Post-acute care strategy and operating-model transformationA regional Medicare Advantage plan needed a more coordinated way to manage post-acute care across utilization management, provider networks, and care transitions.
Overview
A regional health plan serving approximately 100,000 Medicare Advantage members was experiencing sustained growth in post-acute care spending, particularly across skilled nursing facilities and home health.
The issue was not simply higher utilization. Post-acute care was being managed through several disconnected functions, making it difficult to identify the causes of cost growth or implement coordinated improvements.
The Challenge
Post-acute care activities were fragmented across multiple teams:
Utilization management focused on authorizations and continued stays
Network management maintained provider contracts
Care management supported selected high-risk members
Hospital discharge processes were inconsistent
Post-acute providers had limited visibility into plan expectations
Leadership could see rising costs but lacked clarity regarding what was driving them.
The Approach
1. Establishing a Performance Baseline
Developed an incurred-date view of utilization and cost to better understand admissions, length of stay, readmissions, discharge patterns, and provider variation.
2. Redesigning the Network
Evaluated post-acute providers using quality, readmissions, discharge outcomes, access, and total episode cost.
3. Improving Care Transitions
Moved utilization management earlier in the process and improved coordination around discharge planning, level-of-care decisions, and post-discharge follow-up.
4. Clarifying Build-versus-Partner Decisions
Defined which capabilities should remain with the health plan and which could be supported by outside partners.
Illustrative Results
Reduced skilled nursing utilization and length of stay
Improved discharge-to-home rates
Lower readmissions following post-acute stays
Faster initiation of home health services
Better visibility into provider performance
Meaningful medical-cost improvement
Business Impact
The plan moved from a fragmented and reactive approach to a coordinated operating model that aligned clinical decisions, network performance, member experience, and financial outcomes.
This case study is a composite example developed to illustrate Ivy & Anchor Advisors’ approach. Client details and results are illustrative.