Scoring System Can Help Nursing Providers Do More With Less

As skilled nursing faculties grapple with low reimbursement rates and thin margins, a new scoring system for patients could help them allocate already scarce resources.

It could be a useful tool as SNFs prepare for the SNF Value-Based Purchasing (VBP) program, under which the Centers for Medicare & Medicaid Services (CMS) will withhold 2% of SNF Medicare payments starting Oct. 1. And in the wake of findings about the difficulty of avoiding rehospitalization from SNFs, the results of a recent study from the Journal of the American Geriatrics Society could provide some clarity to post-acute providers.

“This line of research has really come from my own uncertainty actually about what happens to the older adult that I discharge to skilled nursing facilities,” Robert Burke, a hospitalist at the Denver Veterans Affairs Medical Center and the lead author on the study, told Skilled Nursing News. “One of the problems that I’ve noticed is that there doesn’t seem to be any way of evaluating these patients. I got no feedback about the people that I discharge for how they did.”


To derive a risk prediction score, the researchers used the 2003-2011 Cost and Use and Access to Care modules of the Medicare Current Beneficiary Survey (MCBS). The surveys, where about 12,000 Medicare beneficiaries are systematically sampled three times a year for a maximum of four years, are matched to nursing home information, including the Minimum Data Set (MDS), and Medicare claims data. This prevents any errors stemming from patient memory, Burke noted.

The goal was to develop a model that could be used for predicting adverse outcomes in Medicare beneficiaries who were discharged to a SNF from the hospital — using information that would be available at the time of SNF admission.

They found that of 2,043 beneficiaries who previously lived in the community and were hospitalized and discharged to a SNF for post-acute care, 589 experienced at least one of the following: readmission, mortality, or long stay.


Readmissions were the most common, occurring for 396 of those beneficiaries, while mortality followed with 215 beneficiaries. Long stay occurred for 72 beneficiaries in the sample.

The researchers found that by using five factors available in the initial MDS assessment, the SNF prognosis score could accurately identify the risk of one of those three events occurring in older adults coming from the hospital to a SNF.

Those five factors were:

1. The Barthel Index, which captures the ability to perform activities of daily living (ADLs) and mobility in various settings

2. The Charlson-Deyo comorbidity score

3. Hospital length of stay

4. Heart failure diagnosis

5. Presence of an indwelling catheter

People’s physical functions, as measured by the Barthel Index, were by far the strongest predictor in whether an older adult going into a SNF would have an adverse outcome as defined by readmission, death or long stay, Burke said.

Though the data set is limited in its small size, the model is unique in terms of providing a prognosis tool, he noted. The model performs well in identifying people who are at less than 10% risk of an adverse event and people who have a more than 90% risk of adverse outcomes, and that can still be useful for SNFs.

“My vision would be that [SNFs] get the new patient from the hospital, they complete the MDS, and then they calculate the score for that patient,” Burke told SNN. “In the setting of limited resources, we should really focus resources and attention on people who are high-risk and not on the people who aren’t. I would envision a SNF using some kind of cut-off… and in really thinking about those high-risk people, what kind of things you can do that would bring more attention, that would keep them safe.”

These could include more frequent physician checks, checking vital signs more frequently for high-risk patients, and devoting more time to medication reconciliation, among other steps, Burke added. With VBP on the horizon, SNFs will have to use all the tools at their disposal to provide better care for less. The prognosis score may have its limitations, but it gives SNFs a window into where they should focus their time and energy.

“It’s about how we can better triage the resources that we have… to be more cost-effective in bringing about better outcomes for folks in skilled nursing facilities,” Burke said.

Written by Maggie Flynn

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