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The Post-Acute Care Management Model You’ve Been Overlooking

by Mary Kay Thalken, RN, MBA on Dec 5, 2018

Senior Patient on PhoneIt’s more important than ever that healthcare facilities keep track of patients’ health long after they leave the hospital. With reimbursement penalties tied to readmissions within the 30-day window, it’s in facilities’ (and patients’) best interest to ensure the optimum health of persons to one month and beyond.

The best way to do this is through regular check-ins with those patients, either via electronic messaging, phone calls or in-person appointments. In some cases, the exact method of communication may hinge on the patient’s preferences and/or needs. Some patients prefer a phone call, while others are more than comfortable communicating via text or email, while still others need a much higher level of in-person attention to ensure care plan adherence.

Differentiating these patients isn’t always as simple as asking them their preferences. It requires close examination of the patient’s condition, the social determinants of health, familial support, insurance coverage and more. Once they’ve been segmented into different populations, you then need to assign staff members to oversee post-acute care management.

This can require an intensive amount of resources and planning. The good news is there’s an overlooked solution that organizations might soon be able to pursue.

RN-Led Patient Engagement Centers

Rather than hire additional staff or add to the duties of current staff, hospitals may work with outside patient engagement centers to hand off patients and, subsequently, to monitor care. We foresee this concept gaining ground as healthcare institutions look to keep budgets under control while still providing an expert level of patient care even after persons leave their traditional in-hospital purview.

In this situation, the outside institution is staffed by Registered Nurses and other professionally certified individuals. These are persons who have years and decades of experience with clinical care but who have chosen to apply these skills in a non-traditional way that they’ve found does the most good for the most people. RN Call CenterHere’s how it works: the in-house nurse or the case manager prepares the patient for discharge, similar to how they would in a traditional format. But once that discharge process is initiated, the patient’s follow-up care plan is sent to the care management/patient engagement center.

At that point, the primary responsibility of communicating with the patient based on the agreed-upon touchpoints transfers to the patient engagement center. The patient will be assigned an RN-certified case manager or a team of persons, depending on their specific needs and required level of care.

This frees up the team at the original acute setting to move on to the next patient, whom they’ll be able focus all their attention on rather than having to keep careful tabs on the persons who have already left their care.

Meanwhile, the discharged patient gets a dedicated team who can see to their needs. This team knows the patient’s history, their risk levels and their particular social determinant challenges, and they can respond as needed to address any issues that arise. Because they have access to the care institutions in that patient’s geographic area, they’re able to schedule appointments, refer questions to the appropriate member of the care team and order prescriptions to be delivered to the pharmacy or sent to the patient directly.

By creating clear delineation between A) the patient’s acute care journey and B) their post-acute care journey, with completely different in-house vs. outsourced staff for each, you can actually create a progressive, productive care management model that benefits providers and patients.

As this concept grows in popularity, health systems and hospitals need to re-evaluate their current practices to determine if this might be the right call for their own workforce and patient population.

We in healthcare will continue to pursue better patient outcomes via innovative care management models, and the option presented above will soon become a positive solution for entities across the nation.

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Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.

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