Accountable care organizations, or ACOs, are responsible for a variety of diverse beneficiaries, many of which have chronic conditions or complex needs. This makes care collaboration essential when it comes to best supporting these beneficiaries and improving care outcomes.
Ensuring seamless care transitions is an important step for improving patient care, as it’s easy for information to get lost or miscommunicated during transitions between hospitals and skilled nursing facilities or other post-acute care (SNFs). Earlier this year, the Centers for Medicare & Medicaid Services (CMS) released a toolkit sharing ways for ACOs to coordinate care for beneficiaries.
This toolkit highlights three primary ways to support beneficiaries requiring treatment in a SNF:
- Establish preferred SNF networks
- Encourage continuous quality improvement
- Dedicate staff to coordinate care with SNFs
Create a Network of Quality Skilled Nursing Facilities
Creating networks of high-performing SNFs enables ACOs to engage with facilities that have demonstrated an ability to provide quality care. Additionally, having preferred SNFs helps clinicians discuss care transitions with beneficiaries and caregivers. Some of the participating ACOs in the toolkit have created brochures or resources highlighting these top SNFs, giving clinicians an easy resource.
Promote On-Going Quality Improvement
Another tip the toolkit shared is to schedule regular meetings for members of both ACOs and SNFs. In these meetings, leaders and staff from the two organizations can collaborate together and determine how to best care for shared patients and beneficiaries. This can include identifying strategies for smoother transitions, determining needs, and discussing outcomes of beneficiaries who have been discharged from SNFs to improve going forward.
Dedicate Care Coordination Staff
When possible, it’s a smart strategy for ACOs to dedicate one or more staff members to coordinate care for beneficiaries requiring care in a SNF. These staff members can oversee the post-acute care plan, admission, stay, and discharge. By having this support, a patient’s experience is improved, and their risk for inpatient readmissions may even be reduced through clear coordination.
Avoidable readmissions cost Medicare an average of $1 billion per year, making efforts to reduce unnecessary readmissions critical for ACOs looking to save on care costs and avoid penalties. By opening communication channels between care settings, all care team members can be aware of critical information and make care decisions accordingly.
For more in-depth information on reducing readmissions and caring for ACO beneficiaries, read this whitepaper.
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