Post-Acute care was broken before COVID-19 - the pandemic might fix it

The COVID-19 pandemic has exposed weaknesses in how our healthcare system handles acute care. We’ve seen widely reported shortages in ICU beds and other critical care resources, limits in our ability to protect healthcare workers from infection, and racial disparities in access to care. The pandemic is also putting a spotlight on the problems with post-acute care, and this is particularly troubling because we have seen some of the worst outbreaks of the disease in skilled nursing facilities, where much of post-acute care happens.

The problem is post-acute care – generally care provided after a patient leaves the hospital – is fragmented, and most patients are either referred to a facility or are sent home with little assistance or support. Nobody is overseeing their care, and primary care providers are often out of the loop.

During COVID-19, that’s a lose-lose scenario. Patients who were hospitalized with the virus are either coming home with a complicated set of instructions, medications, and self-isolation protocols, or they are going to a nursing facility, risking exposing other patients to the disease. Some nursing homes are making judgment calls about protecting their own populations and refusing to take COVID-19 patients, leaving them with limited options. 

This confusing post-acute care scenario is not a new problem that came with COVID-19. It was there all along, COVID-19 just exposed how bad the situation is. We simply need a better path after discharge from a hospital for all patients, and to leverage the home as a core care delivery setting.

The best way to do this is to supercharge care at home, so that people can go home after being discharged from the hospital and heal with the support and care needed to fully recover. Many patients coming out of the hospital after battling a severe disease, injury, or surgery will be managing a complex set of medications and health needs. It is clear we cannot simply send them home with a set of written instructions and assume everyone has the resources to follow them, while also still not feeling at their best. Ideal home care for patients after discharge should include three things.

First, effective delivery of care in the home must include close coordination, follow-up and support throughout their healing process. We have effectively utilized for decades nurse coaching with a registered nurse to follow the patient post discharge. They are there to help patients understand their discharge instructions and answer any questions they may have about their health. Nurse coaches get to know their patients, and are able to support both clinical and non-clinical needs, including social barriers to recovery like food inaccessibility and lack of transportation. This is especially important at this time when hospitals are overburdened, meaning fewer providers are available for regular care and management, and discharge instructions may not be clear or organized. Social distancing measures only exacerbate these issues.

Patients are worried about getting back to good health, managing their medications, and what follow-ups they need to do and where. On top of that, they have the general anxiety that comes with leaving the hospital setting, where there are nurses and other providers readily available to support them and answer their questions. We need to recreate that environment in the home.

Second, we need a robust telehealth system and other tools, like remote-patient monitoring, to ensure these patients get visits with their doctors and other providers frequently, without traveling to another healthcare facility. While telehealth has existed for a long time, it has taken the COVID-19 pandemic to accelerate its adoption. We need to make it the norm for many types of medical appointments. During the pandemic, this helps us protect healthcare workers from additional exposure, while ensuring patients have the care they need. There is a real opportunity to do this, as CMS has updated some of its rules to ensure more telehealth can be delivered to patients. We need to keep those changes for the long haul.

Finally, we need to ensure we’re connecting patients with the community resources they need to heal effectively. That means understanding when patients face non-medical challenges and closing those gaps. For example, we need to be able to understand when patients need meal delivery and connect them with Meals on Wheels, or another local organization that can address non-clinical barriers to healing and recovering at home.  

Ultimately, all three of these changes will not just build a better model of post-acute care for patients recovering from COVID-19, but must be adopted by all as a better path for post-acute care for all patients moving forward.

Jasen Gundersen, M.D., M.B.A., Chief Medical Officer of CareCentrix, a post-acute care and home health company that manages the entire care continuum so more people can heal and age at home. Dr. Gundersen has held various medical and leadership positions in the health care industry, and previously served as President, Hospitalist and Post-Acute Services at TeamHealth.