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Medicare's proposed payment rates and quality programs for skilled nursing facilities (SNFs) have solidified post-acute care's (PAC) partnership in the transformation of healthcare delivery.

Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient care—not just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient's journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

In this 25-page resource, Julia Portale, vice president of community services, Jewish Senior Services, and Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration, St. Vincent's Health Partners, describe how their two institutions have aligned around clinical standards to improve patient care—despite separate parent companies, health IT platforms, and other challenges. 

In this dual venture, St. Vincent's Health Partners (SVHP), a participant in Model 2 of the CMS Bundled Payments for Care Improvement (BPCI) initiative spanning the acute and post-acute settings, created a post-acute care network of SNFs to streamline patients' movement through its clinically integrated network.

As a vetted SVHP network member, Jewish Senior Services, a post-acute care provider holding a 5-star rating in skilled nursing from CMS, contributes to a partnership that identifies potential problems across the patient care continuum and crafts cross-boundary solutions.

This special reports highlights the benefits that resulted when SVHP and JSS reacted to the industry's paradigm shift and opted to collaborate instead of compete in the post-acute care space, placing patients' needs above their organizations'.

Ms. Portale and Ms. Swedberg cover the following points:

• Background on the St. Vincent’s Health Partners Network and its motivation for aligning for change in an era of healthcare transformation;
• Organization, tools and strategies of SVHP's cross-functional cross-boundary Transitions Leadership Group and how the group is breaking down care silos;
• The role of the CMS BPCI initiative as a springboard to network development and collaboration;
• Development of the SVHP best practice-based Care Transitions Playbook documenting more than 140 possible transitions for patients traveling from one setting to another;
• Protocols driving SVHP network success;
• Perspectives from SVHP Network member Jewish Senior Services, from the viewpoint of home care, rehab facility, and skilled nursing facility;
• Opportunities to standardize common acute to post-acute care pathways;
• The challenges of collaboration with organizations that may in certain scenarios also be competitors;
• Prioritizing patients' needs even when delivering the most appropriate care might cannibalize an organization's own services;
• The value of networks and flexibility in a post-acute care world;

Table of Contents

• Aligning Clinical Standards and Provider Demands in the Changing Landscape
  • St. Vincent’s Health Partners Membership
  • CMS Bundled Payments Opportunity
  • Transitions Leadership Group
  • SVHP Membership Criteria for Post-Acute Care
  • Transitions Playbook and Other Tools
  • SVHP Network Collaboration and Successes
  • SVHP Next Steps
  • Jewish Senior Services: Full Continuum of Senior Care Services
  • Referring Hospitals to Post-Acute Care
  • Standardizing and Customizing Post-Acute Care Practices
  • Integrating Across Own Continuum and Others
  • Challenges and Why Network Matters
• Q&A: Ask the Experts
  • Vetting Partners for the SNF Network
  • Examples of Clinical Standards
  • Care Transitions Playbook
  • Workflow Changes on Care Transitions Mapping
  • Tracking Patients’ Progress through Disparate Systems
  • Monitoring Clinical Standards
  • Clinical Challenges in Post-Acute Environment
  • Outcomes and Quality Metrics
  • Recommended SNF Tools
  • Preparing for 2018 CMS SNF Scrutiny
  • Aligning Staff Training with Clinical Standards
  • Remote Monitoring for Recently Discharged Patients
  • Physician Engagement Strategies
  • Sharing Provider Metrics
• Glossary
• For More Information
• About the Contributors