Dr. Amdahl is passionate about post-acute integration and why it matters to stakeholders, patients and their families. After 21 years of clinical pulmonology, much of it in the long-term acute care hospital (LTACH) setting, Dr. Amdahl is now HealthEast’s Executive Medical Director for all of post-acute care. In this interview, we ask questions related to post-acute’s value, payment reform and the challenges ahead.
In this role, Dr. Amdahl will partner with local referral hospital physicians to ensure timely and smooth patient transitions. He will also work to develop clinical protocols that best support patients’ needs. Dr. Amdahl will be active in efforts to educate providers, patients, and legislators about the opportunities and challenges in the post-acute arenas of care.
Remington Report: Describe why integrated post-acute matters.
Amdahl: Integrated post-acute care is increasingly needed to demonstrate our value in the care continuum. Although the transformation from fee-for service to value-based payments is going to take some time to work out the details, the principles that will be used to determine value are already being rolled out. In addition to traditional markers of a satisfactory medical or surgical encounter, optimal patient outcomes now depend heavily on less-traditional measures like patient satisfaction and successful transitions of care. As more patients are pushed out of the acute care setting, post-acute care venues must now be acutely aware of these issues. As a patient moves down the post-acute pathway, each care transition presents a potential obstacle to the desired outcome of “value.”
Integrated post-acute care, either within a single healthcare system or across systems, will provide patients with care that is perceived as valuable. This value will be assured by flawless transitions of care, with optimal caregiver communication, uninterrupted care plans, accurate medical reconciliation and clear instructions for follow-up. If any element of the post-acute clinical spectrum is identified as consistently disrupting the end-result of “value”, then it will become evident to the other members of the care continuum. Additionally, as patients become savvy consumers of healthcare, they also will detect flaws in our delivery of post-acute care. Either of these parties can decide to seek more integrated post-acute care elsewhere.
Remington Report: How does poorly integrated post-acute care impact patients and their families?
Amdahl: Poorly integrated post-acute care will ultimately result in dissatisfied customers. They could be unhappy with any aspect of their care, like flow of clinical data between sites or providers, communication from providers, or instructions for subsequent care. As patients are universally asked to complete satisfaction surveys, they have an outlet to express anger or frustration about perceived flaws in their care. Patients and their families are no longer passive participants in the healthcare process. Technology, particularly the internet and social media, provide nearly instantaneous access to data and opinions about the healthcare experiences of others. As patient satisfaction and other quality data becomes public, poorly integrated care can be expected to drag down provider rankings, impacting future referrals and eventually even reimbursement.
Remington Report: How will post-acute bundling impact ACOs and health systems?
Amdahl: As post-acute care bundling enters our markets, there is going to be a tremendous increase in the scrutiny of post-acute care providers. In the case of prospective bundling, where one entity is given control of the dollars at the initiation of care, they are likely to be very discriminating about the care-participants they are willing to split the money with. I expect that ACOs and larger health systems will want to “control the bundle” for patients attributed to them. This will empower them to set expectations and standards of care that must be met for other providers to continue as a participant. Demonstration of integrated care that achieves shorter duration of care, favorable fiscal outcomes, and more satisfied patients should result in post-acute providers finding themselves invited to participate in multiple bundles.
Remington Report: Describe current provider-created obstacles to post-acute integration.
Amdahl: Providers are slow to recognize that successful clinical encounters are no longer measured solely by control of disease, healing, or a satisfactory surgical outcome. So often, it is assumed by providers that patient satisfaction, medical communication and patient handoff to the next venue of care are either somebody else’s problem, or solved by the presence of an EHR. Poor documentation in the medical record or discharge orders results in duplicative care, medication confusion, misinterpreted instructions and even complications that prolong care or result in adverse outcomes, like readmission. Additionally, the frequent “silos” of care that exist between post-acute care venues permits the lack of provider ownership of the patient. Truly integrated post-acute care demands that providers anticipate the potential pitfalls at every transition of care and actively usher each and every patient into the next phase of care. Provider-to-provider communication – real-time conversation – cannot be overemphasized. Although clearly beneficial in many ways, over-reliance on electronic health records is a threat to effective care transition and integration.
Remington Report: What immediate steps can ACOs, health systems and post-acute providers take to resolve obstacles?
Amdahl: All participants in today’s post-acute care environment need to openly communicate what is expected to impact them in the foreseeable future. Where applicable, consider sharing data about clinical outcomes, financial performance, or patient satisfaction scores. Be proactive in anticipation of bundled payments and talk with expected partners. Be keenly aware of legislative changes on the horizon, like LTAC payment reform, and be sure that other entities understand the impact it will have on current post-acute care practices. Above all, recognize that the way we deliver post-acute care today will not be applicable in the near future, and work together to have a tightly integrated approach.
Brian D. Amdahl, MD, FCCP, MMM, is Executive Medical Director, VP for Post-Acute Services at HealthEast Care System, St. Paul, MN. His medical leadership role includes oversight for Bethesda Hospital, Home Care, LTACH, Hospice/Palliative Care, SNF/TCU, Community Care Management, and Medical Care for Seniors and Community Outreach.
