How Keck Medicine of USC made post-acute care a strategic engine

As value-based care continues to reshape healthcare delivery, post-acute care is emerging as a central component of health system strategy. No longer a downstream function, PAC now directly influences outcomes, efficiency and total cost of care across the continuum.

At Keck Medicine of USC in Los Angeles, this evolution is reflected in a leadership model that closely aligns clinical and operational perspectives. The PAC service line is guided through a strong partnership between Felipe Osorno, chief of post-acute care, and Ramzi Ben-Youssef, MD, executive medical director of post-acute care and co-medical director of the inpatient rehabilitation program at USC Arcadia Hospital. Together, we work with a post-acute care team of hospital leaders, clinicians, case managers and data support to coordinate and scale approaches to post-acute care across the system.

Reflecting on discussions at the 16th Becker’s Annual Meeting in Chicago this last week, a consistent theme emerged: While PAC is widely recognized as essential to value-based care, many organizations are still early in building fully integrated, system-level service lines. Achieving true “systemness” — with aligned stakeholders, shared accountability and consistent workflows — remains a work in progress across the industry.

Despite growing recognition of its value, fully developed PAC service lines remain relatively uncommon. This was another recurring theme at Becker’s highlighting a gap between awareness and execution across the industry. At USC, we have ensured that strategy translates into execution across all care settings.

1. Supporting throughput and access in high-acuity environments: At Keck Medical Center of USC, PAC plays a central role in supporting hospital throughput and access. Through early engagement the PAC service line facilitates timely identification of appropriate post-acute placement options, including inpatient rehabilitation, skilled nursing facilities and home-based care. This integrated upstream approach allows for multidisciplinary coordination and proactive engagement across the continuum. In high-acuity settings, every day in the hospital matters. By engaging early and coordinating closely with care teams, we can help patients transition safely to the right level of care while preserving capacity for those who need it most.

2. Leveraging technology, data and AI with a pragmatic lens: The team has used technology that improves workflow, supports real-time patient tracking and standardized referral pathways. We are also beginning to use AI to support predictive insights such as discharge readiness and readmission risk.

3. Advancing quality, safety and continuity of care: Innovative, visionary and multidisciplinary leadership is essential for these programs to succeed. PAC sits at the intersection of multiple domains — clinical care, operations, finance and population health — and requires leaders who can navigate and align these perspectives effectively. I am actively engaged in the continuum of care leadership group, complex case coordination huddles, utilization management committees and system-level quality and safety discussions, aligning efforts across hospitalists, care coordination and multidisciplinary teams.

4. Enabling sustainable performance in value-based care: As financial and operational pressures intensify, PAC is increasingly central to sustainable system performance. By aligning clinical oversight with operational strategy and equipping teams with the right tools and data, the PAC service line supports efficiency, reduces variability and improves total cost management across episodes.

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