SNFs Break Down Barriers Between Care Partners to Cut Rehospitalizations

Under the new regulatory landscape, avoiding rehospitalizations is king — not just for the skilled nursing facility, but for the hospital and any home health providers that may provide care after discharge.

But too often, SNFs focus on care within the facility only, and don’t take steps to manage the entire process from hospital to home, according to experts who spoke Monday at the American Health Care Association’s (AHCA) annual convention and expo in Las Vegas.

“We are not planning for them to be successful in the SNF,” said Kimberly Green, COO of the Edmond, Oklahoma-based Diakonos Group, LLC.


Instead, at her firm — which provides skilled nursing, assisted living, senior mental health, and other services — the team strives to plan for the resident’s eventual discharge back into the community as soon as he or she steps through the door.

Or even before: The best SNFs should have staff at the hospital before the resident is event released, Green said, ready to listen to the person’s specific goals.

“You want to engage the patient every step of the way,” Green said. “They should be an active partner.”


Too often, SNFs fall into the trap of dictating care without getting a clear sense of what the resident wants, especially for short-term rehabilitation stays, Green said. But is the SNF, hospital and home health agency all are self-focused in this way, it becomes tricky for the patient, with multiple voices telling him or her what to do.

Steven Littlehale, chief clinical officer for data analytics firm PointRight, gave the example of a resident who went from hospital to SNF to home health. Under a variety of Affordable Care Act policies, all three players have a vested interest in making sure that the resident doesn’t come back to the hospital.

For instance, the hospital will receive a penalty if the patient comes back after 30 days, while the nursing home is on the hook for 30 days after admission under the SNF Value-Based Purchasing Program — and 30 days after discharge under the IMPACT Act.

But from a patient’s standpoint, constant check-ins from all three care settings could have the opposite of the desired effect.

“[The resident] is constantly telling us: Listen, I’m disconnecting my phone. You people are driving me crazy!” Littlehale said.

That’s why it’s important for all players to coordinate a care plan together, providing a seamless transition from one setting to the next with the shared goal of avoiding costly penalties.

Even within the buildings, staff can take steps to prepare for the next phase of care. For instance, Green suggested that SNF staff quiz residents on exactly which types of medications they need at each time of day, mitigating the risk of confusion once the resident returns home and may not have round-the-clock supervision.

Discharge risk

A clear strategy is particularly important given the risk of rehospitalization. According to a recent PointRight analysis of more than 500,000 SNF residents, 12% of discharged patients had high impairment related to activities of daily living, while 13% had moderate to high levels of pain and 20% had severe cognitive impairment.

These factors can lead to a significant chance of rehospitalization: Based on that same data, PointRight determined that 20% of those discharged residents had a high risk for future falls, 14% had elevated risk of developing pressure ulcers, and 11% had a general overall high risk of rehospitalization.

“How do we expect medication adherence when 20% of the population that we’re discharging has high cognitive impairment?” Littlehale said. “What are we putting in place?”

Using data to identify these potential pitfalls can play a significant role in improving transitions and avoiding penalties.

“Those risks can be mitigated,” Littlehale said. “We have to be aware and have a way to systematically identify those people who are at risk.”

Written by Alex Spanko

Companies featured in this article:

, , ,