Patients Discharged to Post-Acute Care

1. Patients Discharged to Post-Acute Care 35% of Medicare beneficiaries discharged from short-term acute hospitals receive post-acute care Lower Higher Intensity of Service HOME HEALTH CARE SKILLED NURSING FACILITIES LONG-TERM ACUTE CARE HOSPITALS SHORT-TERM ACUTE CARE HOSPITALS INPATIENT REHAB OUTPATIENT REHAB Patients’ first site of discharge after acute care hospital stay 2% 10% 41% 9% 37% Patients’ use of site during a 90 day episode 11% 52% 2% 21% 61% Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care” * * Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System

2. Multiple Post-Acute Care Settings PHYSICIANS (PRIMARY CARE AND ATTENDINGS) SHORT-TERM ACUTE CARE HOSPITALS 3RD POST-ACUTE SETTING 2ND POST-ACUTE SETTING 1ST POST-ACUTE SETTING • Admit • Care • Discharge • Admit • Care • Discharge • Admit • Care • Discharge MANAGED CARE PAYORS with CASE MANAGEMENT

3. Care Summary Care Summary Care Summary Care Summary Demographics Problem List Allergies Medications Procedures Results Demographics Problem List Allergies Medications Procedures Results Demographics Problem List Allergies Medications Procedures Results Demographics Problem List Allergies Medications Procedures Results HL7 CCD HL7 CCD HL7 CCD HL7 CCD Standard Care Summary (HL7 CCD) Enhances Care Coordination PHYSICIANS (PRIMARY CARE AND ATTENDINGS) SHORT-TERM ACUTE CARE HOSPITALS 3RD POST-ACUTE SETTING 2ND POST-ACUTE SETTING 1ST POST-ACUTE SETTING • Admit • Care • Discharge • Admit • Care • Discharge • Admit • Care • Discharge MANAGED CARE PAYORS with CASE MANAGEMENT

4. ? ? ? ? What is needed to fully coordinate care? PHYSICIANS (PRIMARY CARE AND ATTENDINGS) SHORT-TERM ACUTE CARE HOSPITALS 3RD POST-ACUTE SETTING 2ND POST-ACUTE SETTING 1ST POST-ACUTE SETTING • Admit • Care • Discharge • Admit • Care • Discharge • Admit • Care • Discharge MANAGED CARE PAYORS with CASE MANAGEMENT