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Five Questions to Ask When Selecting a Quality Post-Acute Care Provider

workerscompensation.com
Author: Stan Smith, Senior Vice President, Paradigm Specialty Networks

With 20% of all hospital discharges[i] having a post-acute care (PAC) setting as their destination, it’s essential for workers’ compensation (WC) payers to have the subject matter expertise that enables them to identify quality PAC providers. This is particularly important when taking a closer look at how many injured workers may be represented in this discharge statistic—which may be as high as 150,000 annually.[ii,iii]

While payers are making upwards of 150,000 decisions annually regarding the PAC setting, how do they select the best provider? Each decision can be viewed as daunting, considering that there are more than 60,000 PAC provider locations to choose from across the seven different PAC provider types[iv] ─ skilled nursing facilities, inpatient rehab hospitals, long-term care hospitals, assisted living facilities, traumatic brain injury centers, spinal cord injury centers, and home health care services. Furthermore, most if not all of the 60,000 PAC providers actively engage hospital discharge planning departments with a variety of community relations and marketing activities, as they strive to represent themselves as the “PAC provider of choice.”

The answer to how WC payers can select the best provider is this: Using five simple, action-based questions (shown below), WC payers can engage any PAC provider under consideration to gain relevant information that will reveal the presence or absence of the PAC provider’s clinical best practice capabilities. Just as important, leveraging these five questions will help WC payers identify and avoid those providers interested in merely gaining an easy referral, rather than forming a lasting, effective treatment relationship with an injured worker.

Question #1: Is the provider able to develop, and then be accountable for, successful implementation of an effective and easily understandable Plan of Care? 

Beginning with the pre-admission assessment process, effective PAC providers are able to manage an initial assessment of the most complex post-acute care cases within the demands of often unpredictable and compressed response time frames.

Quality PAC providers employ assessment professionals capable of performing both remote desk review of clinical records as well as tele- or in-person follow-up assessments from which they can quickly provide input regarding the injured worker’s proposed Plan of Care. These same assessment professionals will happily work closely with the injured worker’s family, arranging a tour of their facility and answering any questions about an initial Plan of Care.

Likewise, assessment staff will be accessible to engage a WC payer’s claim professionals or its field-based case management team. Post admission, quality PAC providers proactively engage the injured worker, their family, and payer case management staff at convenient times in ongoing “Care Plan” meetings (either live or via tele-technology). In best practice PAC settings, the individualized Plan of Care will absolutely drive the treatment experience for the injured worker. With providers of lesser quality, this clinical process will appear as an afterthought, afforded little time or focus as the length of stay evolves.

Question #2: Will the PAC provider partner with the injured worker to lead their full exploration of a new sense of self in light of the work-related injury, focused on maximizing the individual’s new level of function within a biopsychosocial treatment philosophy?

Quality PAC providers will be “all about,” pardon the slang, placing the injured worker and their family members at the center of all treatment efforts. This includes assessing and then offering treatment options surrounding all areas of the injured worker’s sense of self that are affected by a complex or catastrophic work-related injury. Over the past 20 years, workers’ compensation catastrophic care and quality PAC providers have adopted this patient-centered focus using the tenets of biopsychosocial care delivery initially put forth in the 1970s.[v, vi]

Quality PAC providers will nurture and encourage the injured worker to maximize their post-injury sense of self, and to explore all creative avenues to capitalize on their level of function and quality of life. As a matter of best practice, PAC providers’ staff will seemingly always have time for questions and actively engage the injured worker and their family during assessment and treatment phases. Providers with a lesser-quality focus will refer to the injured worker in the context of their functional deficits. Likewise, these sub-par providers will appear to be risk averse or unsupportive in allowing the individual and/or their family members to explore an ambitious or highly individualized Plan of Care.

Question #3: Does the PAC provider treat a “critical mass” of “like” patients in their therapeutic setting?

Quality PAC providers will be able to give a reasonable approximation, if not a precise metric, regarding how many patients with health conditions/diagnoses similar to the injured worker currently considered for admission.[vii] Further, best practice PAC providers will be transparent in communicating when the injured worker’s health needs are not consistent with the types of PAC health care services they typically deliver. In short, a high-quality provider will focus on ensuring that their capabilities can effectively match the Plan of Care needs for an admission candidate. Providers with a lesser-quality focus will stumble in their ability to produce metrics about the various types of health condition/diagnosis groupings they treat or may attempt to answer the question with a “generalist” response. They may reply with, “we treat a little bit of everything” or “we can handle most anything that rolls through the door.” Be wary when the PAC provider is not well versed in their admission health condition/diagnosis grouping metrics.

Question #4: Is there a long-term commitment to patients and their families with after-care/post-discharge programming?

Many WC PAC admissions will require a long-term treatment approach, assisting the worker in achieving their highest post-injury level of function and quality of life. When a quality PAC provider engages in post-discharge outpatient or after-care services aided by a comprehensive biopsychosocial model, these services are set up to continually engage the injured worker and their family. Vital outpatient or after-care services will be discussed, planned, and developed well in advance of discharge. In best practice settings, after-care services can also take the form of support and social engagement groups composed of discharged patients and their families. These support groups oftentimes are formal, social communities of active discharged patients with PAC support services delivered months or years beyond discharge. In lesser-quality PAC provider settings, critical outpatient services will appear as an afterthought to inpatient treatment. The injured worker needing these critical services will find them hastily discussed at the final Plan of Care conference which is held one day before the injured worker’s discharge.

Question #5: Can the PAC provider demonstrate published treatment outcomes data, participation in industry best practice programs, utilization of peer-reviewed/evidence-based treatment programming, or discuss current quality improvement initiatives?

It may appear that there’s a lot to this question, but it’s really quite simple. Quality PAC providers will be more than willing to do one or more of the following:

  • Discuss how they are actively engaged in a variety of industry best practice initiatives to drive higher-quality patient care outcomes
  • Provide examples of any activities that have garnered peer-reviewed publication in their PAC specialty
  • Have their clinicians review the evidence-based treatment interventions they deliver
  • Review current internal quality assurance (CQI – Continuous Quality Improvement) initiatives underway to enhance PAC health care outcomes

PAC providers with an intense focus on quality improvement also embrace transparent communication with their stakeholders about those efforts that are underway. Out of necessity, these discussions will involve data/metrics that provide relevant information, while protecting patient data, as required by HIPAA. That said, thoughtful review of the issues covered with this question can and do routinely occur between staff of quality PAC providers and their stakeholders.

Making sense of it all

When PAC providers respond to inquiries, you may hear something of an “alphabet soup” of jargon describing the many different quality initiatives by which a PAC provider can challenge itself. If this occurs, you may ordinarily consider the jargon a positive sign that the provider is fully immersed in partnering with external PAC-based organizations focused on enhanced patient care. This may begin with a provider voluntarily pursuing accreditation through either the: (1) Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) or (2) Commission on Accreditation of Rehabilitation Facilities (CARF).

For skilled nursing facilities and home health agencies, this includes the Centers for Medicare & Medicaid Services (CMS) 5-star quality rating score. (Five stars is the highest score CMS awards, and it is only given to the highest-quality health care providers.) For all seven PAC provider types, it involves working with their respective national professional organizations[viii] in a number of annual member quality initiatives.

Finally, when you suspect you are considering a PAC provider with little focus on quality improvement, you may wish to ask about their voluntary participation in industry CQI programs, keeping in mind that lower-quality providers may not know such programs exist. You may also find that sub-par PAC providers pay lip service to industry CQI programs, citing how they are too onerous to have as quality partners. Further, a lower-quality provider may give a disclaimer that they cannot discuss such activities even generally, due to the confidentiality they must maintain regarding their CQI programs.

The bottom line is this

By following these five simple questions, workers’ compensation payers separate quality PAC providers from those whose goal is simply to boost their weekly enrollment number. When WC payers and their care management teams leverage these five questions, they will ordinarily find that best practice providers will provide in-depth answers to each of these vital questions.

By Stan Smith

Stan Smith is Senior Vice President of Paradigm Specialty Networks. Stan is a licensed Long Term Care Administrator, has 31 years of health care management experience in Post-Acute Care (PAC) settings, including Long Term Acute Care Hospitals, Inpatient Rehabilitation Hospitals, Skilled Nursing Facilities, Inpatient Rehabilitation Units, Assisted Living, and Home Health Services. His experience also crosses Ambulatory Care, Physician Medical Practices, and Clinics. Stan has managed viral outbreak events across multi-facility/multi-state environments and is an invited speaker at national workers’ compensation and PAC conferences on topics including catastrophic injury care management, traumatic brain injury care management, healthcare billing fraud, interpreting medical records, cyberchondrosis, risk management and Continuous Quality Improvement (C.Q.I.). He is also a legal expert testimony witness in cases involving healthcare billing fraud and skilled nursing care administrative negligence.

Paradigm Specialty Networks offers innovative, data-driven network solutions for the most challenging, expensive, and unmanaged segments in workers’ compensation: orthopedic and spine, pain management, addiction, post-acute care, behavioral health, and surgical implants.

Full article on workerscompensation.com:  Five Questions to Ask When Selecting a Quality Post-Acute Care Provider

[i] Tian W. (AHRQ). An All-Payer View of Hospital Discharge to Post-acute Care, 2013. HCUP Statistical Brief #205. May 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb205-Hospital-Discharge-Postacute-Care.pdf, 2.

[ii] Tian’s analysis shows that for a representative year 2013 PAC destination discharges totaled 7,955,700. Further that 1.9% of these discharges occurred in the “Other” category used to capture workers’ compensation payer type discharges. Hence, it is reasonable to project that workers’ compensation discharges then may total up to 1.9% of 7,955,700 or approximately 150,000 annual discharges.

[iii] Weiner J. (JAMA Research Letter). Where Patients go After Hospital Discharge: Trends in Post-Acute Care. April 2018. Journal of the American Medical Association (JAMA), Chicago, IL.  https://jamanetwork.com/journals/jama/fullarticle/2678604, 1-2.

[iv] Provider certification and membership data available from the Centers for Medicare and Medicaid Services, American Hospital Association, American Health Care Association/National Council on Assisted Living, American Medical Rehabilitation Providers Association and Brain Injury Association of America validates 15,268 skilled nursing facilities (SNFs), 1,165 inpatient rehabilitation hospitals (IRFs) and inpatient rehabilitation units (IRUs), 431 long-term acute care hospitals (LTCHs/LTACs), 500+ residential care traumatic brain injury and spinal cord injury centers, 12,200 home health agencies, and 38,000 assisted living facilities in the United States.

[v] Borrell-Carrio, M.D., F, et. al., The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Nov 2004. Annals of Family Medicine. Leawood, KS. https://pubmed.ncbi.nlm.nih.gov/15576544/.

[vi] Spennato, E., Here’s Why Catastrophic Injury Recovery Requires a 360-Degree Approach to Case Management. Dec 9, 2019. RiskandInsurance.com. Horsham, PA. https://riskandinsurance.com/heres-why-catastrophic-injury-recovery-requires-a-360-degree-approach-to-case-management/.

[vii] No metrics are found in PAC health care literature about how many patients with similar health conditions/diagnosis groupings constitute a “critical mass.” That stated, the author’s 25+ years’ experience as a licensed PAC facility administrator/multi-site executive offers that the number begins around 8%-10% of a PAC provider’s rolling inpatient census.

[viii] Skilled Nursing Facilities and Assisted Living Facilities – American Health Care Association/National Center for Assisted Living.  Inpatient Rehabilitation Facilities/Hospitals – American Medical Rehabilitation Provider Association. Long Term Acute Care Hospitals – American Hospital Association Post-Acute/Long Term Care section.  Home Health Agencies – National Association of Home Care and Hospice.