LeadingAge Magazine · September/October 2015 • Volume 05 • Number 05

Partnerships and Integrated Health Care: Creating a Place for Aging Services

September 13, 2015 | by Gene Mitchell

Partnerships and Integrated Health Care: Creating a Place for Aging Services

LeadingAge members create partnerships all the time—with other aging-services providers, human-services organizations, universities, cultural institutions and more. But as health care reform progresses and the principles of population health management gain sway, some of the most important partnerships providers can create—with integrated health networks—should become more and more common.

Long-term and post-acute care providers, by building relationships with managed care organizations, accountable care organizations (ACOs) and hospital systems, can demonstrate how they can help reduce hospital admissions and readmissions, create better health and wellness outcomes for seniors, and create referral relationships.

For perspective on these types of partnerships, LeadingAge talked with Jared Landis, practice manager for The Advisory Board Company, a Washington, DC-based technology, research and consulting firm that specializes in health care and higher education. Landis works in the Post-Acute Care Collaborative within the Advisory Board's strategic research division, working closely with post-acute and long-term care providers. On the LeadingAge website, he has hosted webinars on building relationships with hospitals, physician groups and payers, and is scheduled to do another one on Sept. 22, highlighting key clinical capabilities necessary for market differentiation. Landis will also present an education session, “Integrated Health Networks: Mutually Beneficial Relationships,” at the 2015 LeadingAge Annual Meeting and Expo in Boston, Nov. 1-4.

LeadingAge: Why do senior living and post-acute care providers need to develop the partnerships you advocate with health plans and hospital systems? On the macro level, why does our field, and American health care in general, need such partnerships, and on the micro level, why does an individual provider need them?

Jared Landis: At the macro level, the first reason is improved clinical quality and patient care. We need stronger relationships between acute care hospitals, post-acute providers and senior living organizations to enhance patient care, to improve patient management, and to more safely and effectively return people to their preferred home environment, whether out in the community or part of a senior living campus. There’s a lot of data that speaks to the ineffectiveness of care transitions and the impact that ineffectiveness has on readmission rates and costs.

That leads into the second reason we care about this at the macro level and that’s because of the variation and cost growth that is the result of post-acute care. In 2013 we saw the release of a wide range of data, some from MedPAC [The Medicare Payment Advisory Commission], some from IOM [The Institute of Medicine], and some coming out of a good Health Affairs study, identifying post-acute care as the key driver both of cost growth and cost variability.

Drilling down for an individual provider, when we get into narrowed networks and preferred provider networks—and I don’t want to be too blunt or to oversell it—but an individual provider on the post-acute side should care because if you don’t form these relationships your Medicare business might just dry up. Obviously that won’t happen in every market. In some cases there are more patients than beds, and in rural markets there might only be a few [sites], but in many markets there is enough competition that you’ll be out of business if you don’t live up to the expectations of those forming preferred provider networks.

To answer that micro question on the senior living side … what we’re seeing more of is that now that hospitals, physicians and case managers are paying greater attention to where patients go after discharge, they’re not as willing to send them back to an assisted living provider, for instance, without fully understanding the capabilities of that provider and having confidence that the provider can keep [patients] from cycling back and forth [to] the hospital.

LeadingAge: You referred to assisted living above, but don’t the same points relate to short-term Medicare rehab?

Jared Landis: Absolutely, even more so, in particular those Medicare patients. The preferred provider networks forming tend to be around Medicare patients in a pilot payment model where a hospital or physician group is assuming risk—bundled payments, or ACOs or Medicare Advantage plans.

LeadingAge: And a lot of our members use funds from Medicare rehab to subsidize their Medicaid operations, and that cannot be jeopardized. Our members are all not-for-profits, many have strong religious backgrounds, and staying in business is not just a matter of keeping the doors open, it’s a matter of mission.

Jared Landis: In some instances not-for-profits who understand the market and understand what investments they’ll need to make are sometimes in a better position than for-profit companies. For instance, a not-for-profit might choose to invest in a senior care navigator role—someone who helps coordinate care for individuals leaving [rehab], gets them back to their primary care physician, makes sure medication reconciliation is done, and [takes on] some responsibility for helping patients navigate the system. If you invest in that role, there isn’t a direct [return on investment] for that, but it is an indirect ROI where you will be perceived as a higher-quality partner by the hospital, by the referrer. You’ll be someone they want to work with and in turn it’s making your organization more appealing and ultimately helping you secure a place in those preferred provider networks.

On the for-profit side it’s oftentimes much harder to make that investment in a position without a direct ROI. It’s harder to make an investment in that kind of care navigator role where you won’t see a direct return because you have that responsibility to the bottom line.

LeadingAge: Could you briefly describe the major barriers to growing good relationships between acute care providers or health plans and organizations like our members?

Jared Landis: There is awareness and there are misconceptions and there are actual abilities. On the awareness side, this is really the first time that hospitals and physician groups have had the incentive to pay attention to the post-acute, long-term care, senior living space, so they don’t always understand what’s going on. That’s true for a Medicare service like skilled nursing, so if you extrapolate that to senior living, which is slightly outside the Medicare environment, in a lot of cases the awareness of that service among hospitals, physician groups and case managers can be pretty low.

That leads to the second: Where there is awareness but there is a misperception and they [acute care providers] don’t understand the capabilities of assisted living, at a macro level or micro level. We’ve worked hard with our senior living members to give them a playbook for conveying [their] value to hospitals and physician groups, and one of the key items within that is a capabilities checklist. It’s not rocket science, but it makes a big difference to have a clear list of capabilities you can give to case managers for when they’re thinking, “Can this individual go back to the senior living environment or do I need to keep them in a more medicalized health care facility?” They can use that as a quick guide.

Third are capabilities. There’s a wide range of clinical capabilities among [LeadingAge members], so if you want to have that relationship with hospitals or physician groups or payers, you have to take a hard look at your capabilities. Are we providing enough on-site medical care? Do we have the right linkages with primary care groups to make sure we’re prioritizing prevention and health and wellness among residents?

Some [responsibility] is on the market in terms of better understanding senior living, and some is on senior living providers to elevate their game.

This year’s LeadingAge Annual Meeting and Expo, scheduled for Nov. 1-4 in Boston, MA, will feature more than 190 educational sessions on a wide variety of topics that challenge our field.

Click on “Education Program” at the meeting website to learn about the many forms of education available, investigate specific sessions or download the whole meeting brochure. Here are some of the sessions related to topics in this article:

Monday, Nov. 2

  • 89-B. A Cross Continuum Collaborative: Working Together to Improve Outcomes

Tuesday, Nov. 3

  • 98-D. Integrated Health Networks: Mutually Beneficial Relationships

Wednesday, Nov. 4

  • 104-F. Acute-Care Partnerships: Aligning Systems, Incentives and Outcomes
  • 36-G. Developing an ACO Post-Acute Care Collaboration
  • 106-G. Repositioning Your Continuum of Care to Improve Operating Results


LeadingAge: In terms of service offerings on the part of long-term and post-acute providers—offerings that will make such partnerships more attractive—what would the acute care providers like to see more of?

Jared Landis: The foundation for any good senior living provider to be taken seriously in this space is a good on-site primary care program. You can get to that through a number of different avenues; it doesn’t mean every senior living provider needs to go out and start employing primary care physicians. There is a wide range of options of how you can provide that service on-site, but that is step one [in] saying “we are serious about senior health, and if you’re looking for a partner you should consider us.”

For post-acute providers, they need to master their core business and then build specialty programs off of that core, while at the same time demonstrating they are open to pursuing joint initiatives for the benefit of the hospital and/or patient.

LeadingAge: If you tried to design a partnership that worked well, with both the acute and post-acute partners understanding each other thoroughly, what would define success?

Jared Landis: You need a good communication infrastructure, and obviously IT integration is the most advanced form of that communication infrastructure. But you don’t necessarily have to have an advanced EMR platform to improve communication. You can also look for simplified solutions in terms of sending a comprehensive transfer form with your resident if they do have to go back to the emergency room, making sure a capabilities list is on the back of that transfer form so the emergency physician can see … “They have those capabilities; I don’t need to admit this patient but could send them back, for instance, to this [provider].”

The second thing that is very helpful in this regard is actually some creative funding that is available under a risk-based Medicare program or under a Medicare Advantage program, something like adult day services for instance. If you’re in an ACO and at risk for the total cost of care for your population, isn’t it better to pay a senior living provider for those adult day services rather than risk that frail elderly individual readmitting into the hospital? In a lot of ways that creative funding helps.

In terms of what a win/win on benefits and on outcomes means, on the hospital side they see better performance under risk-based Medicare programs and reduced readmission rates, while learning from the senior living provider nuances of care for the elderly that they haven’t historically had to focus on. For senior living, it means better care, better quality of life, better health and well-being for residents. Secondly, it gets back to that issue of reducing resident turnover, which is a business benefit.

LeadingAge: To date, how is the creation of such partnerships going? If there are not a large number of them, are you optimistic about how those existing examples are working?

Jared Landis: I’m optimistic because of the opportunity for clear wins. We’re not talking about wild futuristic clinical partnerships that require expensive technology and cutting-edge procedures. We’re talking about sitting down at the same table, taking the time to determine why a readmission occurred and what can we do to prevent this. There are some easy wins and a lot of this is about creating lines of communication that have historically not been open. Once people start to see those wins they’ll recognize who is a provider doesn’t just talk the talk but walks the walk.

Once that occurs you’ll see partnerships snowball. At the same time Medicare will continue to ramp up the importance of cross-continuum collaboration in the way they structure their payments so there will be a financial incentive accompanying the positives coming out of these partnerships.

I’m not saying that the world’s going to change overnight; it will take time. Health care institutions are large organizations with a lot of moving pieces. It takes time to change the course of the ship but I am confident that this will be a positive for our health care system, a positive for patients and an area where we see a return on investment.

Earlier you mentioned the larger idea of partnership. One of our beliefs is that the acute/post-acute relationship is not a transactional one. You’ll often see people advising hospitals and health systems in terms of how you approach the post-acute environment and it’s a range of contracting options. Certainly there is that functional element in play, but we believe these are truly relationships. They are driven by people, by a common sense of purpose about providing quality care for patients and residents. We need to start shifting the mindset from a vendor or transactional one to one around true relationships where we jointly come together over a common purpose.