It is no secret that one of the bigger challenges facing hospitals in the world of value-based care is forging partnerships with skilled nursing facilities (SNFs) and creating a system for care transitions that improves quality and minimizes hospital readmissions within 90 days of discharge.
Hospitals require strong collaborations with SNFs and must be able to depend on them to perform effective work. Assessing that effectiveness necessarily means reviewing performance data, which should drive hospitals’ decisions on which SNFs to include in their referral networks. However, hospitals’ choices sometimes are driven by other considerations that seem to trump the validity of performance data.
The Performance Data Challenge
In today's world, many of the choices patients and their families make for nursing home care are driven by referrals from physicians and discharge planners, which often are made based on longstanding relationships rather than on performance data. Although this dynamic is likely to shift as increasing numbers of patients and their families research nursing homes online, and the demands of value-based care will force the change even further, the current dynamic presents a challenge to hospitals that wish to maintain good relationships with physicians and may worry about changes in their referral patterns. Hospitals today also may be concerned about upsetting discharge planners, whose judgment they have trusted in the past. Add to that the possibility of jeopardizing relationships with SNFs, which can influence which hospital patients choose when they have a health issue.
No matter how valid such concerns might be, hospitals should not be swayed in using performance data as the basis for deciding which SNFs to include in their networks. Too much money, in the form of readmissions penalties, is at stake.
The Transition Challenge
Today's world of SNFs is evenly split between privately owned and group-owned operations. There is a wide range of sophistication in the industry when it comes to managing care transitions. To get the results they want, hospitals will need to set standards for providers who want to be included in referral networks.
Here are a few ways hospitals can make the care transition work well.
Take an active role in care after discharge. Traditionally, a patient’s primary care provider is the one who oversees the transition from hospital to nursing home, but the fact is that these days many primary care physicians do not see their patients in the hospital. That role is fulfilled by a hospitalist.
One of the best ways to ensure care is transitioned properly after discharge is to have someone from the hospital involved. That role could be filled by a hospitalist who treated the patient during his or her stay and issued orders for the patient’s care after discharge. The hospitalist could ensure that the SNF receives all necessary information about the patient, including the patient’s medical history and list of medications, and fully understands the patient's care plan.
In all probability, a practical way to ensure this type of transition would be to have the hospitalist oversee the work of a nurse practitioner who would assess the patient upon admission to the SNF. The two providers’ services could be billed to Medicare.
Even if the hospital chose not to involve a hospitalist, the hospital could require SNFs in its network to have nurse practitioners assess all patients on admission and follow the patients’ care for, say, the first 10 days of their stays. In some cases, primary care providers work with nurse practitioners who visit SNFs. To ensure this service is provided for all patients, hospitals could require post-acute facilities to contract with nurse practitioners for this purpose.
But hospitals also may want to consider having a hospitalist go on-site to supervise the process. Although that approach would prove expensive, that cost would have to be weighed against the cost of a readmission penalty in the case of an adverse event for the patient.
Require strong medical review programs. In the current environment, SNFs are not all equally effective in ensuring their performance is assessed by physicians.
For example, when patients are suspected of having urinary tract infections (UTIs), SNFs all too often overprescribe antibiotics because of the significant impact UTIs can have on issues such as patient behavior. The best practice, however, is to be cautious in prescribing antibiotics because of the well-recognized risk of encouraging the spread of antibiotic-resistant bacteria. A strong medical oversight program would ensure that post-acute providers’ patterns in prescribing and other aspects of care delivery are consistently reviewed, with changes ordered if needed. In such a program, the oversight is managed by the SNFs, which contract with a third party medical group that provides physicians, nurse practitioners, and/or physician assistants to oversee the medical care provided to all patients and residents in the SNF. This medical group then coordinates with the hospitalists to ensure continuity of care. The SNFs communicate the performance metrics with the hospital to ensure compliance with hospital requirements.
The oversight should extend to reviewing each unplanned discharge to a hospital, analyzing the reason it occurred, and ordering changes in care procedures if necessary. Making this change would, in some cases, require an expansion of duties for the facility's medical director, or perhaps the addition of an assistant.
These recommendations, if implemented, would significantly change the way most hospitals and SNFs operate, and they represent just a few of the ways the transitions between hospitals and SNFs could be improved. No matter how a hospital chooses to proceed, however, changes are sure to come that will create a new world for hospitals and post-acute care providers.
Derek McLaren is the lead post-acute care consultant in the healthcare consulting practice at LBMC, Nashville, Tenn.