Post-Acute Care/Long-Term Care Delivery System

The Centers for Medicare/Medicaid Services (CMS) has implemented financial penalties for hospitals experiencing high volumes of avoidable readmissions for certain medical conditions. Now, for the first time, hospitals have a financial incentive to collaborate with post-acute care/long term care (PAC/LTC) facilities and providers to improve transitions of care and to reduce potentially avoidable hospital readmissions of their shared patients/residents.

Across the industry, PAC/LTC facilities frequently experience widely variable physician coverage and availability to provide timely, proactive, high quality medical evaluation and treatment of their residents. Residents often experience changes in medical condition during the intervals between Attending Physician presence onsite at the facility, leading to potentially avoidable resident transfers to the emergency department (ED) and inpatient hospitalizations/re-hospitalizations.

Our client, an integrated care delivery system offering an array of home health, hospice, assisted living, and rehabilitation services, sought to examine the feasibility of incorporating the role of nurse practitioners into their PAC/LTC facilities, increasing onsite presence of providers to evaluate and treat their residents in a consistent, proactive, timely manner. Core goals of the initiative included strengthening overall quality of care and reducing potentially avoidable ED transfers and hospitalizations/readmissions. The client engaged Louise Bryde and Bob Moore, both Principals at Stroudwater, to help them make this initiative a reality.

During Phase I of the Engagement, Stroudwater Associates evaluated several NP Models and presented recommendations to client leadership for their consideration/adoption. Stroudwater subsequently researched and developed multiple deliverables related to the selected NP Model, in collaboration with client leadership and staff, including a high-level Strategic and Tactical NP Model Implementation Plan and an internal/external Communications Plan. For Phase II of the engagement, Stroudwater Associates provided comprehensive support to integrate the role of employed NPs into the client’s care delivery system, for implementation on a pilot basis.

Through this engagement, Stroudwater Associates assisted the client to develop the core foundation of information and tools essential for them to implement the NP Model Pilot effectively. Stroudwater also prepared a comprehensive NP Model Implementation Manual, including multiple tools and resources. The Manual addressed all facets of the process to integrate the NP role more broadly into the client’s care delivery system, in preparation for future expansion and integration of the NP Model system-wide.