Continuity of Care from Hospital to Post-Acute Care Facility and to Home

Teresa Williams, MSW, LCSW
Chief Executive Officer – Partner
HomeCare Connect

Some injured and ill workers need to transfer from a hospital to a post-acute care (PAC) facility to continue healing before returning home. Gaps in the continuity of care can arise during these critical transitions, affecting recovery time and outcomes.

There is a wide range of PAC facilities with some specializing in severe burns or catastrophic spinal cord or traumatic brain injuries. Skilled nursing facilities and rehabilitation centers are often used to help people recover from surgery or regain strength and functionality after a long hospitalization. Workers hospitalized with serious COVID-19 cases, particularly those who were on ventilators, may continue treatment in a skilled nursing or rehab center before heading home. 

Working with PAC Facilities

Finding the right place for the injured or ill worker is not easy. Obtaining reasonable rates is harder still.

These are particularly challenging for claims representatives who get a last-minute hospital discharge call on the day of or the day before discharge. They scramble to find a facility that can deliver the type and level of care the individual needs.  The COVID-19 pandemic creates additional barriers because some skilled nursing facilities are not accepting patients.

First, claims representatives need to make sure the facility provides the all the services prescribed in the treatment plan. Some skilled nursing centers do not provide IV therapy, for example.  Some offer physical therapy; others don’t. There are many factors to consider, especially the quality of care provided.

After finding an appropriate facility, the next step is to ensure its rates are fair and equitable given the care that the injured worker needs. Negotiating takes time and expertise.

The PAC market is still the wild west.  Very few workers’ compensation networks exist for skilled nursing or rehabilitation facilities and for centers that specialize in treating traumatic brain injuries, severe burns, spinal cord injuries, and similar conditions.

The negotiator needs to know what the rates should be in a certain jurisdiction and must ensure that the facility will accept them.  This is problematic because only a couple of state fee schedules address PACs and a national PAC company may bill at different rates in different states. 

Most PAC facilities offer a per-diem rate that is supposed to be all-inclusive.  However, some bill services like physical therapy as a separate line item.  The severity of the injury determines the level of care, which can affect rates dramatically.  Additionally, PAC facilities consider workers’ compensation a slow payer and may hesitate to accept comp cases.

Negotiations take a good deal of going back and forth, a process that takes weeks, not days, and is best conducted well in advance of admitting a case.  Otherwise, workers’ compensation insurers, third-party administrators and other payers end up reimbursing fees at off-the-shelf, retail rates.  And, even more importantly, the time spent negotiating can result in an extended hospital stay and delay of care.  That means additional costs and disruption in the continuity of care.

Qualities of a PAC Partner

How does a payer contain costs and ensure continuity of care?  One option is to become an expert in PAC and pricing.  Another is to partner with a company that already is.

It makes sense to work with a home health company that specializes in clinically managing workers’ compensation cases. The partner should be equipped to handle the discharge from the hospital to the facility, oversee facility treatment and contain its costs, and manage the discharge to the home and ongoing home health care. 

Clinically managing hospital-to-facility-to-home care is the way to avoid unnecessary costs and ensure quality care.  The ideal partner has built and credentialed a robust, national network of PAC facilities, including the top-rated specialty centers.  It has vetted the providers for staffing levels, inspection results, and care quality.

Plus, it has researched fees in various jurisdictions and pre-negotiated rates with the facilities that have passed its stringent requirements. In addition, the partner continually checks outcomes and government agency inspections of its network providers to ensure they maintain high quality standards.

The network is just one part of the clinical management solution.  Before transferring an injured or ill worker to the facility, the partner’s clinician, usually a nurse, works with the claims representative and treating physician to create an individualized treatment plan for the facility to follow. 

In addition, the clinician keeps the injured worker and family informed and educated every step of a way. Injured workers and their families are anxious enough; the last thing they need is a surprise trip to a new facility.  Yet, gaps in communication and, consequently, continuity of care are all too common during hospital to PAC center transitions.

To bridge these gaps, a clinician contacts the injured or ill worker to explain why they cannot return home yet, where they are going, and why this facility is the most appropriate for their condition.  The worker needs to know what type of treatment to expect, have a sense of when they will return home, and most important, have a contact person to text or call with questions.

Clear and frequent communication alleviates fear and anxiety and other psychosocial barriers to recovery.  When a worker understands that someone has their back and will make sure they receive the right care at the right time, they are more likely to engage in their treatment and recover faster. It’s important to communicate with the worker and the claims representative throughout the episode of care.

The clinician monitors treatment supplied by the facility to make sure it adheres to the treatment plan.  If the worker is not progressing as expected, they can alert the claims representative and work with them and the treating physician to adjust the therapy.

Monitoring comes with a cost-containment benefit as well. Some PAC facilities go on autopilot and deliver (and bill for) services that are not needed.  Often it is a piece of durable medical equipment (DME) that the injured worker cannot use now or even post discharge. When DME is needed, the home health company can supply it at a discount instead of the facility buying it off the shelf. 

Most facilities charge separately for attendant care if the worker, such as one at risk for falls, needs one-on-one staffing.  Again, this can be staffed more cost effectively through a home health PAC partner that has pre-negotiated rates. The partner should also review invoices to make sure that unnecessary services are not reimbursed, stop their delivery, and ensure that the invoices align with pre-negotiated rates.

Monitoring the recovery progress also informs the all-important planning for discharge into the home. This process goes more smoothly when the partner also oversees the quality and cost of care delivered in the home.  A company that coordinates home modifications, in-home nursing care, and durable medical equipment and medical supplies is well suited to manage discharge into the home.

The goal is to return the injured or ill worker to their home as quickly as medically feasible.  Yet some workers languish in hospitals or PAC facilities while their homes are renovated.

Good coordination ensures that home modifications occur in the fastest time frame possible to avoid extra days in the facility.  In addition to home mods, applicable nursing services, DME and medical supplies should in place when the worker comes home.  Workers need to be able to navigate their homes safely and experience as much independence as possible. 

Injured workers should experience a seamless transition from the hospital to home, even when a stay in a PAC facility is part of the trip. Expert care, continuous communication, and patient education, along with clinical oversight of every aspect of the discharges and care in the PAC facility enhance the worker’s satisfaction, improve outcomes, and reduce costs. At the end of the day, the most important services a PAC partner can deliver are continuity of care, cost-savings and cost-containment, and clinical care and oversight.

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About HomeCare Connect

Specializing in catastrophic cases, HomeCare Connect manages the quality and cost of home health care, post-acute care, DME and supplies, home modification and prosthetics and orthotics for workers’ compensation patients and payers. The Inc. 5000 and the Orlando Business Journal’s lists of fast-growing, privately held companies have captured its rapid growth. Based in Winter Park, Florida, near Orlando, the company serves clients nationally and can be reached at or 855-223-2228.