Care Delivery Across

the Care Continuum:

Hospital–Community–
Home
 Introduction

This chapter sheds light on an often overlooked part of our healthcare system: post-acute care.
Nurses and physicians often lack formal education and training in these settings, which hinders
their ability to understand and coordinate care effectively. As we navigate new healthcare
reforms like the Affordable Care Act (ACA), it's crucial to integrate care across different
settings to improve quality, reduce costs, and enhance patient experiences.

We delve into the various post-acute care providers recognized and reimbursed by CMS (Centers
for Medicare & Medicaid Services) and their roles in the current reform landscape. We discuss
how reimbursement changes are driving new care delivery models that require close
collaboration with post-acute care providers for better outcomes. Informatics, particularly
electronic health record (EHR) systems, plays a vital role in this integration and coordination
effort.
.
 Introduction

Despite being the highest spender per person in healthcare among industrialized nations, the
United States falls short on major health indicators. Healthcare spending is disproportionately
high compared to outcomes, highlighting the need for reform. We explore the economic factors
driving this imperative for change.

.
Development of the National Strategy for Quality Improvement

The current push for healthcare reform and changes in reimbursement policies has been driven
by various researchers, private institutes, and government agencies, each building upon the
work of others. Two influential bodies of work are notable: one from Berwick and colleagues at
the Institute of Healthcare Improvement, which introduced the Triple Aims concept, and
another from the Commonwealth Fund's Commission on High Performance Healthcare System,
which outlined the characteristics of a high-performing healthcare system.

These frameworks redefined the focus of care delivery, emphasizing better care, healthier
communities, and affordability. The Department of Health and Human Services (HHS) adopted
these aims and priorities in its National Strategy for Quality Improvement. This reform
framework, known as the National Quality Strategy (NQS), prioritizes making care safe,
coordinated, evidence-based, and affordable.
Development of the National Strategy for Quality Improvement
For post-acute care providers, one of the NQS priorities focuses on care coordination, with
expectations for managed care transitions and communication across settings. Patients with
chronic illnesses or disabilities are to have a shared care plan used by all providers, coordinated
through primary care and extending into community-based providers. Shared accountability and
access to patient information are emphasized, along with measurement and reporting
requirements.

These mandates have implications for the functionality, standards, and interoperability needed
in electronic health record (EHR) systems across all sectors, presenting both opportunities and
challenges for healthcare providers and organizations.
 Affordable Care Act’s Operational Arms
Two significant health policy bodies established by the 2010 Affordable Care Act (ACA) are the
CMS Innovation Center and the Patient-Centered Outcomes Research Institute (PCORI).

The CMS Innovation Center focuses on patient populations covered by Medicare, Medicaid, or
the Children's Health Insurance Program (CHIP). Its goal is to test new payment and service
delivery models to reduce program costs while maintaining or improving the quality of care. For
example, it explores concepts like "Accountable Care Organizations," where payment is tied to
a bundle of services across the care continuum to manage a population's health outcomes.

PCORI, on the other hand, aims to enhance research on treatment methods, drugs, devices, and
systems by funding comparative clinical effectiveness studies. Its focus is to increase the
quantity, quality, and timeliness of reliable research information and accelerate its
implementation in practice. PCORI has allocated significant funding for research studies,
indicating its commitment to driving rapid change in healthcare practices.
 INTRODUCING THE POST-ACUTE PROVIDERS
Understanding the various types of post-acute care providers and their services can be
challenging, as there are many similarities and differences among them. Typically, post-acute
care includes services provided by home health agencies, skilled nursing facilities, inpatient
rehabilitation facilities, and long-term care hospitals.

Medicare and Medicaid cover a significant portion of the expenses for care provided by these
post-acute providers. Patients who require post-acute care are usually those who are
homebound, need inpatient-level care, have limited mobility, or are nearing the end of life.

The number of post-acute care providers and the volume of patients they serve each year
highlight their importance in the healthcare system. For example, in 2012, approximately 3.5
million Medicare beneficiaries used home health services, and around 1.3 million Medicare
beneficiaries received hospice care.
 INTRODUCING THE POST-ACUTE PROVIDERS
Each post-acute care setting has specific eligibility requirements that must be met to receive
reimbursement from Medicare. For instance, inpatient rehabilitation facilities (IRFs) must
provide intensive rehabilitation therapy for at least three hours per day, five days per week,
and long-term care hospitals (LTCHs) must have an average length of stay greater than 25 days.

Home healthcare is the largest post-acute care provider and continues to grow annually.
Eligibility for home health services is based on being homebound and needing skilled nursing
care or therapy to maintain or improve health status.

Hospice care is provided to terminally ill patients who have a life expectancy of six months or
less. Hospice care is also covered by Medicare, and eligibility requires certification by a
physician that the patient has a terminal condition.

Overall, the increasing demand for post-acute care services is driven by factors such as the
aging population and the need for specialized care after hospitalization or for chronic
conditions.
 The Role for Post-Acute Care Providers
As part of the Care Transitions demonstration projects mandated by the Affordable Care Act
(ACA), there has been a shift towards including other post-acute care providers like hospices
and kidney dialysis centers in care coordination efforts. For example, partnerships between
home health agencies (HHA) and hospitals have highlighted the need for better identification of
patients at the end-of-life stage of a chronic disease. Without this clarity, these patients might
end up being referred to providers focused on rehabilitation or curative care, leading to
frequent emergency room visits and hospital readmissions.

To address this challenge, advancements in care transitions initiatives have relied on

informatics and data analysis. Early initiatives required the ability to track patients who were
readmitted within 30 days of hospital discharge and report back to their partners. However,
many existing systems lack the functionality needed to support seamless care transitions and
coordination. As a result, staff often have to manually track and report patient data.
 The Role for Post-Acute Care Providers
Another important change informed by data analysis was the active inclusion of hospice as a
post-hospital destination. Hospitals began engaging in difficult conversations with physicians,
patients, and families to consider hospice as an option for appropriate discharge placement.
This shift in discharge planning has helped reduce rehospitalizations and improve the overall
care experience for individuals eligible for hospice care.

Understanding the services offered by each post-acute care provider is crucial for aligning
patients' post-discharge care plans with their needs and preferences. By matching patients with
the appropriate setting along the continuum of care, from curative and rehabilitative to
preventative and palliative care, we can work towards achieving the goals of the healthcare
system, such as improving quality of care, reducing costs, and enhancing patient experience.
 CLINICAL INFORMATION SYSTEMS IN POST-ACUTE CARE
Just like how Meaningful Use (MU) incentives have influenced acute and ambulatory care
providers to adopt electronic health records (EHRs), they're also affecting post-acute care
providers, even though they're not eligible for payment incentives. MU encourages hospitals
and physician offices to use EHR functionality, leading to significant changes in how clinicians
work and use data for clinical decisions and care planning. As a result, there's now a push for
data exchange and analytics in the post-acute care community.

In the past few years, there have been significant changes in health policy, driven by legislation
like the Affordable Care Act (ACA) and quality measure definitions from organizations like the
National Quality Forum. Quality measures linked to reimbursement are now required, with a
focus on goals like reducing readmission rates within 30 to 60 days after discharge. Hospitals
are now seeking collaboration with post-acute care providers like Skilled Nursing Facilities and
Home Health agencies to exchange data and improve care coordination. However, many post-
acute care EHR systems are not prepared for this level of functionality.
 CLINICAL INFORMATION SYSTEMS IN POST-ACUTE CARE
While most post-acute care organizations have information systems for clinical documentation,
these are primarily designed for billing and mandatory data submission to CMS. Each post-acute
provider must submit a minimum data set to CMS for reimbursement, shaping the design of
these systems over the past few decades. This regulatory requirement has led to differences in
functionality between post-acute care EHR systems and those used in acute and ambulatory
care settings.
Case Example: Evolution of Clinical Information Systems in Home
Health
In 2000, CMS changed how home health agencies were reimbursed by introducing prospective
payment linked to a new documentation tool called the Outcome and Assessment Information
Set (OASIS). At that time, most systems used paper-based records for clinical documentation,
and agencies relied on their billing and admission/discharge/transfer (ADT) system vendors to
develop solutions for capturing OASIS data electronically. However, these systems were mainly
focused on billing and lacked comprehensive workflow support, integrated patient record
views, and clinical decision support.

The home health information technology (HIT) software market mirrors the fragmented nature
of the home health industry itself. Many small vendors cater to local markets with basic
systems covering front-office and billing functions, along with OASIS capture functionality.
These systems are affordable for the numerous small-sized agencies in the industry. Larger
agencies, including hospital-based ones and the Veterans Administration, have driven demand
for more advanced clinical systems with features aligned with Meaningful Use requirements.
Case Example: Evolution of Clinical Information Systems in Home
Health
Despite advancements, most existing systems prioritize reimbursement processes over clinical
workflow support and lack structured clinical data. This limitation hampers home health
organizations' ability to provide quality care and measure clinical outcomes effectively. Many
major vendor systems still operate on outdated technical platforms, although newer startups
are introducing web-based platforms using cloud technology and iPad devices, offering more
flexibility and potential for rapid development at a lower cost.

These new developments hold promise for the home health and post-acute care sectors,
offering the potential to catch up to Meaningful Use functionality levels in the next five years.
 EHR Adoption Levels in Home Health

Between 2000 and 2013, there were three national surveys conducted to measure the adoption
of electronic health records (EHRs) in the home health industry. These surveys revealed a
notable increase in EHR adoption over the years. In 2000, only 32% of home health agencies
(HHAs) had basic EHR functions, while by 2013, this figure rose to 58%. However, around 40% of
agencies were still relying on paper-based documentation in 2013, with only 42% of them
planning to transition to an EHR system within the next year.

Although these surveys track overall EHR adoption rates, they do not provide insights into the
specific functionalities included in these systems. Essential EHR functionalities today include
clinical decision support, flexible views of patient information, point-of-care documentation
support, telemedicine capabilities, standardized terminologies, and interoperability to exchange
patient data with other providers.
 EHR Adoption Levels in Home Health

A study conducted in 2007 attempted to assess the functionality of EHR systems used in home
health agencies. It found that while most agencies had basic functionalities like patient
demographics and physician's ability to electronically sign orders, features like point-of-care
clinical documentation and clinical decision support were less common. Additionally, sharing
health information with other providers was nearly non-existent due to the lack of enabling
functionality like the Consolidated Clinical Document Architecture (C-CDA).

Although the 2013 survey did not delve into functionality, major vendors in the industry have
since embraced tools like C-CDA to enhance interoperability and facilitate the exchange of
health information among different healthcare providers.
 STANDARDS NEEDED FOR CARE COORDINATION
Standards for clinical information systems are crucial because they ensure that data are named,
stored, and shared in a consistent and efficient manner. This standardization ultimately
improves patient safety and reduces healthcare costs. Various organizations, including
government agencies like CMS and HHS, as well as non-profit agencies like HL7 and IHE, have
been involved in developing and implementing these standards for years.

One example of a standardized tool is the Continuity Assessment Record and Evaluation (CARE)
Tool created by CMS. This tool aims to standardize patient assessment information across post-
acute care settings, allowing for better understanding of care differences and guiding payment
policies. It minimizes provider burden by including only essential items related to severity,
payment, or quality monitoring.

Another focus of standards development organizations is defining the shared care plan, which
can facilitate coordination of care across different settings and disciplines. Standardization of
care plan elements is crucial for exchanging care plans between settings, ensuring continuity of
care. Various organizations like HL7, IHE, and ONC have been working on defining standard care
plans to support care coordination efforts.
 STANDARDS NEEDED FOR CARE COORDINATION
The Consolidated Clinical Document Architecture (C-CDA) is an important tool adopted by CMS
to facilitate patient information exchange. It allows for the exchange of clinical summaries and
care plans between different healthcare providers. Additionally, the 2014 Edition Certification
Program for Health Information Technology requires the use of C-CDA for capturing and
exchanging patient summary information.

Despite efforts to develop and implement standards for care coordination, there is still a lack
of consensus on certain aspects, such as data sets and definitions for patient information
exchange. However, progress has been made with tools like the CARE Tool and C-CDA. The road
to complete interoperability is ongoing, but organizations like IHE have demonstrated success
through events like the Connectathon.

Nursing has played a significant role in standards development for care coordination, with
nurses representing various care environments and contributing to these initiatives in
leadership and supporting roles. Overall, standardized tools and processes are essential for
improving care coordination and ultimately enhancing patient outcomes.
 DISCUSSION
The U.S. healthcare system is undergoing significant changes to address the unsustainable
burden it places on taxpayers, employers, and individuals. With the implementation of
Healthcare Exchanges mandated by the Affordable Care Act, the U.S. aims to provide universal
health insurance coverage, aligning with other industrialized nations.

To achieve better value for money spent on healthcare, reform efforts are focusing on how care
is delivered and reimbursed. Post-acute care providers have the opportunity to become integral
partners at community levels for the first time. Care coordination, which involves preventing
adverse events, ensuring efficiency, and prioritizing patient-centered care, is crucial, especially
for patients with complex medical needs or transitioning between care settings.

However, achieving effective care coordination requires sophisticated electronic health record
(EHR) system capabilities, which may pose challenges for many organizations due to the current
state of information systems in the post-acute market.
As the healthcare system evolves rapidly, clinicians and informaticists need to understand the
entire care continuum. This knowledge is essential for effective care planning and coordination
that involves patients and their families in decision-making.
 DISCUSSION
Moreover, to deliver coordinated care that is inclusive, cost-effective, and achieves optimal
outcomes, healthcare delivery must extend beyond traditional settings like hospitals and clinics
into the community and home environments.

Informatics, particularly nursing informatics, plays a critical role in achieving the National
Quality Strategy's goals of delivering value-based healthcare and improving population health.
Detailed IT requirements are necessary to support care coordination, communication, data
collection, measurement, and reporting across different care settings, which are currently
lacking in many EHR systems.

Nurses and nursing informaticists are well-positioned to lead the development and
implementation of new health and IT systems that enable effective care coordination across
the healthcare continuum.