Short-Term Care Has Role in Skilled Nursing, But Future Remains Cloudy

The shifting tectonic plates in the skilled nursing landscape include a focus on value and a new payment system that puts the focus on medically complex patients and specialties. As providers try to adapt, some have chosen to go all in on a model of care that targets short-stay patients, flying in the face of skilled nursing’s image as a place for long-term care.

How well they’ll succeed remains to be seen.

Transitional Care Management, which is based in Lisle, Ill., and has two skilled nursing locations in the state, is optimistic. The post-acute services provider focuses on short-stay patients and shifting them to the next level of care as quickly as possible. The Arlington Heights, Ill., location’s average length of stay is two weeks, and Transitional Care has three new projects confirmed for Illinois. Unsurprisingly, its leadership sees transitional care as a key part of the landscape.

“I think that’s the bright future for skilled nursing,” Charles Ross, chief strategy officer for Transitional Care, told Skilled Nursing News. “I think it will kind of splinter; I think there will always be a need for traditional skilled nursing … but so many other levels of care have kind of eaten into that traditional space. Assisted living is now a great option for people who might one day in the past have been in skilled nursing … I do think the future is in models like ours.”

Length-of-stay pressures grow

Donna Sroczynski, the president of operations at Chicago-based Symphony Post Acute Network, also believes that long-term care will not go away. Symphony has a mix of long-term and short-term patients, with some facilities heavily focused on long-term care and others tailored to short-stay patients. Though it has a medical resort model aimed at keeping consumers happy, it’s been feeling the pinch of the changing forces from referral partners.

“There’s just constant pressure to lower the length of stay,” Sroczynski told SNN. “We’ve got some partners that require less than 16-day length of stay.”

Symphony’s ultimate task is reducing the cost of care by reducing rehospitalizations, she added. With the new Patient-Driven Payment Model (PDPM) from the Centers for Medicare & Medicaid Services (CMS) taking effect next fall, Symphony is well-positioned for that aspect of the future, according to Sroczynski.

“I don’t know that it will shift the patients that we’re seeking to take, because we’ve been taking higher-acuity, short-stay patients in our Medicare/Medicare Advantage population for a long time,” she said.

But the hospital referring partners, particularly those in accountable care organizations (ACOs), are adamant about the need to reduce reliance on post-acute care, she added.

“They tell us quite clearly that they are looking to cut the number of patients going to the post-acute setting by half,” Sroczynski said.

That echoes a study in Health Services Research, which found Medicare policy changes and market-based pressures are driving SNFs to discharge patients within specified time frames. Ross believes the short-term stay model embodied by Transitional Care is where there will be growth; Michelle Stuercke, the chief clinical officer at Transitional Care, argued this is especially true as consumers become savvier about what they’re seeking in the short term marketplace.

“You don’t see growth in the traditional nursing home need,” Ross told SNN. “We see growth in this model.”

Challenges in volume, finance, timing

But there are some logistical hurdles to building a business entirely around short-stay patients. Patient volume is essential to making such a model work, but that volume is declining, Sroczynski told SNN. Hospitals are pushing patients back to the home and community, she noted. In addition, inpatient stays are declining, as reported in the most recent Medicare Payment Advisory Commission Data Book.

That shift, combined with length-of-stay pressure, makes having a steady stream of patients all the more crucial. But the percentage of patients currently in SNFs that would fit the criteria for short-stay, medically complex care is probably fairly low, Zeke Turner, the founder and CEO of Carmel, Ind.-based Mainstreet, told SNN.* There’s also confusion about what’s covered in a short-stay visit, he added, mostly due to the current Resident Utilization Group — Version IV (RUG-IV) system.

“Unfortunately what happened inside of that was the idea of transitional care, or the short-stay environment, started to become synonymous with the idea of rehab and therapy services,” Turner said. “But those are not the same thing. Transitional care short-stay is really about complex clinical care, so high-acuity medical care with a high degree of nursing services that may include rehab and therapy services, but isn’t necessarily the same as [them].”

Faced with the volume pressure, Symphony is looking to branch out, even though it’s confident in its capacity to take on high-acuity, short-stay patients.

“We’re looking at services and offerings and programs in a different way, and we’ve developed additional programs for substance abuse and dual diagnosis in our facilities,” Sroczynski said. “So we can address the needs of our skilled patients that come to us with other issues like mental health or substance abuse.”

And despite Transitional Care’s optimism on the future of the short-term rehab and stay model, Ross and Stuercke both stressed that the strategy comes with ebbs and flows.

“I think the model works,” Ross said. “I think the market is catching up with the model. We have had periods of time where we’re ahead of the market with our model, and then we have periods where all cylinders are firing perfectly because the referral flow is exactly where we need it to be.”

Mainstreet, for its part, has run into the issues associated with timing. In March of this year, it had to call off its plans to open its Rapid Recovery Center offering, a concept aimed at providing complex clinical medical services, in Arizona. But Turner told SNN he believes in the model of focusing on short-term stay patients, even though he also agrees there will always be a need for long-term care.

“We might be too early to the market,” he acknowledged to SNN. “There’s a fine line between that cutting edge and bleeding edge, but we believe in it and have put a substantial amount of resources towards it, because we see that’s where things are going.”

Written by Maggie Flynn

*Editor’s note: After publication, Zeke Turner of Mainstreet reached out to clarify that the percentage of patients currently in SNFs who would qualify for medically complex, short-term care was low. He added: “I believe, and we are seeing, a large population of people needing care that are not going to SNFs currently, but who absolutely need complex medical care. (For reference, these are the patients either staying in the hospital too long or going home too early. They don’t/won’t go to LTC nursing homes.) This is what generates demand for the sector and properly positioned products.”

*An earlier version of this article incorrectly named Mainstreet as Mainstreet Investments. SNN regrets the error.