Hospitals take pride in developing and managing preferred post-acute networks. You can go to their websites, speak to their case management teams or listen to their presentations, and they all talk about measurements like readmissions, length-of-stay (LOS) in nursing homes and other quality metrics. What you almost never hear about are the patients that are difficult to place, who their preferred network will not touch. This even applies to the health systems that own their post-acute networks.

On average only 30-40 percent of patients are offered beds in the preferred network, and the remaining balance of patients either get discharged to non-preferred nursing homes with lower CMS star ratings or end up staying in the hospital until they improve and can be discharged home. Most of these patients end up having a longer length stay than expected and end up costing hospitals millions of dollars in expenses and lost revenue. Many never improve and end up spending their final days in an acute hospital, surrounded by illness and injury, instead of at home with loved ones or in a facility designed to care for them.

Who are the difficult-to-place patients?

The concept of “difficult to place” varies, but it generally includes patients who are uninsured or under-insured, undocumented, clinically complex with a ventilator and hemodialysis or behavioral health needs that require constant monitoring, and on expensive oncology medications.

What do we do with difficult-to-place patients?

Several strategies have been tested and implemented by healthcare systems. From adding a complex care manager role – or a whole team – to paying for a patient’s care in a nursing facility or long-term acute care hospital, or event paying for transportation to repatriate patients to their home countries.

In my experience, all strategies start with early identification of patients coupled with knowledgeable and diligent staff. Identifying difficult-to-place patients allows staff to start troubleshooting and seeking solutions early, while patients meet the level of care criteria. During the early stages, it is important to engage with the patient’s family and multi-disciplinary team to explore every option, both popular and far-fetched. Listing all the options requires staff to be knowledgeable about available post-hospital care, from long-term care facilities to community health care centers, shelters and more. This also requires staff with the skills to facilitate a discussion with the team and family without making them defensive – knowing when to offer solutions and when to pull back. Persistence is the next important step, evident in the complex care manager who will not give up, will show confidence that the barrier can be addressed and will help the family and care team identify and accept the best solution for the patient given their circumstances.

The broader objective, however, needs to be setting goals for the preferred network that includes placement of difficult-to-place patients. This goal needs to be measured frequently and reviewed at least monthly. If the preferred network member is not meeting its goal, it needs to draft a plan of correction that is shared with the rest of the network. This transparency helps with engagement and peer pressure. If the network member is not willing to participate, the healthcare system needs to be prepared to exclude them from the collaborative.

Working towards a shared goal

A hospital’s preferred network will never be sufficient for all patients. Healthcare systems need to engage with post-acute providers beyond the preferred network and have a cogent plan for leveraging the resources available in their particular regions. In addition to working with families to bring patients home whenever possible, hospitals need to have an expanded network of providers that are willing to take difficult-to-place patients. The expanded network needs to be nurtured with frequent meetings, data and best practice sharing.

In the end, the team needs to track the patient, document each newly identified solution and/or resource, and celebrate each success.

Learn more about Array’s experience with post-acute care facilities by reading our designs delivered book.