Acute Care Transitions to Skilled Nursing Facilities
Skilled Nursing is defined by CMS as nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel.2 To qualify for these specialized services, beneficiaries must meet criteria set by CMS.
“Roughly 40% of Medicare beneficiaries are discharged to a post-acute setting, with roughly half of these to a SNF, which is a nursing home (or distinct part of a nursing home) devoted to providing skilled nursing care or rehabilitation services”.3
The goal of the providers, in the Hospital and SNF settings, is to improve the patient’s health status for a lower (less costly) level of care, and to decrease the patient’s length of stay. With these goals in mind, healthcare leaders emphasize educating staff on appropriate care-transitioning workflows and elements.
Given that discharges from acute inpatient to SNF make up 20% of all Medicare discharges, rehospitalizations from SNFs are costing CMS billions of dollars a year. Policymakers want acute and post-acute care entities to be accountable for readmission rates by provisioning reimbursements based on their ability to manage this metric. This can be a challenge for SNFs when the primary patient population consists of older adults with major comorbidities. This is why health systems and value-based care organizations are aligning with SNFs to create networks of high-performing SNFs that can encourage care coordination strategies between the hospital and SNF care settings. There is evidence that discharge to a SNF with a strong linkage to the hospital is associated with lower readmission rates.4, 5
Take California as an example of healthcare spending (Figure 2). Figure 2 below shows readmission rates (admission to hospital 30 days post-discharge) across post-acute care settings for the entire year of 2020 in California. The diagnosis related groups (DRGs) examined in the figure are three diagnoses following which readmissions are potentially avoidable per CMS:
- Coronary Bypass with major comorbidity – DRG 235
- Major Hip and Knee replacement major comorbidity- DRG 469
- Simple Pneumonia with major comorbidity – DRG 193
In one of the most populated states in terms of Medicare beneficiaries, the SNFs accumulated one of the highest number of episodes, highest number of readmission rates, and the highest amount of total allowed spend in the year.
Care Coordination Data for Beneficiaries in California with Major Comorbidities
Fill out the form above to access our live data dashboard outlining these metrics across Texas, California, and Florida for three different diagnoses.
Patient Driven Payment Model
CMS has made changes to the way they reimburse SNFs by instituting Pay-Per-Performance Initiatives like the Patient Driven Payment Model (PDPM). The goal of this model is to deliver appropriate SNF services based on patient need rather than the volume of care provided. Due to this approach, emphasis has been placed on the assessment of patients when they are transitioned to a SNF. Assessments occur every quarter from admission and are submitted through a minimum data set (MDS) to CMS and will determine how much SNFs are reimbursed. This model challenges SNFs to provide the appropriate amount of care which will prevent over- or under-delivering therapy services.
In order to keep up with the regulations of this payment system, CareJourney has been collecting data and strategizing ways to display quality metrics around PDPM so that members are prepared to make business decisions based on quality measures that drive patient-centered care for SNFs and the management of care for high risk complex adults.
Improving Post-Acute Care Coordination to Reduce Readmissions
Reducing preventable readmissions is critical because they are associated with adverse events, higher healthcare costs and most importantly, deleterious effects on quality of life.6, 7 Care coordination strategies to reduce preventable admissions can include: