Post-acute care: Getting well

Dr. Robert Wenick, MD, Vice President, Population Health

ProHealth Physicians


ProHealth Physicians, part of OptumCare®, is a physician-led health group caring for more than 345,000 active patients with 350 primary and specialty care providers at 85 locations in Connecticut.

Since initiating a Medicare Shared Savings Program (MSSP) in 2013, ProHealth has tracked quality and value for its participating members. Length of stay (LOS) and rate of readmission are two critical pieces of data. 

Length of stay measures how well a health system recuperates sick patients. Readmission rate shows readiness for home at time of discharge, as well as sufficient rehabilitative support after the hospital. 

If a patient stays too long in the hospital, they are exposed to greater cost, both in amount spent on care and exposure to the risks inherent to health care facilities. However, if discharged too early and without the proper rehabilitation in place, patients are at risk for return to the hospital.

Targeting the investment

Looking closely at prior years’ data, it was evident that the greatest expenses from inpatient care came from skilled nursing facilities (SNF). With an average LOS at 28 days and average cost of $560 per day, it was clear that intervention was needed to address affordability. 

As such, ProHealth planned an investment in better coordination to address the quality of post-acute care. By bettering communication between providers at the time of transition from hospital to nursing facility and nursing facility to home, patient recovery would improve.


Piloting the program

In May of 2015, the pilot program launched with two hospitals and four nursing homes, plus a staff of four registered nurses. 

Aiming to improve patient support to lower the number of days required in a facility and decrease readmissions, staff nurses worked to coordinate the efforts of providers involved in a patient’s care. 

For discharge from the hospital to a SNF, the ProHealth coordinating nurse gave a detailed handoff report to the nursing home. Nurses educated patients and caregivers on disease management and improving wellness. 

Throughout their time with the patient, nurses assessed for gaps in care and worked to fill them.

To prepare for the transition home, nurses coordinated with home health providers and issued a discharge note to the primary care provider (PCP). The nurse ensured that durable medical equipment and supplies would be on hand. 

Home health nursing, as well as occupational and physical therapy, were set up prior to discharge, and required to be available in a timely way. Once at home, patients were followed by nurse coordinators for ongoing support over the telephone for thirty days.


Infrastructure of care

The two hospitals and four SNFs expanded to ten major hospitals and ninety nursing facilities. 

Creating partnerships and compacts, non-legally binding agreements that detail professional obligations between hospitals, SNFs, and home health providers, promoted coordination and standardization of services. Providers created a referral network of health facilities and services. 

No patient was required to choose a preferred provider, however nearly all did. Network providers entered in to the compact on the promise of “volume for value.” They could expect to care for the members of ProHealth’s MSSP, and in return they would meet ProHealth value standards. 

Physical therapy, for example, was started within 48 hours so that physical strength recovery after hospitalization would continue its progress.

Additionally, ProHealth targeted corporate hospitals whose ownership extended to SNFs. In contracting these facilities, policies put in place to increase value at the hospital would expectedly be pushed downstream to post-acute facilities under the same corporate umbrella. 

Another key to first establishing, then measuring the intervention was the use of the same electronic medical record (EMR) across all providers.


At the program start, the average LOS for a ProHealth MSSP patient at a SNF was twenty-eight days. Metrics at twelve months post-pilot showed an average LOS at eighteen days. Readmissions were reduced to 14.6 percent of all patients and just three percent of engaged patients. 

Every metric measuring related MSSP expenses — per member per year cost, readmissions, inpatient admissions, SNF admissions, SNF total days and ED visits — went down between 8 and 44 percent.

Improved numbers represent patients that returned home from the hospital faster, healthier, and with the support in place to keep on track in their recovery. 

As a return on the investment in coordinated care, ProHealth showed large improvement in patient outcomes, and saw the savings from fewer hospital days in Medicare billing, and most importantly, affordability of care for our patients.

The transitions of care coordination program showed significant cost and quality improvements. As health care payers and providers continue the move to value-based systems, some key learnings can be highlighted. 

Choosing the optimal population is important. In the case of this intervention, ProHealth found a segment of their membership that was spending too much for not enough benefit, and made intervention where the most value could be gained. 

Configuring a network of providers working in concert to improve patient outcomes helped expand the impact outside the walls of the hospital. Finding experienced personnel, in this case nurses experienced in patient education and knowledgeable of community resources, was a boon. 

By investing in improved quality of care, ProHealth created savings and increased value for patients.


The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice.