In September, CMS selected 741 hospitals to participate in a new reimbursement framework, the Transforming Episode Accountability Model.

Under TEAM, participating hospitals are responsible for the cost and quality of care associated with five surgical procedures — lower extremity joint replacement, hip femur fracture treatment, spinal fusion, coronary artery bypass graft and major bowel procedures — for 30 days after patient discharge. CMS said it aims to “motivate health care providers to better coordinate care and improve the quality of care” with a payment structure that replaces the fee-for-service model.

As health systems prepare for the TEAM’s implementation in 2026, one industry leader whom they might want to call is Felipe Osorno, chief post-acute care officer at Los Angeles-based Keck Medicine of USC.

“I joke that sometimes I feel like I’m the only chief post-acute care officer in the country, because I haven’t found another one,” he told Becker’s. “There are VPs and other continuum of care staff within health systems that worry about this, but as a dedicated role it’s a little bit unique.”

Keck Medicine created the chief post-acute care officer role two years ago, though Mr. Osorno has been with the health system for more than a decade. He holds a dual-chief role, also serving as the system’s chief of staff.

He previously led continuum of care operations at the Keck Medical Center of USC, the system’s flagship academic medical center, where he began to notice how both pre-arrival and post-acute case management lacked operational strategy.

“We’re a tertiary, quaternary center. We focus on the sickest of the sick,” he said. “Being an organization that takes in a limited number of fully capitated risk patients, [post-acute case management was] something we didn’t have to think about too much.”

Mr. Osorno said his role was created to establish a post-acute strategy that would become an integrated part of the health system. Keck Medicine’s focus is not to own post-acute care, but to build partnerships and programs that enhance care transitions and support its primary focus of tertiary and quaternary care.

“We know that to continue to grow, having a pathway to get patients to the right setting at the right time is really important,” he said. “Just throwing a post-acute referral into the ether and hoping someone will take the patient is not a sustainable strategy.”

One of the first moves Keck made was to place its own faculty within six skilled nursing facilities, allowing patients to continue being cared for by Keck hospitalists. Handpicked by the system, Keck worked closely with the facilities to be sure their visions of quality are aligned through education and upskilling.

“We’re hoping that by transmitting some of these skills we can work on problems together, but also that they can build some capability and have the tools to improve the care too,” Mr. Osorno said.

Keck will also ensure continuous care quality through its newly established Keck Academy for Continuous Improvement, the pilot of which begins in September. Through the academy, Keck will train staff members from its post-acute care partners on internal process improvement.

“We’ve seen a dramatic improvement in readmissions and mortality, mostly because we can continue the protocols we started inpatient,” Mr. Osorno said. “Instead of just [handing over] a bunch of discharge orders, we truly see this as: We’re going to continue taking care of the patient.”

Beyond skilled nursing facilities, Keck has started to establish partnerships with home health agencies, hospice providers and long-term care hospitals, where they have started to see care improve through shared accountability, Mr. Osorno said.

Many of these partnerships are made possible by communication dashboards, remote patient monitoring and telehealth. Each facility partner operates at “different levels of sophistication and technology,” which requires some level of flexibility, he added.

“Having one point of contact for escalation makes a huge difference — very low-tech — but we created one phone number for SNFs,” he said. “Of course, we can layer on real-time interoperability of EMRs and AI and telehealth, but sometimes something very simple like one phone number makes a difference.”

Mr. Osorno said he sees tremendous opportunity in the post-acute space for technological entrepreneurship. While he gets pinged by a new vendor every day, he said the current landscape lacks integration.

“One vendor that will do the connection with SNFs, then a different vendor does the connection with home health and a different vendor for something else,” he said. “I would love it if there was one vendor that would help me manage all my needs, but we haven’t found that.”

Despite the many avenues of opportunities, Mr. Osorno said there are still barriers to ensuring seamless post-acute care coordination, one of the most prominent being reimbursement. Payment models for post-acute facilities are not aligned with or equal to the payment models for hospitals.

“If a patient has any needs outside of what a SNF can provide with the basic resources, they’ll lose money,” Mr. Osorno said. “Some patients are basically unplaceable, because folks know that no one’s going to pay for this. How do we build financial models where the money can be spent in the right place?”

As the federal government’s priorities and payment rules shift, Mr. Osorno stressed how important it is for hospital and health system leaders to prioritize effective post-acute care strategies.

“The big pressure we have as a country is to reduce how much we spend in healthcare, and post-acute care will have to be more integrated as part of your strategy,” he said. “People need to think more and more about the beginning-to-end. For us, [patients in post-acute care] might not be in our four walls, but they are still our patients.”

The post Is Keck Medicine’s chief post-acute officer the 1st of his kind? appeared first on Becker’s Hospital Review | Healthcare News & Analysis.