CARE DELIVERY ACROSS THE

CARE CONTINUUM:
HOSPITAL-COMMUNITY-HOME
SHAIRA B. MATAGANAS BSN 2-A
OVERVIEW
a. Post-acute care is a poorly understood segment of
our healthcare system

b. In this chapter, we provide a detailed overview of

the post-acute providers recognized and reimbursed
for their care by CMS, and placed in the context of the
current health reform environment
HEALTH CARE REFORM
The fragmentation of the United States (US)
healthcare delivery system is well documented
DEVELOPMENT OF THE NATIONAL STRATEGY
FOR QUALITY IMPROVEMENT
• The current reform framework and changes in reimbursement policies have
been pushed forward by a number researchers, private institutes, and
government agencies
• Significantly, for post-acute care providers, one of the six national priorities
targets care coordination with expectations for managed care transitions and
communication across care settings
AFFORDABLE CARE ACT’s OPERATIONAL ARM
• The two most influential health policy bodies are the CMS Innovation Center
and the Patient Centered Outcomes Research Institute (PCORI)
INTRODUCING THE
POST-ACUTE
PROVIDERS
 B.
• The numbers of post-acute care
providers and the volume of
patients that each serves per year
show that we cannot reach the
goal of an integrated healthcare
system at community levels
A. without their inclusion in
• CMS includes home health agencies, healthcare reform
skilled nursing facilities, inpatient
rehabilitation facilities, and long-term
care hospitals in this “post-acute
care” category

• To assist in this overview, Table 1

lists each CMS recognized entity, the
type of patient services provided,
differences, patient eligibility
requirement, payment structure, and
episode period Chapter 25
 E.
• Hospice is also covered under the
Medicare benefit, but until
recently, was seldom used as a
discharge destination from a
hospital stay

C.
• Long-term care hospitals (LTCH) and
in-patient rehabilitation facilities
(IRFs) must meet the same conditions
of participation that acute care
hospitals are held to for admissions
and facilities criteria
D.
• Home healthcare is the largest of all
the post-acute care providers and
continues to grow annually
THE ROLE FOR POST-
ACUTE CARE
PROVIDERS
 a. c.
Increasingly, Hospices and It is in understanding the
Kidney Dialysis Centers services that each post-acute
have started to be included care provider offers that we
in planning as Care will be able to align patients’
Transitions post discharge care plan
b. with their needs and wishes

This advancement in care

transitions initiatives
required care planning
changes that depended on
informatics and data
analysis
CLINICAL INFORMATION SYSTEMS
IN POST-ACUTE CARE
 a. c.
Just as Meaningful Use (MU) While the majority of post-
incentives are impacting acute organizations have
acute and ambulatory care
providers, they are also
information systems that
affecting the post-acute care include clinical
providers even though they b. documentation, these are
are not included as eligible designed largely to function
Through the ACA as data captures for billing
providers for payment legislation, quality
incentives and CMS’ mandatory
measure definition work
minimum data bases sets
of the National Quality
Forum, and in
conjunction with CMS’
power of reimbursement
sanctions, the last five
years have seen a
rapidly changing health
policy landscape
EHR ADOPTATION
LEVELS IN HOME
HEALTH
More than 40% of the agencies sampled in 2013 are still
in paper mode for clinical documentation
STANDARDS NEEDED
FOR CARE
COORDINATION
a. Standards for clinical information systems apply to the
ways data are named, stored, and shared, as well as to
promote accuracy and to work more efficiently

b. The Continuity Assessment Record and Evaluation

(CARE) Tool was created by CMS as part of the Post-Acute
Care Payment Reform Demonstration (PAC-PRD)
authorized by the Deficit Reduction Act of 2005

c. Another major focus of Standards Development

Organizations (SDO) has been defining the shared care
plan

d. The Consolidated Clinical Document Architecture (C-

CDA) is the result of a harmonization project addressing
overlapping efforts of HL7, IHE, Health Information
Technology Standards Panel (HITSP), and the Health Story
Project

e. The 2014 Edition Certification Program for Health

Information Technology specifically calls for the use of the
HL7 C-CDA to be used for capturing and exchanging
f. Some of these SDOs have completed their standards
development process and others are still being publicaly
reviewed and revised

g. The ONC launched the S&I Framework in January of

2011 to engage community involvement on
interoperability challenges critical to meeting
Meaningful Use objectives

h. There is not yet one data set or set of definitions

identified for the requirements of patient information
exchange for care coordination or for the care plan

i. The impact to vendors of the standards development

related to care coordination varies based on their current
tools in place

j. Nursing has been represented in all phases and

environments of standards development for care
coordination