The SNF Test: Rethinking Discharge Decisions & Postacute Care Partnerships to Improve Outcomes

With the passage of MACRA and introduction of new reimbursement models, hospitals are analyzing the costs and benefits of sending patients to skilled nursing facilities (SNFs).  

Around five years ago, Robbie Price, MSN, NP-C, began spending one day per week visiting heart failure patients at a local SNF. At the time, Price was working as a nurse practitioner at Stroobants Cardiovascular Center, which is part of the Centra Medical Group in Lynchburg, Va.

With the healthcare industry undergoing structural changes due to the Affordable Care Act and value-based initiatives, Centra decided to launch a program at the Guggenheimer Health & Rehabilitation Center, a SNF the medical group owned. Centra’s leaders were concerned that too many of their heart patients were being readmitted to the hospital. Having Price and other providers visit patients at Guggenheimer would help create some comfort for patients and reduce their risk of returning to the hospital, they reasoned.

Although patients could choose which SNF to enter upon discharge, many selected Guggenheimer. Price and his colleagues began visiting them each week and working with the facility’s staff on the nuances of caring for heart failure patients. They arranged for one of the SNF’s wings to be dedicated to heart failure patients with staff designated to manage those patients. The program is still in place and now includes patients who need rehabilitation following open-heart surgery, valve replacement, arrhythmias or acute myocardial infarction (AMI).

“It really created some continuity,” says Price, who is now the managing director of operations at Stroobants. “These staff members really began to know the patients and know these processes. Three or four years into it, they were taking care of these heart failure patients just as well as any cardiac nurse.”

Complicated decision making

As hospital payments become more tied to meeting quality measures and keeping patients healthy and out of the hospital, physicians and other providers face a conundrum on where to send patients after discharge: home on their own, home with the support of a home healthcare agency or to a SNF.

The Centers for Medicare & Medicaid Services (CMS) defines SNFs as those that provide short-term skilled nursing care and rehabilitation services such as physical and occupational therapy and speech-language pathology services, according to the Medicare Payment Advisory Commission’s [MedPAC] 2017 Report to Congress. Nursing homes, meanwhile, usually offer less intensive services.

Hospitals and practices are conducting more research and analyzing data on the facilities to determine which ones provide the best care. Some are also developing relationships with SNFs, with the goal of monitoring their patients’ progress and preventing hospital readmissions.

The shift comes at a time when hospitals are increasingly responsible for the care of patients for a prolonged length of time. The passage of MACRA introduced payment models that will tie providers’ reimbursement to quality metrics for treating Medicare patients.

Consolidating postacute care options

In 2013, the Centers for Disease Control & Prevention predicted that the number of people using nursing facilities, alternative residential care places or home care services would increase from 15 million in 2000 to 27 million in 2050. This past spring, MedPAC reported that 1.7 million fee-for-service Medicare beneficiaries (approximately 20 percent of hospitalized beneficiaries) used SNF services at least once in 2015. That same year, Medicare spent $29.8 billion on SNF services, about 8 percent of its annual spending.

The emphasis on value-based care and new payment models led Hoag Memorial Hospital Presbyterian in Newport Beach, Calif., to examine its use of postacute care services. A few years ago, the hospital was regularly referring patients to 10 SNFs, accounting for 25 percent of its discharges. The readmission rates were 13 percent for patients sent directly home and 20 to 25 percent for patients sent to SNFs, according to Dipti Itchhaporia, MD, a cardiologist and the hospital’s director of disease management. Itchhaporia and other clinicians were not aware of these variations until they started paying attention to specific metrics.

They launched a collaboration with the SNFs to examine measures such as volumes, readmission rates and lengths of stay for each facility; share patients’ health records; and develop quality metrics, performance measures and a patient-centered hospital-to-SNF discharge packet. The goals were to improve the hospital’s relations with the facilities, monitor the SNFs’ performance and improve the standardized care processes and flow of patient information. For heart failure patients, hospital staff spoke with and trained SNF staff on how to recognize signs of heart failure and created a protocol for them.

The hospital also created report cards for each SNF and evaluated data on their staffing ratios, lengths of stay, 30-day readmissions and Medicare Star Ratings. Based on these data, Hoag decreased its preferred facilities to three. The hospital cannot mandate that patients select a SNF from only those facilities, but Itchhaporia says patients often choose to do so.

The hospital maintains a quality improvement department with staff focused on conditions that CMS tracks for readmissions, such as heart failure, pneumonia and sepsis. Itchhaporia works with a nurse and a nurse practitioner who are in touch with SNF staff on a regular basis.

“This was our attempt to say, ‘How are we going to start participating in this quality, high-value care picture, and how are we going to differentiate ourselves?’” Itchhaporia says. “This was the early start. We’re doing this with the skilled nursing facilities. We’re also doing it with the home health agencies. We’ve done a home health collaboration, also. We’re trying to put in a few other programs like that to try to see if we can improve our care. We know this is part of what we’re going to be judged on.”

Investing time & resources

The federal government is not alone in developing value-based initiatives. Health insurers also are starting to hold hospitals and providers financially responsible for treating patients. Centra Medical Group is involved in insurance programs such as Anthem’s Quality-In-Sights: Hospital Incentive Program (Q-HIP), which examines readmission rates and quality metrics for AMI, heart failure and other diagnoses.

Centra’s partnership with the Guggenheimer Health & Rehabilitation Center has expanded. Price says Centra clinicians may increase their visits to twice per week. In the past year, Centra also added another SNF, Summit Health and Rehabilitation Center, to its cardiology service. A nurse practitioner visits Summit once per week to check on Centra’s patients as well as coordinate with, and receives updates from, the facility’s staff.

“For these programs to be successful, you’re going to have to commit to put some work upfront and you’re going to need commitment from the organization and the postacute care folks,” Price says. Opening the “line of communications” between Centra and the SNFs has been key to helping prevent readmissions.

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“Many times we’ve been able to prevent a readmission by getting a phone call from the [SNF] staff and they’re telling us a patient’s weight is up three or four pounds, they’re a little short of breath,” he explains. Such calls allow the SNF and Centra staff to work together to adjust diuretics or take other steps to defer or prevent an emergency room visit.

Price says that the passage of MACRA and changes in reimbursement have forced hospitals to be more selective as to which patients to send to SNFs. After all, it is cheaper in the short term to discharge patients to their homes. It is also unclear whether hospitals spend more money sending patients to the facilities than they would pay as a penalty for a hospital readmission.

Still, the choice is not just based on finances, Price says. “At the end of the day, you still have to do what’s right for the patient,” he explains. “Taking finances off the table, if you’re a provider and you feel like the patient clearly is not ready to go home and is at risk for readmission, then you certainly should follow your instinct and send them to the facility.”