As skilled nursing facilities face pressures to improve care in an increasingly value-focused world, one provider has been able to lower its rehospitalization rate into the single digits by adding in-house emergency care.

Call9, which is based in Brooklyn, N.Y., and embeds paramedics on-site at skilled nursing facilities, partnered with the Archdiocese of New York’s long-term care arm, ArchCare, to bring the emergency services to two of ArchCare’s nursing homes. The collaboration began in December of last year, and has begun to lower rehospitalizations, according to Call9 and ArchCare.

That’s a particularly beneficial development with the new Patient Driven Payment Model set to take effect October 1, 2019, ArchCare President and CEO Scott LaRue told Skilled Nursing News.

“Homes are going to be rewarded who are taking care of the more clinically complex patients,” he said. “Not patients who are driven by therapy minutes and rehab. And what we’ve been doing strategically, even prior to this new model, is improving our ability to take care of more clinically complex patients. One of the tools in the toolbox that will allow us to do that is this relationship with Call9.”

Cutting hospitalizations and costs

One of the facilities in which ArchCare embedded Call9 was its Terence Cardinal Cooke nursing facility in Manhattan, which has more than 600 beds and “a very clinically complex population,” LaRue said. At that facility, the 30-day readmission rate was lowered to the single digits, while 71 of 82 patient emergencies in May were treated in place with Call9, according to ArchCare and Call9.

Overall hospitalizations at the Terence Cardinal Cooke facility fell to below 2%, according to LaRue.

Call9 embeds an emergency medical technician onsite 24/7. In addition, there’s always an emergency physician available to see a patient remotely, along with observational physicians who are also remote.

ArchCare also has a nurse practitioner who serves as a clinical facility liaison associated with the nursing home, Call9 co-founder and CEO Dr. Timothy Peck told SNN.

LaRue and Peck declined to provide specific numbers for how much implementing the program cost ArchCare.

“Call9 charges insurance companies for seeing their patients just like any other provider that would be in a nursing home,” Peck said. “And then there is an arrangement to cover some of the services with the nursing home itself.”

The benefits of the program, however, “far outweigh the investment for the ongoing cost to have the services in the building,” LaRue said.

For ArchCare, there’s another key wrinkle: It has had an Institutional Special Needs Plan (I-SNP) since 2009, which covers “a couple thousand” patients in ArchCare’s nursing homes. The I-SNP, a type of Medicare Advantage program covering beneficiaries in need of in-home nursing care or confined to an institution, has proven advantageous to a certain profile of provider. In addition, since ArchCare functionally serves as the insurer for residents enrolled in its I-SNP plan, the provider has an additional incentive for ArchCare to cut costs — and emergency room (ER) trips and hospitalizations are a major cost.

“For ArchCare, because we’re the payer, we know that an average hospitalization is going to be about $13,000, so everyone that stayed, you figure you’re saving $13,000 — and that’s just a hospitalization,” LaRue said. “This isn’t even counting the avoided ER visits … So just avoiding the ER visit, you’re statistically dropping the number of opportunities for hospital admission.”

Preparing for the future

The contract between Call9 and ArchCare will be in place for “a couple years,” Peck said, but the goal is to maintain and expand the relationship over time: ArchCare is trying to move as quickly as possible to extend the relationship to its five other nursing homes, LaRue said.

Setting up Call9 requires a building-wide assessment to pin down its information technology backbone, and what it would take to implement the program in the building. The facility must have a robust electronic health records system and have strong Wi-Fi access throughout the building, but sometimes even these attributes will need to be enhanced.

“The IT needs are huge,” Peck said. “You need a partner who’s dedicated to making their building wired, as ArchCare already was doing.”

But the ability to avoid hospitalizations will have a direct effect on the bottom line. SNF operators will automatically lose 2% of their Medicare reimbursement under the new skilled nursing facility value-based purchasing program (SNF-VBP) rules taking effect in October of this year. In order to earn that back, providers must hit certain performance benchmarks, with readmissions serving as a key metric.

In that light, treating emergencies in place can mean savings even for facilities that aren’t doubling as payers.

“I think this kind of relationship is going to be only more valuable, not less,” LaRue said. “As your reimbursement and quality ratings are more and more weighted with an indicator around hospitalization, rehospitalization rates, those operators that are going to be successful are the ones that creatively find ways to manage the patient in the lowest-cost setting, with the best quality outcomes.”

Written by Maggie Flynn