How Data and Technology Are Strengthening the Relationships Between Accountable Care Organizations and Skilled Nursing Facilities

As the post-acute care industry continues transitioning towards a value-based care system, skilled nursing facilities (SNFs) should start to consider participating in an Accountable Care Organization (ACO) to not only help in achieving optimal outcomes but improving patient care journeys uniformly. Building a clinically robust continuum of care includes long-term acute and post-acute care hospitals and providers collaborating effectively. Even though only a small percentage of patients require care in post-acute settings, this number is growing, with the volume of referrals to skilled nursing facilities (SNFs) having grown more than 10% in the last two years. These patients also often require the most complex and costly care, accounting for nearly $60 billion of annual Medicare spend, putting them at a higher risk for readmission, as they often suffer from multiple chronic conditions and have the greatest need to be treated by practitioners and specialists on an ongoing basis.

Accountable care organizations are designed to put patients at the center of care to help them navigate a complex health system – particularly receiving extra help managing chronic diseases. These coordinated care efforts put forth by ACOs help ensure chronically ill patients get the right care at the right time, with the goal of avoiding unnecessary duplication of services, avoiding hospital readmission and worsening of conditions, and preventing medical errors. ACOs also place financial responsibility on providers in hopes of improving patient management and decreasing unnecessary expenditures, all with the patient and their journey at the forefront of these efforts.

But SNFs have been reluctant to participate in ACOs. According to a whitepaper published by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) and the National Association of ACOs (NAACOS), less than 2,000 SNFs actively participate in ACOs, which is about 10 percent of SNFs in active operation nationwide. Even then, this percentage is concentrated in a small amount of ACO’s leaving 70% of them to have no SNF representation. A national ACO survey revealed that over half of ACOs had no formal relationship with SNFs, yet the majority of ACOs are forming preferred SNF networks to improve collaboration between patients, providers, and facility staff, as well as to address the increase and variation in healthcare spending on this area.

But this dynamic could change quickly as Hospital Readmissions Reduction Program continue to penalize SNFs that have higher rates of readmissions, withholding Medicare reimbursements for facilities. With more SNFs being penalized and an increasing number of patients being referred to home health care, participating in an ACO may be a strategic solution to improving care coordination, organizational goals, and patient outcomes overall.

Enhanced care coordination made easier through technology & data

 A delicate balance of technology and human resources will ensure the seamless transition of care for complex and chronically ill patients from hospitals to SNFs to home, reducing fragmentation and improving the overall quality of care. By leaning on real time data & predictive analytics, integrated electronic health records (EHRs), telehealth services, data driven performance metrics and patient centered care plans overall, the healthcare system will see enhanced care coordination that encourages active patient engagement in their own health journey, especially when care can be tailored to their individual condition, higher compliance with treatment plans and better health outcomes, which actively support the ACO’s objectives of quality care and cost reduction. These results and enhanced coordination are crucial for ACOs, which benefit from improved patient outcomes and satisfaction — key metrics in shared savings calculations — while ensuring the collaboration between ACOs and post-acute facilities that develops the foundational relationship spurring the improvement of outcomes.

• Real time data & predictive analytics: Leveraging real-time data from remote patient monitoring and then using advanced analytics allows ACOs and SNFs to better coordinate care, helping them make more informed clinical care decisions that ultimately avoid readmissions or worsening of conditions. Predictive analytics and historical data can be leveraged to predict potential health issues or at-risk patients and proactively intervene before they escalate, thereby reducing emergency room visits and hospital readmissions. 
• Data driven performance metrics: Real time data can also inform tracking and reporting, providing ACOs with the insights needed to continuously improve care processes and partnerships. This data and other technological tools used to inform a patient’s care journey enables proactive health management and timely interventions that prevent costly complications and emergency care that can erode shared savings and cost patients their lives.
• Integrated electronic health records: Additionally enhanced technology and data sharing, particularly when talking about EHRs, ensures all care providers on the patient’s care team has access to the most up-to-date comprehensive medical history to prevent medical errors and enhance the quality of care from different providers. This sort of integration that technological advancements provide allows for seamless information sharing and continuity of care in one of the most complex areas of healthcare, where gaps and information silos can be detrimental to patients.
• Telehealth services expansion: Leaning on tech and data to improve continuity of care can simultaneously expands access to telehealth services, which can in turn provide continuous patient monitoring and support for complex conditions, particularly in the areas that need it most, like rural or underserved communities. Telehealth can facilitate regular check-ins, medication management, and timely interventions for patients without needing in-person visits or monitoring. This eases the burden on the limited provider or facility staff and allows them to see and deal with the issues that are high priority while still provide quality care all around.

How ACOs and SNFs can collaborate effectively going forward

While ACOs are still working to increase the percentage of involvement of long-term or post-acute care providers, most are currently developing networks of high-performing SNFs, ensuring that health systems can direct patients to facilities that offer the best care available. This strategic development is crucial for maintaining control over the quality of care that is currently being provided across different settings, further enhancing the potential for shared savings.

As ACOs and long-term or Post-Acute care facilities continue to enhance data sharing and analytics through technological facilitation, some next steps to fortifying a strong relationship between these entities should look to establish comprehensive integration protocols, strengthen patient engagement initiatives, and monitor and adjust care strategies while expanding training and support for providers and staff to align with ACO goals and protocols to further foster a culture of continuous improvement around patient-centered care. 

These next steps will build on a strong foundational relationship between entities which will in turn be more effective in enhancing patient care, reducing costs, and improving overall healthcare outcomes not only benefiting patients but also contributing to the sustainability and efficiency of the healthcare system as a whole.

Photo: everythingpossible, Getty Images

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