By: David E. Storto

Tags: coordinated care , redesigning care , industry interactions

As someone who has spent their career in the area of rehabilitation and post-acute care, it is truly a very exciting time. With the focus shifting to population health management and as reimbursement moves more to episodic and global payments, the coordinated use of an entire continuum of care to encourage lifelong wellness and function will become increasingly important. Those of us at the Spaulding Rehabilitation Network and Partners HealthCare at Home, who have long known the value of rehabilitative medicine and home care, say, “Welcome to the party, where have you been?” Effectively using post-acute care can keep people healthier and out of emergency departments and the acute hospital.

All of us within health care have long known that hospital readmissions impose a burden on patients and their families, and now they may result in penalties to acute care hospitals. The initiatives we are planning and implementing together across the full continuum to reduce re-hospitalizations - as well as address a host of other challenges in an era of reform - will serve as models for others and support Partners’ continued success as a health care system.

When building the Spaulding Rehabilitation Network and Partners HealthCare at Home, our goal was to create an integrated continuum that could offer seamless transitions between levels of care. Our caregivers touch thousands of lives each day via inpatient and outpatient rehabilitation, skilled nursing settings and in our patients’ homes in the community. As a fully integrated part of Partners HealthCare, we have created a systematic approach to effectively manage the challenges providers must navigate, as well as create a unique model that allows our patients to receive the right care at the right time to maximize their recovery and independence.

While the outcome of health care reform remains to be determined, I feel more confident than ever that any solution will require the effective use of post-acute care.