Partnerships and Value

Reducing SNF Readmissions Through Hospital-SNF Collaboration

November 30, 2017 11:12 am

An innovative collaboration between a hospital and a skilled nursing facility (SNF) in Michigan has been designed to meet the challenge of preventing avoidable hospital readmissions.

The Affordable Care Act includes several provisions aimed at improving the quality of U.S. health care and reducing its cost, including one focused on preventing avoidable readmissions, which is an important goal that has challenged providers across the nation. Spectrum Pennock Hospital (SPH) and its SNF partner, Thornapple Manor, both in Hastings, Mich., have met this challenge and significantly reduced hospital readmissions with an innovative collaboration that owes its success to its focus on improving communication and care transitions.

Sidebar: Focus on Eliminating Avoidable Readmissions: Historical Perspective 

The SPH-Thornapple Partnership: Initial Steps

In October 2014, an executive at SPH who had been leading the hospital’s readmissions reduction efforts and the administrator from Thornapple Manor met to review data on readmissions to SPH from the SNF, and they concluded that the numbers posed a very real concern. Descriptive data from SPH for calendar year 2014 indicated that 28 percent of the hospital’s readmissions came from Thornapple Manor, with mean charges per admission of $19,328. The two leaders immediately initiated discussions on how to address this problem.

The leaders both acknowledged the need for using a common data source to analyze the causes for readmissions, so for this purpose, they decided to use PEPPER data for all-cause, all-condition readmissions. a PEPPER data differ from the Inpatient Quality Report data provided by the Centers for Medicare & Medicaid Services (CMS) in that the PEPPER data are reported quarterly rather annually and include all non-risk-adjusted readmissions. Additional analysis found the source of readmissions to be evenly divided between febrile illnesses and exacerbation of chronic conditions.

The two leaders’ discussions quickly led them to conclude that best course would be to assemble a planning group with representatives from both organizations, including social workers, nurses, medical providers, and administrators. The group was charged with using the Plan-Do-Check-Act (PDCA) methodology to analyze the two organizations’ data and processes.

Extensive planning by members of both organizations resulted in multiple PDCA cycles. The original Plan was for a midlevel provider to deliver care during the day on Monday through Friday, with the hospitalists providing coverage on nights and weekends. The Do part of the process was performed by carrying out this medical coverage plan. During the Check phase, the expected reduction of emergency department (ED) admissions during nonprimary coverage hours was not fully achieved, and the continuum of care was not as consistent as expected. Finally, the Act phase involved making a change in medical coverage, with the midlevel provider being responsible for care during the day as before, while also taking off-hours on call.

The positive effects of this change were an increased continuum of care with a reduction of ED admissions and an improvement in care outcomes as anticipated. The PDCA process also helped foster an environment of mutual trust, and it has been maintained throughout the process.

The findings of the analysis also led the planning group to conlcude that the majority of hospital admissions were unnecessary and a direct result of how Thornapple Manor’s medical authority—i.e., the decision-making of care professionals regarding care for the SNF’s residents—was provided.

A Review of the SNF’s Medical Authority

At the time of the study, an out-of-town contracted medical group was charged with medical authority at Thornapple Manor. Midlevel practitioners from the medical group provided coverage three times per week and physicians performed site visits twice monthly. All other medical concerns arising during off hours or at times when the group’s providers were not present were covered by telephone consultation, which often resulted in residents being sent to the hospital for testing and admission.

These findings prompted the planning group to propose changes to Thornapple Manor’s medical authority and transfer criteria. The group recommended cancelling the medical authority contract with the out-of-town provider and establishing a relationship with SPH’s hospitalist group.

The new medical authority agreement called for one midlevel practitioner from the hospitalist group to be on-site at the SNF daily—at a cost no greater than that of the previous contract. The hospitalist group also established work-up and transfer and treatment criteria, which ultimately resulted in fewer residents being transferred to SPH for medical work-up and admission.

Having a midlevel practitioner available seven days per week has resulted in many benefits, the most significant being improved quality of care and increased access to care for the SNF residents, and a financial benefit for both the organizations and the residents. The residents have benefitted indirectly from the greater SNF stability and decreased system costs that trickle down to them. System costs for an admission include, at minimum, two ambulance transfers, ED evaluation, inpatient admission of at least three nights, and incremental costs.

Although different practitioners are on site or on call on different days, each practitioner is on site frequently enough to have ample time to engage with patients and become knowledgeable about their conditions and needs. This increased knowledge allows the care professionals to better observe subtle physical changes in residents and prescribe early diagnostic and treatment interventions—a clear benefit to the residents.

The shift to using a local provider group to deliver all care to SNF residents closes the continuum-of-care loop. A disruptive trip to the hospital often can be avoided by performing the diagnostic testing (such as blood draws for lab studies and simple radiologic imaging) at Thornapple Manor. When a resident must be transported to the hospital for testing, the SNF’s medical provider routinely sends a report to the provider at SPH who is to receive the patient, explaining the medical concern, discussing the potential medical workup, and reinforcing the point that follow-up medical treatment for the resident is available at Thornapple Manor.

After the SPH provider performs the medical workup at the hospital, he or she discusses the findings with the Thornapple Manor provider. During the findings report, the two practitioners discuss a plan of care to address the findings and, whenever possible, this plan of care is merged with the plan of care at Thornapple Manor, thereby enhancing the continuum of care.

The communication link between two trusted medical colleagues is a key element of this process. When the hospital physician sends the resident/patient back to Thornapple Manor, he or she can be confident that the resident will be under the watchful care of a trusted medical provider and colleague who will diligently follow the same patient-centric plan of care and make appropriate adjustments.

Another component of this process is the effectiveness of a well-functioning team. Providers recognize and appreciate that they are working as a team to ensure each resident’s continuity of care rather than as individual providers carrying out individual tasks.

An interview with a medical provider at Thornapple Manor elicited multiple examples of the previously cited benefits, where subtle physical changes were detected in residents, leading to early interventions. In one instance, the medical practitioner noticed that a resident who was normally at breakfast was still in bed. Upon examining the resident, the practitioner found early signs of heart failure, performed early interventions, and the resident was up for breakfast the next day. Most noteworthy was the midlevel practitioner’s commitment and devotion to the residents, as evident in frequent references to them as “my patients.” Simply put, this arrangement fosters relationship-building between practitioners and residents.

Prior to implementation of this approach, patients discharged from the hospital would undergo a battery of lab studies only to be subject to the same lab studies on admission to Thornapple Manor. Under the new relationship, Thornapple Manor accepts discharge lab studies from the hospital, thereby eliminating this duplication and realizing the obvious benefits of reduced cost of care and much improved experience for residents.

Program Results

An analysis of readmission data following implementation of the collaboration found that readmissions declined by 90.6 percent, correlating with in a statistically significant drop (p-value 0.000) in actual hospitalization PEPPER data. Monetarily, from August 2014 to June 2016, these readmissions were valued at a median of $19,328 per admission, adding up to a savings of $927,744 over the study period.

Of note, the collaboration has helped stabilize census days and revenues for Thornapple Manor. For the hospital, it has been a breakeven venture that includes decreased revenues from fewer hospital admissions, fewer CMS readmission penalties, and increased revenues from the new income stream generated through the hospitalist contract with Thornapple Manor.

For the hospital, the arrangement has produced the intangible benefits of improved quality scores and patient satisfaction, negatively offset by increased work to reduce recidivism, which has somewhat reduced staff availability for other projects. Meanwhile, for Thornapple Manor, the arrangement has produced clear benefits to residents from avoided hospitalizations. And for society overall, it carries the benefits of helping to reduce federal expenditures on health care.

An Improved Life Experience for Residents

The benefits to Thornapple Manor’s residents in terms of an improved quality of life due to reduced life disruptions—which was made possible by on-site performance of medical work-ups and treatment—bear special emphasis. The life disruptions for residents include the concerns of delirium and loss of function. The community of elder-care providers has recognized these two phenomena and has developed a variety of inpatient hospitalization and ED programs over the past few decades to address the challenges they pose. Most of these programs address delirium by providing physical spaces that are quieter, brighter although more softly lit, less busy, and consistently staffed by allied and medical providers. b Although some loss of function is almost always associated with elder hospitalization, several inpatient programs have been developed to minimize the loss of function through increased physical activity. c From the hospital perspective, these programs include physical therapy and occupational therapy. On the SNF side, the programs include restorative therapy focusing on maintaining levels of function such as mobility and range of motion. The SNF also uses the EDEN care model—a holistic approach focusing on emotional, spiritual, and physical support.

Summary Discussion: Success Factors and Implementation Challenges

The collaboration between SPH and Thornapple Manor to prevent avoidable readmissions is a creative and economical solution to a difficult problem, and its clear benefits make it worthy of being emulated by other hospitals and SNFs. By replacing out-of-town medical providers with medical providers from the hospital’s hospitalist group, the approach appealingly aligns local resources and organically connects the two organizations while improving communication between them and closing the continuum-of-care loop.

Moreover, such an arrangement can bring even more profound benefits for a SNF’s residents in improved care, as described here, thereby addressing the very core of a provider’s healthcare mission to deliver the best possible care experience to each patient. Through increased day-to-day interactions, medical practitioners develop deeper relationships with patients, and having such a close familiarity obviates the need for a practitioner to perform additional diagnostic tests to “get to know” each patient, allowing for deeper patient-provider discussions over time regarding treatment options and goals.

The benefits of this improved interaction and communication between patient and provider—a direct outgrowth of the focus on having SNF residents receive their care from a local provider group—are reflected in four interrelated areas of improvement.

Improved safety. Safety is enhanced through reductions in the need for diagnostic tests and hospitalizations and improved handoffs between providers who are knowledgeable of the resident and provide a closed continuum-of-care and communication loop.

Improved quality. Improved safety correlates with improved quality, which is further enhanced by the prevention of life disruptions from avoidable trips to the hospital.

Improved satisfaction. The safety and quality factors combine with residents’ improved ability to sustain a consistent lifestyle and develop a close relationship with their medical providers to enhance residents’ experience.

Improved financial stability. This benefit includes greater income stability for both organizations, plus a new income stream for the hospital.

The effectiveness of SPH’s and Thornapple Manor’s approach is reflected in its very simplicity. In this respect, the success of the approach can be attributed to three essential factors:

  • A focus on delivery of care by providers located within the SNF’s community
  • An emphasis on communication among providers and organizations within a closed-loop continuum of care
  • The willingness of the SNF and hospital to work together and resolve differences with the goal of delivering patient-centric care within a closed continuum of care

For organizations that wish to pursue a similar approach, be they hospitals or SNFs, the advantages described here can be persuasive in fostering a prospective partner’s receptivity to the arrangement.

It should be noted, however, that the broader applicability of SPH’s and Thornapple Manor’s approach is limited by the fact that these organizations are located in a rural community. It could be challenging to implement a comparable model in an urban environment, where the greater number of hospitals and SNFs could increase the complexity of negotiations and of contracting with a provider group to provide a closed-loop continuum of care. For this reason, it remains for this approach to be tested in a larger community with more hospitals and SNFs.

The SPH-Thornapple arrangement also presents two other limitations that should be noted. First, it involves only a single provider group to furnish both hospital and SNF coverage. If more than one provider group were involved, communication problems could develop that could compromise the ability to close the continuum-of-care loop. With the presence of different factions, it could be more difficult to foster a collective willingness among providers to work together to the benefit of their residents/patients. Second, the SPH-Thornapple relationship involves only a hospital and a SNF, and the model therefore has not been tested in other types of relationships, such as those involving assisted living facilities and primary care groups.

In sum, SPH and Thornapple Manor’s arrangement provides a viable model that demonstrates how two organizations can work together for their mutual benefit to achieve financial stability. More important, it also shows how they can collaborate for the benefit of the residents who make up their shared patient population, by ensuring the residents receive more stable care, which can be delivered more effectively by locally situated providers than by out-of-town contracted providers.

Such a model ultimately has broad significance as an effective means for addressing the nation’s problem of avoidable readmissions to hospitals from post-acute care facilities. The benefits and lessons learned from this case example, therefore, should inform other organizations’ strategies as they seek to address this ongoing challenge.

Raymond J. Higbea, PhD, FACHE, is Assistant Professor of Health Administration, Grand Valley State University, Grand Rapids, Mich.

Steve Marzolf is chief nursing officer, Spectrum Pennock Hospital, Hastings, Mich.

Donald Haney is administrator, Thornapple Manor, Hastings, Mich.


a. PEPPER refers to the Program for Evaluating Payment Patterns Electronic Report. PEPPER constitutes an activity of the Centers for Medicare & Medicaid Services’ Division of Compliance Projects and Demonstrations. The program provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. For more information, go to

b. Young, J., Cheater, F., Collinson, M., et al., “Prevention of Delirium (POD) for Older People in Hospital: Study Protocol for a Randomized Controlled Feasibility Trial,” Trials, Aug. 8, 2015.

c. Ågotnes, G., Jacobsen, F.F., Harrington, C., & Petersen, K.A., “A Critical Review of Research on Hospitalization From Nursing Homes; What Is Missing?” Ageing International, March 2016.


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