Many factors influence the success of a patient’s transition from one healthcare setting to another, but few have the impact of a trusted partnership between different providers in different settings.

_MG_3329VertCare transitions occur each time a patient moves from one setting to another. Patients treated at a short-term acute care (STAC) hospital, for instance, might be discharged to a post-acute care setting such as an inpatient rehabilitation facility to receive additional treatment. These transitions occur more often today as a means to prevent patients from regressing and having to be readmitted to the more costly setting of a STAC.

According to a research letter in the Journal of the American Medical Association, discharges from STACs to post-acute care among Medicare beneficiaries increased from 21% in 2000 to 26.3% in 2015.

With each of these discharges comes a transition in care – an opportunity to create a seamless, healthy experience for the patient, and an opportunity for the providers to create a successful patient outcome over an episode of care without incurring stiff penalties for a STAC readmission.

Those regulatory penalties – coupled with forward-thinking providers and Centers for Medicare and Medicaid (CMS) value-based initiatives such as Accountable Care Organizations (ACOs) – are leading to more partnership arrangements in which providers pair up to create a healthcare network, share information and goals, and work together on behalf of the patient.

It sounds ideal on paper, but creating such partnerships takes effort and commitment. Here are four keys to getting started.

  1. Find the right partner
    When considering partners to improve care transitions, you likely want to consider geography, as distance can hinder the ability of a STAC and a post-acute provider to best coordinate care. You obviously want to look at potential partners’ CMS quality scores, readmission rates, clinical programming and available services. You’ll want to gauge physician alignment, and you will certainly want to discern whether the potential partner has a genuine interest in participating and achieving shared goals.

    Presenting your data and your potential partners’ data to each of your community healthcare agencies and providers referral sources is a good measure to see how your network development effort is received by your constituents. If your due diligence indicates a good fit, you and your respective legal teams will need to work out a formal agreement.

  2. Create and even expand your network
    You and your partner seek to improve care transitions for better outcomes and a decrease in avoidable readmissions. Identify all challenges to achieving this goal, develop steps to partner around clinical quality and determine and work toward your ultimate ambitions. Bring in additional partners if it strengthens your capabilities and value proposition.

    This will involve a lot of communication and collaboration to determine how to best coordinate care between the inpatient team and upstream and downstream providers. You’ll work through common continuum-related issues such as medication reconciliation and patient and family education and engagement. You will design episodic clinical pathways and evidence-based discharge protocols based on patient complexity and individual needs.

  3. Identify and work toward components of good collaboration
    High performing networks not only improve care transitions, but also care overall. To get to that point, you will identify team members and clinical point persons from each partner and member of the network. You will need to agree upon expectations around common processes such as discharge turnaround time and admission criteria by type of setting. And you will create transition processes and pathways, identify reporting format and frequency, and outline joint quality committee meeting frequency and objectives.

  4. Define success and go after it
  5. The reporting and communication aspects of your partnership are essential for a number of reasons, foremost of which is accountability. You and your partner(s) will establish and communicate goals to measure the effectiveness of your efforts and fine-tune them with the data you receive.

    Some obvious metrics in the STAC-PAC relationship would be to reduce readmissions and lengths of stay, improve key quality indicators, increase patient volumes and identify and eliminate gaps in care. You would want to see an increase in patient satisfaction/Net Promoter scores, and if rehabilitation is part of the picture, improved Functional Improvement Measures (FIM) scores.

    Your partnership can not only lead to better metrics indicating improved care transitions and patient outcomes, it can also strengthen patient empowerment, prevent overutilization or duplication of services and avoid delays in care.


If you would like to know more about forming partnerships to create healthcare networks, please check out this white paper.

For more information about how KHRS is setting the standard for successful care networks, contact us today.