SNFs seeking to strengthen their position as a preferred provider or ACO participant within the ACO LEAD Model should consider implementing a comprehensive post-discharge follow-up program. This approach can support inclusion as a preferred provider with a LEAD ACO. Below are five key drivers of ACO success and how a SNF post-discharge program can help support each one.
Promote High Primary Care Attribution Stability
High Primary Care Attribution Stability reflects the model’s structural ability to keep patients aligned with the same ACO over time. When an attributed patient seeks care outside the network, the ACO loses influence over costs. To maximize returns, the ACO must keep patients within its preferred provider network.
Role for SNF Post-Discharge Follow-up: The opportunity for post-discharge follow-up is not only to support attendance at follow-up appointments but also to reinforce the ACO’s value to the patient and the importance of continuity with the same care team. Reminding patients of their ACO membership and emphasizing that keeping visits within the ACO helps the care team remain better connected and more proactive in managing their health can help reduce ACO leakage.
Achieve High Patient Satisfaction Scores
Key for ACO Success: A patient experience survey referred to as a “CAHPS Survey” is required for all LEAD ACOs. The CAHPS patient experience survey is administered annually to capture year-over-year performance changes. The responses to this survey will be combined into a single CAHPS Composite Score, which serves as a critical component of the model’s quality performance score.
Role for SNF Post-Discharge Follow-up: The post-discharge follow-up adds a meaningful human element of care and continuity that resonates with patients, especially those who may not fully understand that all providers within the ACO are working together to support their health outcomes. These one-on-one conversations can also help improve performance on CAHPS survey measures such as Care Coordination and Health Plan Information.
Promote Preventive Care Measures for Chronic Care Provided by the ACO
Key to ACO Success: LEAD requires a “Prevention and Quality Plan” (PQP) for high-needs patients, such as those with multiple chronic conditions. There are also claims-based quality measures for unplanned admissions and emergency department utilization among patients with multiple chronic conditions, which can be reduced if the patient population engages with the ACO’s prevention initiatives as part of the PQP.
Role for SNF Post-Discharge Follow-up: The post-discharge call is an opportunity to raise awareness and promote programs offered as part of the PQP. The rapport built through conversations can naturally lead to a “soft sell” by simplifying the steps to get started, which can help overcome common behavioral and system barriers that make these programs underutilized.
Reinforce Chronic Care Exacerbations Follow-up Care
Key to ACO Success: One of the quality measures that applies to “Standard” and “New Entrant” LEAD ACOs is “Timely Follow-Up After Acute Exacerbations of Chronic Conditions (TFU)”. TFU is defined as the percentage of acute events related to one of six chronic conditions where follow-up care was received within the time frame recommended by clinical practice guidelines in a non-emergency outpatient setting.
Role for SNF Post-Discharge Follow-up: As part of the post-discharge follow-up, an objective of the conversation can include a reminder to the patient that if they have an event, such as an ED visit or hospitalization, they should always let their PCP know right away, reinforcing that patients use their PCP as the hub for all their care. This reinforcement can be key, as it is easily forgotten over time.
Reduce Hospitalizations
Key for ACO Success: Keeping patients out of the hospital is the fastest way to both lower costs and raise quality scores. This exposure to spend is specifically measured in two of the LEAD claims-based quality measures, “All-cause unplanned admissions for older adults with multiple chronic conditions” and “Days at home for patients with complex, chronic conditions.”
Role for SNF Post-Discharge Follow-up: Post-discharge follow-up calls after an SNF stay have proven to reduce readmissions by identifying early warning signs, medication issues, and care plan gaps before they escalate into acute events. They also improve patient understanding and adherence by reinforcing discharge instructions and ensuring timely access to outpatient care, both of which are consistently associated with lower readmission rates.
SNFs are vital partners for LEAD ACOs working to achieve the model’s performance goals. If your organization is looking for a partner to complement your current follow-up program, please visit Nexus Health Resources to learn more or schedule a consultation.
