Competing Incentives: Lowering SNF Length of Stay Raises Readmission Risk by 4 Times

Length of stay and readmission rates have risen to the top of most skilled nursing providers’ top watch lists, as pressure to lower both has increasingly affected their shot at appropriate reimbursements and slots in key partnerships.

But a new study from New York University’s School of Medicine found that the readmission risk for certain patients rises substantially with early discharge, illustrating the tenuous balance between the two benchmarks.

Focusing only on skilled nursing residents with heart failure, the NYU team — led by NYU Langone Health professors Himali Weerahandi and Leona Horwitz — found that residents discharged after two days were four times more likely to be readmitted to a hospital as other patients who stayed longer. For stays of one to two weeks, the early readmission risk was cut in half, with further risk decline after day 14.

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That doesn’t mean that the transition was smooth even for those who spent a significant time in the SNF: Almost a quarter of the more than 67,000 SNF stays included in the survey timeframe resulted in a rehospitalization.

“While this heightened risk of readmission immediately after discharge from SNF may be related to patient-level factors, the persistence of increased risk across multiple cohorts of patients suggests that the disruption in care continuity when a patient is transferred from SNF to home may be playing an important role,” the study team wrote.

With the Medicare reimbursement landscape shifting to an increasingly value-based model, the federal government has taken significant steps to reduce the amount of time that residents stay in SNFs — while also penalizing providers that don’t do enough to prevent them from returning to the hospital. For instance, the rise of Medicare Advantage plans has frequently been cited as a reason for length of stay pressures, as these public-private insurers want residents to go to the lower-cost home setting as quickly as possible.

That said, operators also face an automatic 2% cut to their Medicare rates if they can’t lower reimbursements under the new SNF Value-Based Purchasing (VBP) program. The first round of VBP assessments dinged 73% of providers, with only 27% seeing static reimbursements or a bonus as a result of care improvement.

In analyzing the results, the NYU team concluded that providers need to put a greater focus on the SNF-to-home transition process for all residents — arguing that while operators have begun to implement evidenced-based discharge plans, the actual execution is scattershot.

“Patients discharged from SNF may benefit from discharge planning since during a SNF stay medications may be started or adjusted, diets may be monitored and lab tests may be obtained, which may need post-SNF discharge follow up,” the researchers concluded.

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