In the new world of value-based health care, success for hospitals increasingly depends on partnering with nursing homes and other post-acute-care providers that can play a big role in improving a patient’s overall quality of care after discharge and in minimizing hospital readmissions.
Minimizing readmissions is important, because Medicare penalizes hospitals for excessive return stays within 30 days of discharge on the grounds that they may indicate problems with the quality of care received during the first admission or a lack of care co-ordination after the patient leaves the hospital.
That means hospitals must have strong collaborations with nursing homes, also known as skilled nursing facilities, or SNFs, and must be able to depend on them to perform effective work. Assessing that effectiveness necessarily means reviewing performance data, but that’s where things can get complicated. While performance data should drive hospitals’ decisions on which SNFs to include in their referral networks, hospitals’ choices sometimes are driven by other considerations.
The challenges of relying strictly on data
Many of the choices patients and their families have been making for nursing home care traditionally have been driven by referrals from physicians and hospital discharge planners. Those referrals, in turn, often are made based on longstanding relationships rather than on performance data. That’s already changing, though, as increasing numbers of patients and their families research nursing homes online.
The demands of value-based care are forcing a further change, which presents a challenge to hospitals that wish to maintain good relationships with physicians, and may worry about changes in their overall referral patterns. Another potential concern for hospitals is upsetting discharge planners, whose judgment they have trusted in the past. And, finally, there’s the possibility of jeopardizing relationships with SNFs, which can influence which hospital patients choose when they have a health issue.
Still, hospitals ultimately will have to use performance data as the basis for deciding which SNFs to include in their networks. Readmissions penalties are just too costly to do otherwise.
The hospital’s role in patient transitions after discharge
There’s a wide range of sophistication in the long-term care industry when it comes to managing care transitions and setting standards for quality. To get the results they want, hospitals will need to set standards for providers who want to be included in referral networks.
Two key ways hospitals can meet their goals are to take an active role in care after discharge and to require that SNFs in their networks have a medical review program.
While traditionally a patient’s primary care provider was the one who oversaw the transition from hospital to nursing home, these days many primary care physicians don’t see their patients in the hospital. That role is fulfilled by a hospitalist.
One of the best ways to ensure that care is transitioned properly after discharge is to have someone from the hospital involved. The hospitalist who treated the patient during their stay and issued orders for the patient’s care after discharge could be the person to do that or could supervise the work of a nurse practitioner or physician assistant who would assess the patient on admission to the SNF. The two providers’ services could be billed to Medicare. Either way, they 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.
As an alternative to involving a hospitalist, the hospital could require SNFs in its network to have nurse practitioners or physician assistant assess all patients on admission and follow a patient’s care for, say, the first 10 days of their stay. To ensure this service is provided for all patients, hospitals could require post-acute facilities to contract with nurse practitioners.
Although it may be more expensive, hospitals might consider having a hospitalist go on-site to the SNF to supervise the process. That cost would have to be weighed against the cost of a readmission penalty in the case of an adverse event for the patient.
Medical review programs
In the current environment, SNFs are not equally effective in ensuring their performance is assessed by physicians.
Take for instance, a situation in which a patient is suspected of having a urinary tract infection (UTI), which are common in post-acute care facilities. All too often, SNFs overprescribe antibiotics because of the significant impact UTIs can have on issues such as patient behavior. However, best practices call for clinicians to be cautious in prescribing antibiotics because of the risk of developing antibiotic-resistant bacteria.
A strong medical oversight program would ensure that post-acute providers’ patterns in prescribing and other aspects of care are consistently reviewed, with changes ordered if needed.
Such a program would be managed by the SNFs, which typically contract with a third-party medical group to provide physicians, nurse practitioners and/or physician assistants to oversee the medical care provided to SNF patients. This medical group then coordinates with the hospitalists to ensure continuity of care. Performance metrics are communicated with the hospital by the SNF to ensure compliance with hospital requirements.
The medical review should also include an examination of each unplanned discharge to a hospital, analyzing the reason it occurred and ordering changes in care procedures, if necessary. SNFs may have to expand the duties of their medical director or add an assistant to set up such a program.
If implemented, these recommendations 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, changes are sure to come that will create a new world for hospitals and post-acute care providers.
Derek McLaren is a senior manager and lead post-acute care consultant in the health-care consulting practice at LBMC in Nashville. Contact him at email@example.com or 615-309-2636. LBMC offers a Guide to Post-Acute Care as a free download.
Originally printed in The Tennessean.