Balancing Risks, Rewards of Targeting Higher-Acuity Residents in Skilled Nursing

Over recent years, as length of stay and reimbursement have declined in the skilled nursing space, one trend has risen steadily: the acuity of the patient population.

It’s a trend that multiple executives in the skilled nursing field have observed, particularly as the industry prepares to pivot toward the new Patient-Driven Payment Model.

But it’s also a trend that hospitals have been watching closely, Angie Roberson, the president of the American Case Management Association (ACMA), told Skilled Nursing News.

“From the hospital perspective, we see very ill patients being discharged much sooner, and we do feel like we are sending patients with higher complexities to skilled nursing partners in the community,” Roberson, who also serves as the director of case management for the Spartanburg Regional Healthcare System in South Carolina, said.

There are some specific populations that pose challenges for hospitals, Roberson said, citing conversations with its members from around the country. Patients on long-term ventilation who also require hemodialysis are hard to place in the facilities, simply because of the equipment and care requirements. Other challenging populations include patients with behavioral needs and complex wounds, mainly because of the cost of the antibiotics involved.

“The cost of some of this care is so expensive that oftentimes the reimbursement for the SNF doesn’t cover the cost,” she told SNN. “You end up with a person who’s in a gap, if there’s nobody to provide their care and treatment for them in a home setting.”

Conversations and partnerships

Patient demographics vary considerably depending on geographic location, Tim Fields, the co-founder and CEO of Ignite Medical Resorts of Niles, Ill., told SNN. The company, which specializes in higher-end facilities for post-acute residents, currently operates in the greater Kansas City and Chicago markets, and when it comes to where patients go after a hospital stay, those regions differ greatly.

“A new tracheostomy patient would never go to a [long-term acute care hospital] or an acute rehab facility in Chicago,” he said. “But in Kansas City, they would go there almost all the time.”

Donna Sroczynski, the president of operations at Symphony Post Acute Network — which operates in Illinois, Wisconsin, Indiana and most recently, Michigan — also emphasized this point.

“We find hospitals are very different, markets are very different, and physician practice patterns differ from geographic area to geographic area,” she told SNN.

The landscape has shifted considerably over the past decade, Roberson said, and many SNFs are trying to increase their clinicians’ skill levels to deal with the changing population.

In fact, she’s seen SNFs partner with hospitals to bolster staff competencies, sending employees to the acute setting in order to work on simulations, mannequins, and other training devices. Hospital respiratory therapists will go to SNFs to offer in-services and education, Roberson said.

One of the results has been that new tracheostomy patients, who used to be particularly challenging to place in a SNF, have a much easier path to the post-acute setting, she told SNN.

“Just at my organization, we approached some of the facilities who were forward-thinking and asked: Would you be wiling to learn some new skills, and would you be willing to have equipment in place so you could meet the needs of the patients?” Roberson explained. “We saw that. Now some SNFs employ respiratory therapists and so discharging patients with trachs is not as complex as it once was.”

Sroczynski confirmed this trajectory for patients with new trachs. Symphony has also worked with major systems such as UChicago Medicine to build out pulmonary or cardiac programs to care for higher-acuity patients.

“The key component in that was the competency and qualifications of the nursing staff that worked on those units, and making sure they were adequately trained and prepared to take care of those patients,” she said.

Those training partnerships with hospitals were vital to getting the programs off the ground, she said, and the collaboration has gone both ways: On occasion, Symphony has approached hospitals with Medicare claims data to show where their programs could help with patient needs, while other times hospitals have approached Symphony to ask for help placing difficult patients.

The challenges

But operators considering making additions to their service lineups need to consider some of the challenges. One issue Roberson has seen relates to reimbursement, particularly around antibiotics.

“Oftentimes the reimbursement for the SNF doesn’t even cover the cost of the special bed and the high-dollar antibiotics that some of these folks need,” she said. “So you end up with a person who’s in a gap; if there’s nobody to provide their care and treatment for them in a home setting, they really need to be in a skilled environment. It’s a gap that exists.”

SNFs also need to make sure, when they’re approaching payers and referral sources, that they know the decision-makers at their partner hospitals and managed care organizations (MCOs), Fields said.

“I’d sit down with multiple levels, so you’ve got to find sometimes the right people to talk to,” he told SNN. “So maybe sometimes it’s the director of case management. Sometimes it’s the chief nursing officer. Sometimes it’s the CEO … and usually with the MCOs, it’s not the person in charge of contracts. There’s usually a chief medical officer of the plan, or a vice president that’s over the plan.”

Another issue, both for SNFs and the hospitals with patients ready for the SNF setting, is the fact that patients who are particularly complex — whether through difficult behaviors or acute medical conditions — tend to draw attention from regulators, she said. Though Roberson stressed that her experience comes from the hospital side of the continuum, she said she’s heard that surveyors tend to focus on medically complex, high-acuity patients within a given building.

Roberson also noted that families, when given a choice, won’t always choose four- or five-star facilities, but rather the ones where they know the staff and are familiar with the care — intangibles that aren’t always captured in the federal star rating system on the Centers for Medicare & Medicaid Services’ (CMS) consumer-facing Nursing Home Compare website. Though Roberson emphasized that the rankings have validity, experience with families makes her think those ratings don’t tell the whole story, especially when it comes to complex patients.

“I do think there is some truth to the [idea] that facilities that take your more complex patients, when they’re surveyed under the SNF regulations, I think they struggle with some of the regulations,” Roberson said. “I don’t think it always means they’re providing a low quality of care.”