Some researchers have backed the use of “SNFists,” or clinicians trained to track patients discharged into SNFs.

July 5—In an environment of alternative payment models and greater shared risk, some hospitals are looking to partner with local nursing homes to improve post-discharge care coordination, reduce hospital readmissions, and decrease costs, according to a new white paper.

The research explores the “frontier of opportunity” in improving healthcare quality and reducing costs:  post-acute care. The Leavitt Partners white paper looks at a range of collaborations between hospitals and skilled nursing facilities (SNFs) partnering to improve outcomes for discharged high acuity patients.

Those collaborations take different forms. The paper described a Palomar Health project in which hospitalists in 2015 were assigned to 12 SNFs. After one year, the 30-day readmission rates dropped from 9 percent to 1 percent.

The research was funded by long-term care provider Ensign.

Natalie Burton, who leads Leavitt’s payment delivery transformation practice, said a growing number of health systems, including the Cleveland Clinic, Banner Health, and Catholic Health Initiatives, have established preferred provider networks for post-acute care and refer discharged patients to nursing homes that demonstrate higher quality outcomes. Burton said those systems reduced readmissions and have shorter patient lengths of nursing home stay compared to non-preferred SNFs.

“Getting patients to the appropriate level of care is also key,” Burton said in an interview. “Insuring that patients are treated at the right place at the right time helps manage the overall cost of care. We’ve also seen improved quality outcomes and higher patient satisfaction.”

Cheryl Phillips, M.D., a geriatrician and the senior vice president of public policy and health services for Leading Age, an association of not-for-profit nursing homes, said the white paper is “exactly what I’ve been preaching about to our members for years. If you want to survive in this environment of bundled payments, managed care, and accountable care organizations, you need to partner with hospitals.”

Partnership Challenges

Such collaborations face two challenges, Philllips said in an interview.

“Many hospitals never thought of SNFs as potential partners or resources, but as places to discharge patients and hope they don’t come back again,” she said. “Too often hospitals don’t reach out to SNFs or develop quality measurements or information-sharing collaborations. And many SNFs have never needed to worry about referrals or creating strategic relationships with hospitals. Changes in payment models are driving this.”

The lack of care coordination between hospitals and SNFs around discharged patients, Philllips said, is not only costly to Medicare, but also to patients, who suffer conflicting advice about medication reconciliation, testing, and care plans.

“When you have fluid integration from time of hospital admission throughout the nursing home stay, there is much less risk of error, better coordination when patients go home, and decreased length of stay and readmissions,” she said.

David Grabowski, a Harvard Medical School professor of health care policy speaking as a private citizen and not a newly named member of the Medicare Payment Advisory Commission (MedPac), said the healthcare system has done “a terrible job” with hospital discharges.

“Hospitals had little incentive to work with nursing homes and follow up on their patients’ care. But with the movement to global accountable payments and CMS’ readmissions penalties, much more attention is being paid to this issue,” Grabowski said in an interview.

He said hospitals have begun to invest in these models.

“The best models we’ve studied are those in which health systems own or have strong affiliations with nursing homes. We’ve seen better outcomes when hospitals discharge to their own SNFs and already have information sharing and strong clinical ties,” Grabowski said.

Tracking Approach

Grabowski endorsed the concept of hiring “SNFists”—trained and credentialed providers—to track discharged patients into SNFs.

He said after decades of operating in silos in which nursing homes were dependent on hospitals for referrals in a one-way relationship, a team-based approach is taking hold.

“The good news is there is a lot of attention around SNFs, which are viewed as an ATM for healthcare reform” he said. “There is a perception of waste and inefficiency there and SNFs are feeling pressure to deliver shorter lengths of stay.”

David Gifford, senior vice president of quality and regulatory affairs for the nursing home organization, the American Health Care Association (AHCA), agreed that hospital payment models are impacting where hospitals refer patients after discharge.

“We’re seeing hospitals doing this in two different ways: working closely with SNFs to address the needs of those discharged patients or viewing SNFs as cost centers, which frustrates our members who actually want to partner more with the hospitals on patient care,” Gifford said in an interview.

Gifford said SNFs have average profit margins of 1 percent to 2 percent.

“CMS recognizes that if hospitals are reducing costs and improving care, they should share in savings,” he said in an interview. “We (SNFs) are excluded from that and too often treated as vendors instead of as partners.”

Bruce Chernof, MD, president and CEO of The SCAN Foundation, said the nation is “at the cusp of a really important transformative moment in healthcare: fee for outcomes.”

“It’s no longer enough to be responsible for what’s happening within the four walls of a provider, whether that’s a hospital, skilled nursing facility, or physician office,” Chernof said. “Outcomes matter and that demands on a greater shared focus on the continuum of care and forces providers to share risks and rewards together.”

Chernof said successful examples of hospital-SNF collaborations exist where the financial range of risk encompasses the full set of services patients need.

Most Important Need

“To achieve a high quality continuum of care, all of the providers in that process need to operate sustainably. It has to make sense financially,” Chernof said in an interview. “The single most important thing that would push this discussion forward is a targeted set of quality measures that would drive shared savings. Until we put our money where our mouths are and enumerate the outcomes we value, it will be harder to push these kinds of collaborations forward.”

Alex Stemer, MD, an infectious diseases specialist and the medical director of two Northwest Indiana SNFs, said hospitals prioritize nursing homes that can document low readmission rates.

“It can be a successful partnership,” Stemer said in an interview.

Stemer said if hospitals are really interested in lowering readmissions, they should bring in SNFists to work in teams with SNF nurse leaders.

‘That’s a model that is evolving,” he said. “And sharing medical records doesn’t necessarily require a financial partnership, but allowing information sharing to improve patient care.”

Teja Singh, MD, medical director for continuum care at Palomar Health, said the system hosts monthly roundtables with area SNFs to review industry policy changes, insurance updates, and evolving regulations and is narrowing its provider network to six SNFs. He said collaborating SNFs must achieve at least three stars with Nursing Home Compare, follow Palomar metrics, agree to length of stay and readmission requirements, and participate in regular discharge meetings.

Singh said local SNFs realize they must be more competitive.

“Most local facilities are reducing long term care beds and increasing skilled nursing beds,” he said. “Medicare pays better than California’s Medicaid program and they hope to pick up more skilled beds to increase their margins. SNFs understand that the market and industry are changing and value-based payments are the future.”


Mark Taylor is a freelance writer based in Chicago.

Publication Date: Wednesday, July 05, 2017