Poor Transfers Confuse Residents, Could Cost Skilled Nursing Facilities Money

Attend any industry conference, and you’ll likely hear multiple panels discuss the importance of care coordination: In an era of managed Medicare, accountable care organizations (ACOs), and value-based purchasing, players along the acute and post-acute care continuum have a financial incentive to seamlessly transition residents from hospital to nursing facility to home.

But on the ground level, the transfer isn’t always smooth, and new research claims that even the resources that exist for residents and their families don’t give them the information they need most.

“When patients and families choose PAC settings and providers that do not match their needs and are not of high quality, risks rise for re-hospitalizations, emergency visits, declines in physical or psychological function, lengthy stays in a SNF, increased likelihood of becoming a nursing home resident, and mortality,” the report, issued last week by the United Hospital Fund, argues. “Such poor outcomes exact a toll on patients and families and drain our collective health care resources.”

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Those stats aren’t just a concern for residents: Under the SNF Value-Based Purchasing (VBP) model and other new payment schemes, providers can take direct hits on their Medicare reimbursements by failing to hit certain quality benchmarks, including re-hospitalizations.

While official government sources such as the Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Compare tool have been developed and improved to help residents and families make decisions about transfers, they only contain limited information — and not necessarily the data points that people want to know the most.

“I am committed to quality measurements, absolutely, in terms of a driver of improving patient safety and the delivery of health care services, on the one hand,” Lynn Rogut, director of quality measurement and care transformation at the New York City-based United Hospital Fund, told SNN. “And on the other hand, I totally believe that that information is not all that useful to consumers when they’re making health care decisions. These are decisions about the care they want to receive, or decisions about the providers they want to receive it from.”

Rogut and her colleague Pooja Kothari, program manager at the non-profit, identified a host of different metrics that families want but can’t necessarily find. “Structural” characteristics include basic information like ownership, hospital affiliation, visiting hours, and the availability of private rooms, while more qualitative concerns include doctors’ and nurses’ bedside manners, the existence of pending lawsuits, and accurate reviews from current residents and their families.

That wealth of desired information pales in comparison to what people actually receive during the transfer process at most hospitals. Most residents, Rogut and Kothari argue, are given at most two days to peruse a list of local skilled nursing facilities. During that time, they may be limited by managed insurance restrictions that they don’t fully understand, as well as hospital employees’ concerns over running afoul of anti-kickback and other steering laws.

“An additional but more nuanced federal regulation permits but does not require hospitals to refer patients to the CMS Compare websites or official state websites for more information about PAC providers and help patients find or interpret quality-related information,” the authors wrote. “This distinction between permitting and requiring the provision of information about PAC providers can get lost on the ground, when hospitals concerned about compliance may err on the side of legal caution.”

While the IMPACT Act of 2014 allows for greater information sharing between hospitals and residents, Rogut and Kothari note that CMS hasn’t yet taken action on issuing a final rule on the subject, with a deadline of November 2019.

“In the meantime, patients and family caregivers are left to muddle through,” they wrote.

The United Hospital Fund, a non-profit that advocates for health care causes in New York, isn’t alone in its focus on care transitions. A study of patients in a special program at Cedars-Sinai Medical Center in Los Angeles found that a dedicated handoff program reduced rehospitalization risk by about 29%, while other firms have sought to hire staffers devoted solely to the transition process.

Rogut pointed to a proprietary tool called CarePort, a kind of care transitions software that aggregates information from government databases, facilities’ own websites, and other sources, allowing residents and their families to see a bigger-picture view of their choices. But she emphasized that there may not be a silver bullet to solve the problem, even as the rise of care coordination incentivizes providers to find solutions.

“We’ve still got some pretty enormous silos between the hospital setting and post-acute care settings,” she said. “And so those silos are still getting in the way of efficient and effective handoffs and transitions.”

Written by Alex Spanko

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