This document summarizes discussions from a series of panel discussions on the future of post-acute healthcare. Key concerns discussed include the need for better coordination and pathways between acute and post-acute care to reduce hospital readmissions, ensuring clinical staff in skilled nursing facilities have sufficient skills and training, understanding new models like Accountable Care Organizations, managing increased utilization of managed care plans with lower reimbursement rates, and navigating changes to state Medicaid systems. Potential solutions focus on developing partnerships across settings, sharing clinical information, participating in advocacy, and using technology and analytics to improve coordination and decision making.

1. CONCEPT.
WHAT A
OVER 30 YEARS OF EXPERIENCE
PROVIDING THE HIGHEST QUALITY
OF REHABILITATION SERVICES
The Changing Face
of Post-Acute Health
Care 2014 and Beyond

2. Concept Rehab, Inc., a regional provider of rehabilitation
services with over 30 years of experience, engaged 20
industry experts in a series of panel style discussions
regarding the dynamics of current issues and future
concerns in post-acute health care.
The goal for the process was to glean insight, opinion and
information from a diverse cross section of participants
enabling all to better prepare for the future in post-acute
health care.
The following is a synopsis of the “Concerns and Solutions”
relating to the common threads which resonated
throughout the series.

3. T H E C H A N G I N G F A C E O F P O S T - A C U T E H E A L T H C A R E 2 0 1 3 A N D B E Y O N D
Change the Paradigm of Thought
Skill Level of Clinical Staff
T H E C O N C E R N
T H E C O N C E R N
P O S S I B L E S O L U T I O N S
P O S S I B L E S O L U T I O N S
There is a great need for a change in thinking with regard to the continuum
of care, especially from acute care to the post-acute section. The New
England Journal of Medicine recognizes the PAC spending from 1994 –
2009 is growing at a rate of 99% - 250% depending on diagnosis. The
House Ways and Means Committee is hosting hearings to expedite PAC
reform. Simply, payors want patients to transfer to SNF’s quicker, stay
for shorter episodes of care and avoid hospital readmissions.
Hospitals are being penalized for readmissions, which is complicated by
disconnects between acute care and post acute regarding clinical pathways
and appropriate discharge planning needed to reduce risk of readmission.
Better assessment and response to changes in condition need to occur
in the SNF rather than quickly discharging a patient for care in the
hospital setting.
One of the most prevalent themes was a concern about the overall skill
level of SNF clinical staff, primarily nursing and nurse aides. Hospitals are
now penalized for high readmission rates and SNF’s will likely follow suit in
2016. Readmissions may occur more frequently when a portion of direct
care staff lack the critical thinking skills to accurately assess the patient and
communicate appropriate concerns to the physician. Nursing Assistants
may have insufficient education or experience with regard to what
observations should be reported daily so that in-house interventions are
initiated sooner; reducing the need for hospital readmissions.
The other shortfall noted with regard to SNF employees was their
inability to deliver concierge like care if they themselves have never
experienced this level of service. There is a high level of turnover and often
the SNF setting is not viewed as a desirable workplace setting.
· Develop alternative delivery models
to increase the SNF role to treat
without the “3 Day Stay”
· Encourage physicians or physician
extenders (CNP/PA) to attend onsite
to patients daily
· Have tools such as INTERACT to
assist with critical thinking and
decision making
· Establish agreed upon pathways of
care to be followed in PAC setting
upon discharge from hospital
· Hire RN’s in place of LPN’s as acuity
of patients requires higher skill set
· Use software and checklists that
assists with critical thinking and
decision making to assess patients
appropriately before deciding to
discharge to the hospital
· Incorporate concierge level of
service training in orientation
process for nurse aides.
· Require prompt and accurate
ancillary services such as x-ray, lab
and pharmacy to provide nursing
staff with timely results in-house
rather than in the hospital

4. Understanding and Initiating ACO
Relationships
Maintaining and Optimizing
Profitability
T H E C O N C E R N
T H E C O N C E R N
POST-ACUTE CARE FACTS
P O S S I B L E S O L U T I O N S
P O S S I B L E S O L U T I O N S
Although there are 32 Pioneer and 221 Shared Savings Program Account-
able Care Organizations (ACO) many aspects of these partnerships remain
vague and ill-defined. How does each ACO get developed? How is the
bundled payment divided and will it be timely to all members? How does
PAC become viewed as a “preferred provider”? If SNF’s or HHA currently
rely on referrals from more than one hospital, what happens to those refer-
rals if they align with only one in an ACO model? Panelists discussed these
issues at length, and the results varied within each geographical market.
Published data reveals the top 13 ACOs created savings of $87 Million; a
portion of ACOs reduced readmissions by 63%; and Nine Pioneer ACO’s
left the program.
Profitability is a prominent concern among all PAC pro-
viders. Doing more with less is the new normal. With the
incidence of chronic diseases and multiple co-morbidities
increasing, the acuity of care needed has skyrocketed
costs yet reimbursement has not followed. Under
Affordable Care Act, the PAC Sector is slated to endure
$415 Billion in fee-for-service cuts from 2013-2022.
Furthermore, Baby Boomers have higher expectations of
the level of care, amenities, and quality of services they
receive, which drive increased costs. Private rooms,
rehab suites, Wi-Fi, and coffee bars are the expectations.
All panelists acknowledged the necessity to cut costs in
order to remain viable. Many foresee margins falling
even further in the next five years.
· Develop partnerships with the
hospital; reach out to them if they
don’t come to you
· Data and clinical/quality outcomes
are driving forces in these
conversations
· Establish a means of symbiotic
communication by sharing clinical
pathways so that hospitals and
post-acute providers form a true
continuum of care with data
tracking points
· Consider developing niche services
and specialty programs
· Look at Disease Management across
the continuum from hospital to
home health as a means of cost
containment, shared risk model
· Participate in any and ALL advocacy
opportunities that support changes
to the reimbursement system
• 20% of Medicare beneficiaries are admitted to a SNF after acute care
• 1 in 4 Medicare patients return to the hospital within 30 days DURING their SNF stay
• All hospital readmissions cost Medicare $4.34 billion in 2006

5. T H E C H A N G I N G F A C E O F P O S T - A C U T E H E A L T H C A R E 2 0 1 3 A N D B E Y O N D
Managing the Increased
Utilization of Managed Care
The Changing Medicaid
System
T H E C O N C E R N
T H E C O N C E R N
P O S S I B L E S O L U T I O N S
P O S S I B L E S O L U T I O N S
In 2013, 28% of all Medicare Enrollees selected a Medicare Advantage
Plans. In many regions, SNF providers’ skilled census consists of 50% -
60% Managed Care versus Medicare Part A. Each managed care
organization has a specific negotiated payment rate and structure.
Typically, most case-managed plans have significantly lower rates and
shorter lengths of stay than traditional Medicare. This can cause
beneficiaries to choose to discharge prior to achieving the highest level
of safety/independence and increasing the chance for readmission to the
hospital within 30 days. Recently, several large managed care plans have
released up to 40% of providers from their network, and based such
decisions on the CMS 5 Star Rating system. Additionally, as many as
300 hospital/health systems are now offering an insurance product as
means to capture the “Premium Dollar”.
There seems to be a great deal of uncertainty with regard to the
future of Medicaid in all states. By 2014, 26 States, including
Ohio, Michigan, and Pennsylvania will offer Managed Long-Term
Services and Supports (MLTSS). These programs are a system
of managed care plans selected to coordinate physical,
behavioral and LTC services for persons with Medicare and
Medicaid eligibility. According to the Advisory Board Company’s
Post -Acute Care Collaborative there has been a 269% rise in
MLTSS enrollment from 2004 – 2012. With most post-acute pro-
viders’ census being 75-85% Medicaid, the impacts are great.
· Be selective when partnering with
Managed Care organizations
· It is imperative to communicate with
ancillary departments the
reimbursement structure and
contractual requirements to assure
compliance and manage financial
margins
· Be realistic when budgeting for
census and be certain to account
for changing trends
· Continue to follow legislation through advocacy groups
and associations
· Seek to-the-minute knowledge to afford quality
decision making and effective change management.

6. T H E C H A N G I N G F A C E O F P O S T - A C U T E H E A L T H C A R E 2 0 1 3 A N D B E Y O N D
Overwhelming Increase in
Audits
Keeping Pace with I.T. Demands
T H E C O N C E R N
T H E C O N C E R N
P O S S I B L E S O L U T I O N S
P O S S I B L E S O L U T I O N S
A general consensus of the group was that audits are overwhelming in their
number, consume a great deal of non-billable time and are very nebulous in
the regulatory control that oversees them. Some providers have had to add
staff simply to address audits. Payment taking up to 18 months or greater
is detrimental to cash flow. The appeal process is complicated and long.
The current wait period for an ALJ hearing is over 223 days.
Information Technology is a critical cornerstone to many of the post-acute
care initiatives. Care practices and collaborative partnerships are
dependent on sharing of health information between providers.
Unfortunately, there are no “universal specifications” used by IT developers,
which can cause interference in data sharing. Regardless, technology is
essential to long term success.
· Use a software that accounts for audit
trends, one which makes changes in
their programs to address needs in
documentation
· Implement a compliance triple check
process in your facility
· Be stringent in education of
documentation requirements to
decrease likelihood of denials on the
front-end
· Document the utilization of
evidence-based programs
· The use of Telemedicine, particularly
in rural areas, can increase patient
access to care, improve patient
accountability and decrease
re-hospitalization
· Technology advances can decrease
staff downtime but can be cost
prohibitive to smaller SNF’s
· Data outcomes packages can be
purchased as add-ons to validate
value as a post-acute partner
UNDERSTANDING DUAL ELIGIBILITY
• 10.2 million Americans qualify for dual eligibility
• The dual eligible population costs 60% more than non-dual beneficiaries
• This section of beneficiaries make up 16% of Medicare but account for 25% of the spending
• Dual eligible individuals comprise 18% of Medicaid but account for nearly 50% of
Medicaid spending
www.ncsl.org

7. Post-acute health care will continue to change but several principles
will remain constant; we must provide the best possible care and
demonstrate excellent outcomes while maintaining profitability. As
the future moves to ACO’s and hospitals are now penalized for
readmissions, SNF’s and HH agencies must take the initiative to reach
out and establish collaborative relationships with referral sources.
Care of patients with chronic diseases and comorbidities can’t be
treated in isolation and must be part of care across a continuum.
Clinical pathways of care need to be developed encompassing acute
care, SNF and HH. We need to change the mind set of patients,
families, physicians, nurses/aides, therapists and all staff to one of
assessing and treating the patient in house instead of rushing to
readmit to the hospital. Education levels and skill sets for staff must
increase in order to make this happen.
To remain viable and continue to provide excellent care to patients,
we must make money while demonstrating patient, family and staff
satisfaction. Technology continues to change and we must embrace it
as a means to an end. Sweeping reform in health care is sure to result
in further reductions and only time will allow us to see the global
affects on our industry. If as PAC providers, we shift our thinking,
partner with savvy acute care entities and keep patient care at the
forefront, we can position ourselves for a viable future while continuing
to treat patients with the level of care they require and deserve.
I N C O N C L U S I O N

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