Hos­pi­tals se­lect pre­ferred SNFs to im­prove post-acute out­comes

Modern Healthcare - - NEWS - By Me­lanie Evans

Last year, Ban­ner Health of­fi­cials in­ves­ti­gated the op­er­a­tions, cul­ture and qual­ity of care at nearly 100 skilled-nurs­ing fa­cil­i­ties in the greater Phoenix metropoli­tan area. The due dili­gence was done to limit the fa­cil­i­ties rec­om­mended to pa­tients leav­ing its hos­pi­tals who needed short­term skilled-nurs­ing care, which out­side the hos­pi­tal can be in a nurs­ing home or in stand-alone fa­cil­i­ties. Of the more than 90 ap­pli­ca­tions Ban­ner re­ceived for in­clu­sion in the se­lect group, the sys­tem chose only 34 SNFs.

Those pre­ferred providers agreed to work closely with Ban­ner to re­turn pa­tients home quickly and pre­vent re­peat hos­pi­tal vis­its, in ex­change for a greater vol­ume of re­fer­rals. That could in­crease Ban­ner’s mar­gins and save Medi­care money. It also may shake up the Phoenix-area skilled-nurs­ing mar­ket.

Not sur­pris­ingly, fa­cil­i­ties ex­cluded from the Ban­ner net­work have not ac­cepted the de­ci­sion qui­etly. “Some were not so kind,” said Lisa Frank, Ban­ner’s se­nior direc­tor of post-acute ser­vices.

In ad­di­tion to Ban­ner, other sys­tems cre­at­ing se­lect net­works of SNFs in­clude Catholic Health Ini­tia­tives, the Cleve­land Clinic, Henry Ford Health Sys­tem, Part­ners Health­Care and Atrius Health. They are re­quir­ing fa­cil­i­ties to sub­mit ap­pli­ca­tions that in­clude qual­ity data, ques­tion­naires and in­ter­views, and they are typ­i­cally se­lect­ing less than a third of the SNF fa­cil­i­ties in their mar­kets. Some hos­pi­tals and health sys­tems al­ready are find­ing that us­ing pre­ferred SNFs leads to shorter lengths of stay in the nurs­ing fa­cil­i­ties and re­duced hos­pi­tal read­mis­sion rates.

Na­tion­ally, 1 out of 5 pa­tients in tra­di­tional Medi­care who leave the hos­pi­tal go straight to a skilled-nurs­ing fa­cil­ity, which is cov­ered un­der Medi­care Part A for a limited pe­riod of care. Now, hos­pi­tals want more in­flu­ence over where pa­tients go and what hap­pens while they are there. Un­der pre­ferred net­works, pa­tients cov­ered by tra­di­tional Medi­care gen­er­ally have their choice of SNFs. But hos­pi­tals hope to sway their choice by con­vinc­ing them the qual­ity of care is bet­ter in the pre­ferred net­work.

“Pa­tients end up mak­ing the right de­ci­sion a lot of the time,” said Dr. Tarek El­sawy, vice pres­i­dent of re­gional med­i­cal op­er­a­tions and af­fairs for the Cleve­land Clinic re­gional hos­pi­tals and fam­ily health cen­ters. El­sawy’s sys­tem used in­fec­tion rates, length of stay and hos­pi­tal read­mis­sion rates to se­lect eight pre­ferred nurs­ing homes with SNF units, though it is look­ing to ex­pand that net­work.

Pre­ferred SNF net­works rep­re­sent an ag­gres­sive new strat­egy by hos­pi­tals to gain more con­trol over qual­ity and costs in the largely in­de­pen­dent skilled-nurs­ing fa­cil­ity sec­tor. SNF op­er­a­tors range in size from mom and pop fa­cil­i­ties to large na­tional com­pa­nies such as Kin­dred Health­care, Ge­n­e­sis Health­Care and ResCare.

Hos­pi­tals are seek­ing to hold post-acute-care providers accountable be­cause they have more at risk

un­der value-based pay­ment mod­els.

“We def­i­nitely think there is a sub­stan­tial op­por­tu­nity to re­duce cost and im­prove qual­ity,” said Christina Sev­erin, CEO of Beth Is­rael Dea­coness Med­i­cal Cen­ter’s physi­cian or­ga­ni­za­tion, which cre­ated its own skilled-nurs­ing net­work.

Ban­ner has found that pa­tients sent to pre­ferred fa­cil­i­ties have stays that are five to seven days shorter than those sent to non­pre­ferred fa­cil­i­ties. And all but one fa­cil­ity in Ban­ner’s net­work hit their tar­gets for read­mis­sions.

Atrius Health, which se­lected 35 SNFs out of 100, found that av­er­age length of stay in pre­ferred fa­cil­i­ties is no more than 15.8 days, com­pared with 22.3 days out­side the net­work, said Dr. Richard Lopez, Atrius’ chief med­i­cal of­fi­cer. And hos­pi­tal read­mis­sions are 25% lower for pa­tients us­ing the pre­ferred net­work.

The po­ten­tial for sav­ings is sig­nif­i­cant. Nurs­ing home-based SNFs are Medi­care’s sin­gle big­gest ex­pense for post-acute care. The CMS spent $28 bil­lion on skilled-nurs­ing care in 2013, up from $13.6 mil­lion in 2001. SNF costs vary widely across the U.S. for rea­sons un­re­lated to lo­cal costs or med­i­cal needs, the In­sti­tute of Medicine re­ports.

For skilled-nurs­ing fa­cil­i­ties that are ex­cluded from pre­ferred net­works, the loss of pa­tients could be crit­i­cal. “For many providers, it could be life or death,” said James Michel, direc­tor of Medi­care re­search and re­im­burse­ment for the Amer­i­can Health Care As­so­ci­a­tion, which rep­re­sents nurs­ing homes.

Health sys­tems us­ing pre­ferred net­works have de­vel­oped cri­te­ria for se­lect­ing SNFs us­ing state health and safety re­ports and qual­ity mea­sures re­ported to Medi­care. This in­cludes how well nurs­ing fa­cil­i­ties pre­vent pres­sure ul­cers, man­age pain and pro­vide vac­cines. Hos­pi­tal of­fi­cials also scour Medi­care billing data to re­view fa­cil­i­ties’ av­er­age length of stay and what per­cent­age of pa­tients re­turn to the hos­pi­tal within 30 days.

Michel said some sys­tems are set­ting im­pos­si­bly high stan­dards, and he urged hos­pi­tals to con­sult with nurs­ing fa­cil­i­ties in de­vel­op­ing qual­i­fy­ing cri­te­ria. For ex­am­ple, some hos­pi­tals are re­quir­ing skilled-nurs­ing homes to have elec­tronic healthrecord sys­tems, but nurs­ing-care fa­cil­i­ties gen­er­ally are far be­hind hos­pi­tals and med­i­cal prac­tices in this area.

Of 140 skilled-nurs­ing homes that ap­plied to be in­cluded in Part­ners Health­Care’s Mas­sachusetts’ net­work, Part­ners se­lected 47. Two fa­cil­i­ties op­er­ated by He­brew Se­niorLife—He­brew Re­ha­bil­i­ta­tion Cen­ter in Bos­ton and its cam­pus in Ded­ham—made the cut. Part­ners now re­ports data back to the He­brew Re­ha­bil­i­ta­tion Cen­ter so the fa­cil­i­ties can track their per­for­mance on re­fer­rals, length of stay, read­mis­sions to the hos­pi­tal and other mea­sures.

He­brew Re­ha­bil­i­ta­tion now sees more Part­ners pa­tients, but they don’t stay as long, said Mary Moscato, pres­i­dent of He­brew Se­niorLife’s health­care ser­vices and He­brew Re­ha­bil­i­ta­tion Cen­ter. The shorter stays have cre­ated enough ca­pac­ity to meet a larger de­mand from Part­ners, she added.

An­other skilled-nurs­ing home, Win­gate at Bos­ton, did not make Part­ners’ cut. Deepa Eber­lin, the fa­cil­ity’s ad­min­is­tra­tor, said she plans to reap­ply. “Every­body wants more busi­ness from them,” she said.

Other fa­cil­i­ties re­jected by Part­ners Health­Care ap­pealed the de­ci­sion. “Our mes­sage is that we have set clear cri­te­ria and we’re happy to work col­lab­o­ra­tively” with nurs­ing homes to im­prove their qual­ity, said Dr. Sreekanth Ch­aguturu, Part- ners’ vice pres­i­dent for pop­u­la­tion-health man­age­ment.

Health sys­tems that have es­tab­lished pre­ferred net­works are work­ing closely with their SNFs. Some have de­ployed doc­tors and care man­agers to the SNFs to bet­ter man­age care. They also are col­lab­o­rat­ing with the pre­ferred fa­cil­i­ties on health in­for­ma­tion tech­nol­ogy.

In Lin­coln, Neb., Catholic Health Ini­tia­tives se­lected half a dozen skilled-nurs­ing homes for its pre­ferred net­work. CHI found that re­turn trips to the hos­pi­tal within a month of dis­charge de­clined to 11% last De­cem­ber, from 15% when the pre­ferred net­work was launched in April 2014.

Aimee Mid­dle­ton, ad­min­is­tra­tor of the South­lake Vil­lage Re­ha­bil­i­ta­tion and Care Cen­ter, which was se­lected by CHI, said the pre­ferred fa­cil­i­ties in Lin­coln have seen more pa­tient vol­ume as a re­sult of the net­work ar­range­ment. In ad­di­tion, work­ing more closely with CHI’s hos­pi­tals has made physi­cians and hos­pi­tal staff more aware of the ser­vices skilled-nurs­ing fa­cil­i­ties of­fer.

For ex­am­ple, South­lake can ad­min­is­ter in­tra­venous drugs. In ad­di­tion, the fa­cil­ity now em­ploys only reg­is­tered nurses to care for re­ha­bil­i­ta­tion pa­tients, al­low­ing the fa­cil­ity to care for more com­plex pa­tients, Mid­dle­ton said. That could help re­duce hos­pi­tal read­mis­sions.

Ta­mara Cull, CHI’s na­tional direc­tor for value-based pay­ment, agreed that the part­ner­ship has ben­e­fited both sides. “We learned as much from them as they learned from us,” she said.

“For many providers, it (the loss of pa­tients) could be life or death.”

James Michel, direc­tor of Medi­care re­search and re­im­burse­ment, Amer­i­can Health Care As­so­ci­a­tion

Shorter stays at two He­brew Se­niorLife’s cen­ters in Mas­sachusetts have cre­ated enough ca­pac­ity to serve more Part­ners pa­tients.

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