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Evidence is key to attaining best outcomes outside the four walls of the hospital

February 19, 2021
Health IT
Staci Porter
By Staci Porter

Most hospital-based physicians have a strong sense of the importance of basing patient care on the best available evidence to improve the patient care, standardize decisions, and improve outcomes.

However, caregivers working beyond the four walls of the hospital (e.g., those in the post-acute setting and pre-acute chronic care management setting), face a unique challenge. It isn’t that pre- and post-acute providers don’t practice evidence-based medicine; the challenge is in making this information available in an easily digestible way. It is critical that all members of the care team – including the case manager, prescribing provider, nursing team, physical therapist, occupational therapist, nutritionist – have access to the latest evidence-based recommendations and guidance updated and informed about diagnoses, treatment options and care plans.

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The use of evidence-based interdisciplinary care plans is essential to ensuring patients receive proper care and management. The ideal care plan library will include recommended evidence-based guidelines for the testing and treatment of patients experiencing a range of long-term conditions, such as chronic obstructive pulmonary disease, depression, diabetes, and heart failure. Each care plan should be based on a whole-person care approach that considers a patient-centered model to treating physical and psychosocial needs and delivering preventative care.

Why evidence matters for pre- and post-acute providers
Pre- and post-acute caregivers, including those at skilled nursing facilities, rehabilitation centers, long-term post-acute care centers, and population health management organizations, are an invaluable component of the care continuum. These caregivers are dedicated to helping smooth the transition process from hospital to home for patients and their families and keeping them healthy in the communities. They also play a key role assisting hospitals and other providers in preventing avoidable readmissions. In the U.S., it is estimated that one-in-five hospital patients are discharged to post-acute care settings such as skilled nursing facilities or long-term care hospitals.

Post-acute providers’ progress toward value-based care, however, has lagged much of the rest of the industry, as a recent Black Book Research survey illustrates. The survey of 1,640 long-term and post-acute care providers revealed that almost 90% of skilled nursing and sub-acute facilities predicted no shift in the portion of their payments through value-based care models in 2020.

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