How Primary Care Providers Can Impact Post-Acute And Long-Term Care

As health care increasingly shifts towards value-based care (VBC) models and away from the traditional fee-for-service, the role of the primary care physician is more crucial now than ever. Primary care physicians serve as gatekeepers of patients’ health and have an inherent responsibility to coordinate care across the entire health care continuum.

Yet PCPs often lack the time, resources, or energy to do so, which puts an immense strain on providers and negatively impacts the quality of care and outcomes, especially patients with complex or chronic conditions that require more coordinated care.

When managed effectively, ensuring seamless transitions of care between acute to post-acute or long-term care settings is crucial to ensuring positive outcomes and avoiding hospital readmissions or worsening conditions.

The Critical Role of PCP’s In Post-Acute and Long-Term Care

Within value-based care, primary care physicians are expected to take a proactive approach to patient management, especially for those vulnerable patient populations with chronic conditions and complex cases. These patients often rely on their PCP to effectively manage their chronic conditions, such as diabetes, heart disease, or COPD, and dramatically reduce the chances of a hospitalization or readmission.

In a patient-centered medical home model (PCMH), PCP’s lead a multidisciplinary team in providing comprehensive and continuous care. These clinicians can be highly effective in managing transitions between care settings for complex and chronic patients by coordinating timely follow-ups, medication reconciliation, and education of the patient and their family or caregivers. PCPs are leading the effort in maximizing patient outcomes and are better able to prevent complications leading to increased readmissions.

In fact, many studies have shown that having PCPs involved and engaged in the management of chronic or complex conditions can lower readmission rates significantly for patients recently discharged. This approach helps prioritize long-term health over episodic treatment, improving patient outcomes overall and aligning with VBC goals throughout the care journey.

Leveraging Technology and Care Team Collaboration to Ensure Improved Outcomes

PCPs should leverage data analytics and real-time monitoring tools to help identify high risk patients and intervene before conditions worsen or health deteriorates. This includes understanding and knowing when patients are in hospital settings, better aligning on a care plan for post-discharge care or tracking medications and follow-ups through telehealth and patient monitoring software to ensure patients are adhering to their care plan. Leaning on advanced analytics and monitoring and reporting technologies allows PCPs to collaborate more closely with the broader health care team to ensure that patients remain healthy and don’t experience a worsening of conditions.

Clear and effective communication throughout the care journey and particularly during care transitions is vital to effective care. Care coordination teams must clearly communicate the care plan to patients and their family or caregivers, especially when the patient is transitioning from a hospital to post-acute care settings. For complex patients, medications need to be appropriately adjusted and practitioners and specialists must consistently follow-up to understand how patients are progressing.

PCPs play an extremely important role in ensuring the transitions of care from hospitals to post-acute care settings, like skilled nursing facilities (SNFs) or long-term care facilities, are as smooth and seamless as possible. With PCPs’ direct touchpoints with patients and their caregivers or families, they are well positioned to and lead collaborative efforts between their practices and out-patient facilities to reduce hospital readmissions and improve patient outcomes overall.

The Future of Care Coordination for Post- and Long-Term Care

As we continue to move forward into this age of technology-enabled change, there needs to be a better understanding of patient care journeys – from hospital to SNF and to home health care – to avoid dire situations and hospital readmission. The mission of post-acute health care settings is to effectively deliver the right care, at the right time, regardless of the care setting. When patients recover and gain more independence and quality of life, everyone benefits – the patient, their family, and the health care system overall.

Medicare spends about $17 billion annually on hospital readmissions, many of which are avoidable. Readmissions are one of the hardest challenges to solve in health care. Fortunately, PCPs, working collaboratively with a patient’s specialists and care coordinators, are ideally positioned to coordinate care interventions when needed and support patients’ recovery.

To address current challenges and shape a better future for care coordination, PCPs must leverage all the tools they have at their disposal to keep a close eye on patients entering and leaving acute and post-acute care settings. Armed with digital technology and advanced analytics to strengthen collaboration and communication between practices and facilities, along with innovative companies and partnerships that work to fill in the potential gaps in care transitions, PCPs are at the heart of improving patient outcomes and satisfaction overall.

Additionally, as the health care landscape continues to evolve, PCPs can also begin to integrate advanced technology like artificial intelligence (AI) and machine learning to elevate their management of at-risk patients. AI-driven predictive analytics can offer PCPs insights into patient risk for readmission and can inform more precise care plans.

With the increased amount of face-time PCPs have with patients, as compared to other specialists and providers, a PCPs involvement in managing chronic and complex conditions to ensure additional care transition support is crucial and vital to the success of care transitions and reducing hospital readmissions. The future of health care relies on PCPs on their ability to navigate and lead the complexities of delivering high-quality, value-based care.