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Skilled Nursing

OIG Series 5: Coordinating Skilled Nursing and Home Healthcare

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The Challenges of SNFs and HHAs

Joanne M. Chiedi, the Acting Inspector General of the Department of Health and Human Services, defined three primary challenges when implementing and managing SNFs and HHAs:

  • Their services are generally not included in ACO structures
  • Providers who do not align with value-based care objectives are less inclined to include them
  • The strict “3-day rule” clause for Medicare Part A beneficiaries

ACO arrangements often lack SNFs and HHAs because they are ineligible to be formal providers and can only join a network of preferred providers. There is generally not an incentive to include them in different ways, either. As we have discussed in previous series installments, providers mainly receive their reimbursement based on the amount a facility spends, so some individuals prioritize operating less expensively than others. The “3-day rule” proves challenging for patients who would benefit from SNFs. Three days is the minimum amount of days a Medicare patient must be fully admitted to the hospital before they qualify for transfer to a SNF, even if it would be more cost-effective and beneficial to do so sooner.

The five strategies these ACOs mastered working with SNFs and HHAs were:

  1. Designating SNFs and HHAs as preferred providers
  2. Putting ACO staff in SNFs to monitor patients
  3. Conducting prompt care hand-offs
  4. Including primary care physicians (PCPs) in the treatment of patients
  5. Using a SNF 3-day rule waiver

Designating SNFs and HHAs as Preferred Providers

There are still ways to include SNFs in an ACO’s initiatives without making them formal providers– they can be preferred providers. Essentially, a SNF that is a preferred provider means that a particular ACO adds them to their extended network of specialists. The ACOs in the study reviewed the selected SNFs’ claims data before making them preferred providers. Some utilize the Centers for Medicare & Medicaid Services (CMS) quality rating system to ensure they have at least three stars. Chiedi notes in the study that almost half of the chronicled ACOs impose strict guidelines on their providers, such as mandatory data sharing, attendance at ACO meetings, and the promise that they will accept any eligible patient that selects them.

Putting ACO Staff in SNFs to Monitor Patients

SNFs can work alongside ACOs without being formal or preferred providers, too. In select ACOs, they have members of staff placed inside SNFs to manage beneficiaries belonging to the ACO. They keep track of care plans, attend meetings regarding the treatment of their beneficiaries, advise on their discharge timeline, and propose possible care changes. One ACO experienced a 25% drop in SNF stays by placing additional geriatric and specialized nurses inside facilities.

There are complexities associated with home health agencies; they tend to be somewhat of a magnet for fraud. These ACOs do less hands-on work in home health, but one ACO has regular disciplinary care meetings with their staff and a representative of the HHA. Another has team members whose role is to keep home health appointments organized and confirm they have the equipment they need.

Conducting Seamless Care Hand-offs

Chiedi referred to this transfer process specifically as a “warm hand-off.” A warm hand-off is facilitating the in-person transfer of a patient to their home or other places of care, which can include SNFs and HHAs. The personal touch brings a great deal of peace to both the patients and their family members while undergoing the transition to post-acute facilities. One ACO in the study assigns care managers to patients to monitor their progress for 30 days in these new care settings to make sure their transport needs, medical equipment, and medications are in order.

Including Primary Care Physicians in the Treatment of Patients

The ACOs in the study incorporated the expertise of primary care physicians to assess needs versus potentially unnecessary forms of treatment in their transitioning patients. One ACO had their primary care physicians help decide if beneficiaries need SNFs, or if HHAs are more suited to their care needs. PCPs are also involved in home health orders to review their treatments, especially physical therapy. One ACO achieved a 21% reduction in SNF spending and credited the accomplishment in part to the involvement of PCPs.

Using a SNF 3-Day Rule Waiver

The 3-day rule waiver was a privilege that only six ACOs out of 20 had at their disposal. There are eligibility requirements to apply, but if accepted, beneficiaries can go to an approved SNF from their primary care physician, their home, or the hospital if they stayed less than three days. The 3-day rule waiver was also a significant deterrent from unnecessary emergency department (ED) utilization:

“One of these ACOs also attributed a reduction in emergency department spending to the use of the waiver. The ACO cited an example of a beneficiary who had a history of frequent and inappropriate emergency department visits who was able to get needed care at a SNF by being directly admitted from his primary care office.”

Skilled nursing facilities and home health agencies are often underutilized, but these ACOs proved that with additional coordination, the benefits are incredible. Join us next week as my colleague, Kelly Kolepp, reviews how these ACOs addressed behavioral health and social determinants of health (SDoH) to provide holistic healthcare.

Maha Salah-Ud-Din is the Director of Advisory Services at Lightbeam.

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