Editor’s note: This is the fourth installment in Dr. Smythe’s four-part series on fostering healthcare innovation to face some of the biggest challenges fronting healthcare today. This post focuses on Post-Acute Care, while the previous posts discussed Treating Patients as Consumers, Operations 2.0 and Chronic and Behavioral Care.

Every science consists in the coordination of facts; if the different observations were entirely isolated, there would be no science.

For many, an introduction to Post-Acute Care comes when a family member is being discharged after an inpatient stay and not quite prepared to be fully independent. What type of facility should be chosen? How do you discern differences in quality or cost? In other cases, a cascade of events leading to this same scenario can be initiated by a readmission to the hospital due to a post-operative complication, or an inappropriate discharge to the home setting when more (or different) support would have been ideal.

Choosing the right care placement post-discharge can often lead to confusion and uncertainty, but can often have more impact on patient disease and social outcomes than the preceding provision of acute care.

On the other side of the equation, providers have always known that when the patient leaves the four walls of hospital it can significantly impact cost and quality. This  includes things such as hospital readmissions, but also DRG overruns and untoward morbidity and mortality when patients are readmitted, at times repeatedly, in extremis.  In addition, providers face an increasing depth and breadth of new post-acute care administrative management challenges, including financial reimbursement in ACO and bundled pay arrangements, patient safety and satisfaction measurement and policy mandates. These considerations add considerably to the complicated and constantly evolving healthcare environment.

According to Alix Partners, Medicare spending for post-acute care services has more than doubled during the decade from 2001 to 2011, making it the fastest-growing sector of healthcare. Furthermore, the number of people 65 years or older will double to 81 million and constitute one-fifth of the population by 2040. While efforts to encourage wellness with new tools and approaches will be increasingly effective, some conditions (such as those related to cardiovascular and oncologic disease) are currently the unavoidable imperatives of aging.

Post-acute care represents a relevant and timely challenge to solve at best, if not a burning platform. Technology applied to post-acute care can help improve patient care and providers’ ability to meet both quality and financial accountabilities. Here are the leading opportunities to consider.

Patient Discharge

A patient transitioning between a hospital and a post-acute setting (and potentially back and forth) can have multiple medication lists, different durable medical equipment (DME) orders, and a confusing array of discharge documentation. Preferred post-acute facilities are not always connected to the hospital's discharge process or machinery, and may have different or insufficient definitions or objective measurements of quality.

The Agency for Healthcare Research and Quality (AHRQ) defines care coordination - deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care – but we struggle to provide for this. There is often a significant lack of communication between acute and post-acute care providers, and among post-acute, long-term and community providers themselves, making it difficult to coordinate care.

Few systems have truly effective integration across inpatient and outpatient care and post-discharge settings, even if they own or manage some of the assets. To maximize safety and certainty means providers need insight and access to a patient’s care throughout this process—which requires maximum communication between care settings.

Emerging technologies help providers better manage care coordination, including tools to identify, communicate and track patient follow-up across multiple sites beyond the EMR. Furthermore, technology can detect when patients begin to decline and then trigger alerts enabling providers to deliver just-in-time care appropriately, to prevent hospital admissions/readmissions, improve patient outcomes and reduce the total cost of care.

Medication adherence

For providers, one of the biggest opportunities to reduce preventable readmissions or disease complications is medication adherence. According to The American College of Preventive Medicine (ACPM), 20–50% of patients don't take their medication as prescribed for a variety of reasons: low health literacy, cost, lack of understanding why they need the medication, and inadequate follow-up, among others. 

Aggregating medication information from multiple sources, coupled with automated rule engines to create structured medication reviews for providers to use with patients, are ways that emerging technologies can provide value. There are a number of companies developing innovative solutions, including Proteus Digital Health. The company has developed a revolutionary approach to medication adherence and patient activation. Using an ingestible sensor, a wearable sensor patch and a user-friendly app, this digital medicine solution provides better insights into patient health habits promoting a healthier dialogue and improved treatment plan.

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