Blue Sky Therapy Blog

Creating a Continuum of Care for Your Organization

by Donny Orengia

What is “Continuum Care”?

The continued shift to value-based care has created an environment where continuum ability is not only needed, but necessary. Both the government and private systems are working toward creating a health care system that is fueled by reimbursement which is driven by quality and with that, many health systems are seeking implementation of two-sided risk sharing payment models to ensure their down stream partners are properly incentivized (or penalized, for that matter) to provide stellar care.

Imagine this. An individual has a fall and subsequent hip fracture. They were rushed to emergency and scheduled for surgery. After several days in the hospital patient heads to a SNF. They discharge after 19 days to their home with a prescription for Home Health. After that, patient’s PCP recommends Outpatient Physical Therapy to regain prior level of function.

Consider: At minimum, this patient interacted with two dozen individual practitioners/clinicians between doctors, nurses, therapists, etc. In many instances this SNF is not tied to the originating hospital. Nor is the Home Health agency tied to either. Additionally, the Outpatient PT clinic is not associated with any of the aforementioned. Talk about an amalgamation of best practices and clinical protocols. How can we ever be consistent?!

The mission of the Health Care Payment Learning & Action Network (HCPLAN) is “To accelerate the shift to value-based care in order to achieve better outcomes at lower cost.” With an organizational goal of reaching 100% of Medicare and Advantage payments tied to these types of models by 2025 and with support from healthcare behemoths like Premier (4,100+ hospital and health system members), Florida and North Carolina BlueCross/BlueShield groups (more than 5 million and 3.8 million members respectively), and UPMC Health Plan (more than 4 million members) it’s safe to assume that with this sort of backing and goal setting that we are well on our way to a realization of full value-based care.

Effective and Efficient

A very realistic way to start (or improve) working toward alignment with these goals is to create a continuum of care for your organization. Easier said than done, right? You are already busy enough with day-to-day operations and implementing much more ground level strategies to improve patient care and coordination. Good news… we can help!

As a strategic partner, Blue Sky Therapy has helped to create an effective and efficient model that allows our partners to create alignment across the entirety of the post-acute space. More specifically, this has allowed our SNF partners to strengthen their relationships with ACOs and BPCI participating hospitals, home care agencies, Assisted Living facilities, physician groups. We can now more effectively and efficiently transitions patients through their episode (e.g. from SNF to home, from skilled home care to in-home part B therapy and on to outpatient clinics, etc. all overseen by the same organization with a common goal.)

So, how do we do this, you ask? Let’s talk about it.  

Practical Applications

We will look at some real-life examples of how Blue Sky’s continuum coverage has empowered our partners and helped to reduce rehospitalizations and improve outcomes through the post-acute episode.

Scenario: One of Blue Sky’s PTs, we will call her Sandy, recently found a perfect opportunity to leverage continuum knowledge and positioning to help mitigate a rehospitalization.

Sandy works some of her days in a SNF, “Poplar Place”, as well as sharing time providing home health therapy services for a partnered agency which shares a strong relationship with Poplar Place due to their quality of care.

Sandy was providing home health physical therapy for Mrs. Doe, a patient she’d been introduced to at Poplar Place, so Sandy was very aware of Mrs. Doe’s healthcare needs and recent history.

While Mrs. Doe’s primary reason for entering a SNF was due to her recent fall and elbow fracture, through her stay it became known that Mrs. Doe showed signs of mild cognitive impairment. Through her stay at Poplar Oaks Sandy came to learn that Mrs. Doe was staged as a Level 5 (based on Allen Cognitive Levels and SLP screening) so Sandy knew that while Mrs. Doe had some mild impairments, she was still functioning very independently for a majority of tasks.

As Sandy continued to visit Mrs. Doe for her home health therapy sessions, Sandy started to notice Mrs. Doe’s cognitive decline. Mrs. Doe stopped eating regularly, was not showering regularly, and just generally sensed that Mrs. Doe was not motivated to take care of herself as she should.

Luckily, Sandy, a highly skilled and aware Blue Sky therapist with access to a strong continuum focused team, was able to notify the home health agency and Poplar Place of Mrs. Doe’s decline so the necessary intervention could take place prior to Mrs. Doe declining further and very likely resulting in a rehospitalization.   Even more so, recognize the fact that this possible rehospitalization would have had nothing to do with Mrs. Doe’s original SNF stay reason (elbow fracture) but nonetheless would have been considered a rehospitalization.


This story is a common one. But the intervention… maybe not as much. The average and median Traditional Medicare length of stay for the 2,373 SNFs we analyzed was 26.39 and 26 days, respectively. In our experience it seems like the average Home Health episode is 45-60 days. So that means on the low end we are around a 60-day window for total skilled episode and on the high end, 86. While this average seems like it may cover that 90-day window, for the most part, we all know that with the proliferation of Advantage plans, there are SNF stays much closer to 15 days and home health episodes decreasing as well. This is where In-Home therapy can play a huge role in your patient’s success.

As an outpatient rehab provider, Blue Sky has the ability to go directly into a beneficiary’s home and deliver part B therapy services once they are discharged from their skilled place of care with a home health agency. We have been experiencing a decrease in therapy visits under the new PDGM model so not only does it increase duration of face time with a patient to help with that rehospitalization metric, but it also is delivering much needed therapy intervention that has diminished since the onset of PDGM.

Our In-Home therapy model is a no brainer for SNF and home health partners. In essence, it’s a referral process that gets put into place and there is newfound comfort in the continued oversight of a patients care plan beyond the historical “norm” that is SNF -> Home Health.

The impact this has on trended readmissions rates* can be astonishing. One partnered facility has trended 30-60-90-day rates of 9.25%, 15%, and 18%, respectively. To put into context, the entire market average for the 102 surrounding facilities is 13.87%, 19.13%, and 21.97%.

60-90 day window importance.

Interested in seeing just how much we can help your hospital partners save by reducing readmissions through continuum of care coverage?  Click on "Cost Savings Via Readmission Mitigation" to see just how much we help health systems!

Hospitals Skilled Nursing Facilities Readmissions continuum of care

Cost Savings Via Readmission Mitigation

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