Use This Checklist for Intra-PAC Transitions Success

You may have already seen our new white paper, focused on the emerging trend towards intra-post-acute care (PAC) transitions. Forcura looked at why these transitions are beneficial to patients and post-acute care providers, as well as some of the challenges that remain for these transitions to occur smoothly – like payment system incentives, sufficient education and truly interoperable technology.

We also examined how some post-acute providers are preparing to improve or increase care transitions across their service lines. They’re expanding existing services, determining which providers offer the highest quality care, and ascertaining how their own businesses perform today relative to impending value-based criteria.

It’s never too soon to begin developing your own strategy to embrace the shift towards more transitions within post-acute care.  Here’s a handy action list to help you get started…or keep moving.

  • Be creative and agile.
    You’ve had to be more flexible and ingenious than ever in the face of COVID-19. Keep that energy going and don’t fall back into established ways of thinking.
  • Prioritize efforts that will have the most positive impact on patient outcomes. Balance financial considerations with what patients truly need and where they’ll receive the best care.
  • Gather patient data where it’s available. Many states now have information repositories for health insurance claims information from all health care payers.
  • Work with your referral community to determine what data networks they use. Being able to share information quickly and easily will make you better and more frequent partners.
  • Invest in technology integrations where appropriate. Look to improve real-time input and output, as well access to existing data sets.
  • Seek and adopt consistent technology standards, like FHIR. These standards are making inroads among technology vendors; your support will move them towards widespread, beneficial implementation. 
  • Look for fluid, flexible tools to do targeted data exchange. By integrating these tools, you’ll increase the odds of keeping patients stable across the care continuum. 
  • Leverage data analysis and business intelligence. The metrics can help you refine services, by showing patient gains during episodes, as well as admission and readmission rates.  
  • Create a holistic understanding of each patient, including support systems. Listen carefully to the desires and goals of patients and their families/caregivers. They may need resources you haven’t previously considered, like unskilled or palliative care.

Stop Being Reactive

It’s true that payment models and reforms have not kept pace in rewarding best practices. But to ensure that each patient gets the right care, you can’t let economic drivers dictate care transitions. It’s time to reconsider established practices – and begin taking a more proactive, patient-driven approach. Could a patient leaving the hospital receive home health care instead of going to a SNF? Would the quality of life for a SNF patient improve with a move to hospice? Have the needs of a home health care patient changed enough that Meals on Wheels and a homemaker would be sufficient?

As your intra-PAC patient transitions increase, you have a lot of options to consider. Use this checklist to find just the right one for each of your patients. 

Kate 6-Retouched


As Forcura's Director of Communications and Brand Strategy, Kate brings a robust background and knowledge of the healthcare and post-acute industry to Forcura. She also represents Forcura as a social media ambassador at events around the country, is an on-camera reporter and interviewer, and host of our Innovate Jax podcast.

Connect with Kate on LinkedIn. 

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