The problem is, a lot of health care — not just in the post-acute care space, across the board — is based on dogma,” Rajesh Aggarwal, senior vice president of business development at Jefferson Health, said during a Wednesday panel discussion on post-acute care transitions at the Home Health Care News Summit in Chicago. “There needs to be the death of dogma.”

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Using data to measure resident needs and outcomes — and then taking that information to Medicare Advantage plans and hospitals — has arisen as a hot talking point in the skilled nursing space, as new government payment models leave both hospitals and their post-acute partners on the hook for complications that occur during a set period of time, regardless of setting.

It’s a movement that Joseph Kiernan, chief strategy officer of the New Jersey-based post-acute provider Ocean Healthcare, summed up succinctly back in 2018, when he declared the old-school breakfast meetings with referral partners a thing of the past.

“It’s no longer about donuts — it’s about data,” Kiernan, whose company offers a range of services including skilled nursing and home health care, said. “If you want to come and have meetings, that’s great — in God we trust, but everyone else must bring data.”

Kiernan was also on hand at the conference this week to discuss the challenges Ocean Healthcare faces when caring for about 5,000 residents every day, many of whom are in the process of being transferred from one setting to another — either within the network or to external partners. Though the company maintains its own home health and hospice business lines, the realities of geography and volume make partnerships necessary, Kiernan said, giving him a unique view of the landscape.

“The alignment is really complex. My primary referral source owns their own home care,” he said. “I’m a preferred provider in their network. They’re in their bundles. I’m a post-acute provider within that bundle. You take all of this and say: How do you make this work?”

The panelists aren’t alone in identifying care transitions as a key area of stress and confusion for providers and residents alike. A 2018 report from the United Hospital Fund determined that patients and their families aren’t given enough useful information about their choices during the journey from acute to post-acute — and that picking the wrong facility can lead to increased risk of rehospitalizations, emergency department visits, and death.

Even when operators invest in technology that can potentially help them manage transitions, nursing home staff often aren’t given enough training to use the systems and don’t always integrate them into their normal workflows, a study released in January determined.

Panelist David Baiada — CEO of the Moorestown, N.J.-based BAYADA Home Health Care — described the problem even more bluntly to kick off the discussion.

“I think care transitions are one of the worst experiences that humans have to go through in life,” Baiada said.

For Aggarwal, at least, improving care transitions starts with an acknowledgement that all of the assorted players have the same goal: a shared responsibility for resident care along the continuum, and creating pathways that work for not just for health care companies but for the actual patient.

“It’s the right thing to do — to look after patients when they’re outside our four walls,” Aggarwal said.

To that end, Kiernan calls on partners both upstream and downstream to think beyond their individual silos.

“We’re telling everybody: Get outside the lane,” he said. “Step outside, cross over, and that’s really where the higher quality patient care and the better results are coming from.”

In order to accomplish that feat, Baiada repeatedly emphasized the need for in-person meetings among all of the stakeholders involved in senior care. He cited instances of potential partners sending letters through the mail to ask about striking up a formal relationship — or, conversely, sending Dear John letters to announce the breakup of an existing relationship, a distant form of communication that Baiada described as “absurd.”

“It’s basic kindness, and humanizing the strategic alignment that has to happen,” Baiada said of sitting down around a common table. “And the only time we’ve ever seen it work, which is sadly way fewer than it should, is when that happens.”

That’s where the dogma-breaking data comes into play: To have the kinds of honest conversations about care that Baiada craves, both acute- and post-acute providers need to look at outcomes without their preconceived biases about what’s right for patients, Aggarwal argued.

“Honesty, integrity, trust, and transparency,” Aggarwal said, listing the attributes that good players need to have. “That comes from having objective, real-time data which we can both understand — for everyone in the room — and build upon.”

It isn’t just a matter of surviving the current landscape, either. Baiada pointed to growing demographic needs for all kinds of elder care as the population ages, arguing that there’s plenty of business to go around — but that the larger post-acute industry could shoot itself in the foot if it hews too closely to the old tribes of separate disciplines.

“We have a belief that there’s immense, almost immeasurable unmet need for the work that we do over the long run,” Baiada said. “Things break when I watch organizations squabble over referrals — when at the end of the day, in a community, whether you own the capabilities or not, there’s a lot of people who need help.”

No matter what eventual form a skilled nursing provider’s collaborative efforts take, Kiernan noted that time is of the essence as networks continue to narrow and payment models push for greater partnerships.

“Call them before they call you. Go in, set the tone, and get a seat at the table. Start having the conversations if you haven’t already,” Kiernan said. “Have them early on, because otherwise, you’re going to come in a little bit too late, and someone’s going to have set the tone for you.”

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