“What Would It Take to Transform Post-Acute Care?” 2019 Conference Proceedings on Re-envisioning Post-Acute Care

Significant health care reforms resulting from the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) and Protecting Access to Medicare Act (PAMA) have important implications for patient selection, payment, and outcomes. These reforms promote new relationships between clinical care sites through joint accountability for costs and development of standard outcomes. The reforms also place a new emphasis on clinical outcomes—such as reducing hospital readmissions—as a part of new value-based payment models. This new landscape for post-acute care (PAC) provides an opportunity to improve the quality of care for older adults through alignment of policy reforms with research and practice in PAC. However, hospitals and PAC providers often struggle to keep pace with reforms and have limited ability to share and disseminate best practices. In fact, industry, policy, and academic conferences occur independently, with different audiences, even though the themes discussed bridge clinical arenas. Conferences that unite the different stakeholders invested in PAC are needed to enable new directions in the field.

We proposed a Patient-Centered PAC conference series, which was funded by the NIA, with the mission of improving care for older adults in PAC. This national conference series is designed to bring together research, industry, and policy stakeholders to promote collaboration within and across disciplines, a patient-centered policy and research agenda in PAC, and serve as a hub for the identification and promotion of novel initiatives. The first of these conferences was held as a 2-day conference in April 2019, to promote collaboration and create a patient-centered policy and research agenda in post-acute care. The theme of this conference was “Reenvisioning Post-Acute Care.” Two questions framed conference planning and discussion: (1) “If you had the power to do away with the current system and re-create PAC from scratch today, what would it look like?” and (2) “If a landmark study/initiative/policy change occurred in 2024 and you made it happen—what would that change be and how did you make it happen?” Conference speakers were national leaders in PAC research (including measurement and assessment), policy, and industry (agenda available at http://www.togetherweimprovecare.org).

Through keynote addresses and breakout sessions, attendees identified actions to inform research, policy, and clinical care agendas. The recommendations from the 82 conference attendees are discussed below and highlighted in Table 1. Attendees represented diverse perspectives, including academic institutions (from students to full professors), policy-making organizations, and industry including PAC leadership and clinicians.

Table 1.

Recommendations Identified From Overarching Conference Questions

Question	Recommendations
If you had the power to do away with the current system and re-create post-acute care from scratch, what would it look like?	Integrate reimbursement for medical care with services across the continuum of care Invest in PAC training to match needs of PAC patients Expand the community role for nursing facilities while investing in physical space and technology Leverage existing data to improve care Engage stakeholders
If a landmark study/initiative/policy change occurred in 2024 and you made it happen—what would that change be and how did you make it happen?	Remove policy and regulation that impedes change and innovation Capture data at point of care Intervene on highly relevant patient concerns and conditions

Key Recommendations

QUESTION 1: If you had the power to do away with the current system and re-create post-acute care from scratch, what would it look like?

Recommendation 1.1: Integrate Reimbursement for Medical Care With Services Across the Continuum of Care

PAC is not integrated into the rest of the health care system. Current reimbursement structures create a false dichotomy between medical care and PAC services. Payment models should instead blend medical care with home- and community-based services for older adults to meet needs where and when needed, rather than being driven by what is available or reimbursable in a PAC setting. Blending medical care and services also better matches the changing needs of patients transitioning from highly specialized medical care to rehabilitation and reintegration into the community. Currently, services throughout this continuum are not routinely aligned or integrated, which often results in care fragmentation.

Reimbursement models are needed to catalyze the coordination and alignment of services across settings to promote the financial viability and sustainability of blended care models. Examples of such programs are Department of Veterans Affairs (VA) Home-Based Primary Care coupled with VA-supported Home and Community-Based Services (HCBS),^1,2 and the recent authorization for Medicare Advantage plans to begin to pay for home and community-based services,³ Hospital at Home,⁴ and Special Needs Plans.^{5, 6} The success of Programs for the All-Inclusive Care of the Elderly in delaying older adult institutionalization is notable,^1-3 and the rollout of a unified payment system for PAC also holds promise.⁷

Recommendation 1.2: Invest in PAC Training to Match Needs of PAC Patients

Many healthcare professionals (from physicians to certified nursing assistants) are not exposed to PAC during training, and the evolving landscape of PAC may call for new roles. Clinicians and staff throughout the healthcare system should rotate through PAC settings such as skilled nursing facilities (SNFs) and home health agencies as a training requirement. Additionally, PAC has lagged in personnel training, certification, and credentials to match the changing demographics and complexity of PAC patients. New roles could include “complexivists” or “complex care specialists” who lead interdisciplinary teams to care for high-risk, high-need patients across care settings. Other opportunities include creating career ladders for personnel with high turnover rates but key roles in facilities (eg, certified nursing assistants).

Recommendation 1.3: Expand the Community Role for Nursing Facilities While Investing in Physical Space and Technology

In the United States, most counties have a nursing facility. As a result, nursing facilities could be re-envisioned as a community center for all aspects of community and medical care for older adults,⁸ which could include functioning as an adult day center, Area Agency on Aging hub, or a center for older adult population health that coordinates medical and community-based supports. Such ideas have implications for how the physical space of facility-based PAC is organized, shifting from staff-centered to person-centered and community-directed. Other possibilities include rebranding PAC units as “Patient/Staff Engagement and Recovery Centers” that heavily involve the use of technology, including use of consumer technologies such as smart speakers that are voice-activated to promote patient engagement with recovery.

Recommendation 1.4: Leverage Existing Data to Improve Care

Big data and technological advances have the potential to influence recreation of PAC. Algorithms already in use identify high-risk older adults in SNFs using routinely gathered data to prompt provider action. Others help guide clinician decisions about what type of PAC might be most helpful for a patient. The NIH-funded Center for Large Data Research and Data Sharing in Rehabilitation is an example of the large amount of patient data already collected and available that could be leveraged to improve PAC outcomes. The enforcement of value-based payments for SNF care is likely to spur further investment in big data approaches.

Recommendation 1.5: Engage Stakeholders

A diverse group of PAC stakeholders including clinicians, staff, patients, and caregivers are all important to transformational change, yet their voices are often missing in efforts to recreate PAC. Stakeholder engagement boards have been created in PAC including medical providers, leaders, frontline staff, patients, and their family to identify research priorities including polypharmacy, care transitions, mental health, and quality of life.⁹ Stakeholders could guide efforts in quality improvement, academic research, culture transformation, and corporate initiatives.

QUESTION 2: If a landmark study/initiative/policy change occurred in 2024 and you made it happen—what would that change be and how did you make it happen?

Recommendation 2.1: Remove Policy and Regulation That Impedes Change and Innovation

Policy and regulations are frequently barriers to transformational change. Examples include state licensure laws (which often prevent facilities from expanding their scope of practice). In addition, regulatory barriers (such as the required 3-night stay or “homebound” criteria) were identified as obstacles to PAC innovation. Organized stakeholder groups are needed to lobby Congress to address policies and regulations that obstruct PAC innovation.

Recommendation 2.2: Capture Data at Point of Care

To catalyze landmark studies, better measurement is needed across care settings, in addition to interoperability of electronic medical records. Gaps in access to data and data transfer across facilities are major limitations to coordinating PAC services. Current measures are insufficient, and new methods of capturing and using data at the point of care are needed. The lack of patient-reported outcomes—including how often patient goals are reached in PAC—is striking and warrants substantial development. Learning Health System processes, where data (particularly patient goals and objectives) are gathered daily, analyzed to identify opportunities, and fed forward to clinicians at the point of care, are needed.

Recommendation 2.3: Intervene on Highly Relevant Patient Concerns and Conditions

A strong emphasis is needed to measure and intervene on highly relevant conditions such as frailty. Increased attention to frailty in PAC could be transformative for vulnerable older adults at high risk for adverse outcomes. In addition, palliative care consultation in SNFs is emerging as an essential but under-used resource to address patient concerns and conditions.

Implications for Research and Policy

Overall, the backbone of research, policy, and new PAC models should be person-directed goals. Clear consensus was reached regarding the need to harmonize a needs-based suite of services within an integrated network of medical care for PAC supported by concomitant reimbursement models. To meet this aspiration, interprofessional teams will need to partner with the surrounding community and work at the top of their professional scope while leveraging data and technology to provide optimal care. Objective data, including patient-reported outcomes, need to be collected and automated to minimize data-collection burden, and will need to measure what patients and family members value most. Value-based measures need to be cross-culturally validated, available across settings, and integrated into real-world use by PAC industry leaders with input from patients, caregivers, staff, and clinicians. Stakeholders should also be engaged in the development of both research and policy from initial conceptualization through implementation, evaluation, and dissemination.

Attendees were uniformly struck by how complex the PAC system is and how difficult it was to re-envision an entire care system. Moving forward, the next steps will focus on the unique challenges of implementing both research innovations and evidence-based practices in PAC.