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Post-acute care (PAC) is a care continuum that follows a hospital stay or an episode of acute care. There are multiple kinds of post-acute care facilities, such as home health care, rehabilitation facilities, long term care facilities (SNFs/ nursing homes), and hospice care. 

PAC services are designed to help patients and residents recover from an existing illness or injury so they can regain their independence and return to their previous level of functioning. PAC services are often used to treat patients who have complex medical needs that require ongoing care and monitoring. Therefore, it can also include home visits from a qualified nurse. 

PAC providers often work with residents and their families to develop a plan of care using an effective long term care software that meets the patient’s unique needs.

Post-Acute Care vs Skilled Nursing

The question of post-acute care vs skilled nursing can be answered by saying that skilled nursing is a form of post-acute care, as are home health, palliative care, hospice, and outpatient rehabilitation. 

Skilled-nursing facilities provide custodial and medical care to patients and residents who are unable to care for themselves. Some post-acute care services that skilled nursing facilities provide include:

A healthcare worker provides post-acute care services to senior woman.
Skilled-nursing facilities provide custodial and medical care to patients and residents who are unable to care for themselves.
  • Wound care
  • Pain management
  • Medication management
  • IV therapy
  • Nutritional counseling and support
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Psychotherapy/behavioral health services

SNFs—commonly referred to as “nursing homes”—are highly regulated by the Centers for Medicare and Medicaid Services (CMS). To qualify for Medicare reimbursement programs, SNFs must meet and report numerous quality measures as determined by the Skilled Nursing Facility Quality Reporting Program (SNF QRP).

The SNF QRP measures are based on several factors, such as the number of days a patient spends in a facility, the number of post-acute care services provided, and the number of post-acute care complaints filed. Data for the SNF QRP measures are primarily collected and submitted through three methods:

The data collected through the SNF QRP are used to calculate several quality measures. These quality measures are then reported on the Centers for Medicare & Medicaid Services (CMS) Nursing Home Compare website. If quality measures are not met, facilities will receive a low 5-star rating, which can negatively impact their census levels.

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5 Tips for Post-Acute Care Management

The post-acute care phase of the continuum of care is a critical time for residents and their families. For SNF and nursing home residents with complex health needs, post-acute care management (PACM) is essential to ensure quality and coordinated care is provided. Post-acute care management includes a variety of activities such as:

A senior citizen in a post-acute care facility.
The post-acute care phase of the continuum of care is a critical time for residents and their families.
  • Discharge planning: This is the process of identifying the patient’s post-acute care needs and selecting the most appropriate provider based on those needs
  • Case management: This is the ongoing coordination of care between the patient, their family, and their health care team
  • Transitional care coordination: This is the coordination of care between the acute care facility and the post-acute care provider
  • Utilization review: This is the process of reviewing a patient’s medical records to ensure that the level of care they are receiving is appropriate
  • Quality assurance: This is the process of monitoring and evaluating the quality of care provided to residents

Post-acute care examples include physical therapy, occupational therapy, speech therapy, and other rehabilitative therapies. And the team or facility staff at a skilled nursing facility typically includes a discharge planner, case manager, social worker, and nurse, who all play a critical role in caring for the residents. Due to the high complexity of the continuum of care, the facility administrator needs to create a post-acute care management team that can work together and provide residents with coordinated and high-quality care.

The evaluation of post-acute care vs. skilled nursing naturally leads to asking: what is the difference between acute and post-acute care? 

Acute care is medical care given to patients with a sudden illness or injury that requires immediate medical attention. The primary goal of acute care is to stabilize the patient’s condition so they can be transferred to a more appropriate care setting, such as a post-acute care facility. Therefore, acute care is commonly what is found in hospitals and clinics.

On the other hand, post-acute care is given to patients after they have been discharged from the hospital and are transferred to a skilled nursing facility, hospice, outpatient rehabilitation, outpatient social work, or home health. Nursing home administrators looking for effective post-acute care management strategies should apply these five strategies to manage their post-acute care setting successfully:

1.   Build strong relationships with post-acute providers in your area

Effective post-acute care management in an SNF.
Post-acute care providers should be selected based on the needs of the patient or resident and not just on availability.

Effective team management means sharing resources and accountability while building trust across different areas of care. This ensures the continuity of care for patients and better patient outcomes. Therefore, it is worth scheduling regular meetings and site visits to different post-acute care providers, taking the opportunity to build and nurture relationships while learning about their services.

2.   Identify the right site of care to coordinate better care 

Post-acute care providers should be selected based on the needs of the patient or resident and not just on availability. Therefore, it is helpful for an administrator to make data-based decisions about post-acute providers to decide what is best for each patient. This ensures that patients receive the care they need while avoiding unnecessary readmissions.

3.   Embrace data analytics

Data analytics can help post-acute care providers identify trends, optimize care delivery, and improve outcomes. In particular, data used to track post-acute care quality measures, such as length of stay and readmission rates, can identify areas for improvement and ensure that your facility is providing high-quality post-acute care.

4.   Engage patients, their families, and caregivers

Patient and family engagement is essential to post-acute care success. Therefore, it is encouraged to educate patients and their families about the different post-acute care options and the importance of following discharge instructions. Whenever possible, involve them in the decision-making process with information and resources to help them prepare for their new role.

5.   Use technology to foster communication

Technology can help post-acute care providers stay connected with patients and their caregivers. Remote monitoring and video visits can allow providers to track patients after discharge while avoiding unneeded, costly stays in skilled nursing facilities. A suitable care coordination team will also provide clear instructions to patients following their discharge.

The Importance of Post-acute Care in Long Term Care

Post-acute care is an essential phase of the continuum of care for residents in long term care. This type of care can be complex and challenging, but it is essential for helping residents recover and regain their independence. The key is to ensure that post-acute care management is properly coordinated so that the residents can receive high-quality care.

For nursing home administrators, building strong relationships with post-acute care providers, utilizing data analytics, engaging patients and their families, and using technology to foster communication are important steps in creating an effective post-acute care management plan. By following the above tips, you can ensure that your facility provides the best possible care for residents during this critical phase.

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Elijah Oling Wanga