Skilled nursing facilities are being pushed by both the health care system at large — and, more directly, their referring hospital partners — to improve outcomes and lower readmissions, while also saving money.
To accomplish those aims, it’s essential for SNFs and hospitals alike to have a handle on their data — but that process isn’t always simple for care providers on either side of the divide, as one hospital system in Detroit discovered when looking to improve its relationships with its skilled nursing partners.
Turning to Nursing Home Compare and claims data from SNFs may seem like the place to start, but those numbers are out of date by six months to a year, Sue Craft, vice president for inpatient case management and post-acute care services at Henry Ford Health System, told Skilled Nursing News.
That became a major issue when Henry Ford began examining its readmission data after getting hit with penalties from the federal government a little less than a decade ago. In response, executives started looking at its post-acute care facilities — with a particular focus on SNFs.
“One of the major barriers to a health system working with a SNF is performance metrics,” Craft said. “Currently, what we have available to us is Nursing Home Compare, but that data is old, and the lag becomes a barrier.”
Targeting real-time data for patients
When Henry Ford began digging into its internal data, it found that patients discharged to SNFs had “incredibly high readmissions,” Craft said. This was true almost every way the data was sorted, though heart failure, chronic obstructive pulmonary disease (COPD), and sepsis were some of the diagnoses that saw particularly high readmission rates.
Henry Ford also determined that it was struggling to achieve the metrics that count in the shift to value-based care, Craft said: Medicare spend per beneficiary, for example, was much higher at Henry Ford compared with other hospitals.
And since Henry Ford doesn’t have any SNFs in its eight-hospital health system, it had to develop partnerships with SNFs in the local market to improve care, Craft said.
“We really looked at referral patterns and quickly identified the ones most of our patients were selecting,” she explained. “And then we invited them to become part of a collaboration.”
Leaders focused on using metrics like readmissions to improve processes and hold SNFs to a certain accountability level, she added. Two years into its work on this project, which began around 2013, Henry Ford created a preferred SNF network. But that wasn’t an automatic fix for the data problem.
For one thing, facilities rated higher in Nursing Home Compare were prone to taking patient populations with relatively lower care needs, such as joint patients. Meanwhile, facilities that take on more medically complex and difficult patients — facilities with which Henry Ford works closely — have lower ratings and higher readmissions.
“We have a list of metrics [SNFs] have to adhere to, and one of the challenges for us is that a lot of that data was self-reported,” Craft said. “So it was a burden on the facilities as well.”
As a result, it turned to CarePort Health, a care coordination software company owned by Allscripts Healthcare Solutions (Nasdaq: MRDX), to get a better handle on the real-time data of the health system’s patients. The company provides several solutions aimed at connecting acute- and post-acute care settings, working with more than 1,000 hospitals and 100,000 post-acute providers.
CarePort’s original focus was on transitioning patients from the hospital setting to the post-acute setting, CarePort CEO Lissy Hu told SNN. And though its solutions now span the continuum from home health to dialysis, the focus remains on connecting acute patients to the right post-acute setting.
“I think there was a time when there was a mentality of: We send our patients out from the hospital to the SNF, and that was it,” she told SNN. “It was just a black hole.”
And it worked the other way for SNFs as well, she noted. SNFs are often asked to share outcomes for specific patient populations, such as those in an accountable care organization (ACO) — and frequently would find that data hard to track.
A two-way window
Four of Henry Ford’s hospitals are on CarePort’s platform, and it requires all of its preferred facilities — roughly 36 — to participate in the program. Other requirements for preferred SNF partners include a two-hour timeframe for a response when Henry Ford asks if they can medically accept a patient. The hospital system also looks at the percentage of referrals a given SNF accepts, as well as readmission data that it pulls internally, Craft explained
Henry Ford’s hospitals have fully implemented three of CarePort’s software solutions, which educate patients on facilities, track them along the continuum, and monitor outcomes across different post-acute settings. The last is particularly useful for SNFs, given how often they’re on the hook for readmission rates when a patient goes back to a hospital after they’ve left a SNF within the 30-day readmission window, Hu told SNN.
Craft agreed that readmissions for patients who go to a SNF, particularly if they are sent to another hospital outside of the Henry Ford system, is a concern. Another problem is that sometimes a patient who was in theory discharged to a SNF might be intercepted by family members who then decide to take the patient home.
Using the software allows the hospital system to keep track of admissions and discharge information more easily, though it’s early days for insights; CarePoint began the process during the fourth quarter of last year and became fully integrated on March 1.
But the hospital system is mining the data now. And as it works to improve its outcomes and its understanding of how patients move through the post-acute care continuum, Craft emphasized that transparency is key for both SNFs and the hospitals that work with them.
“I think from the hospital perspective, we’re really looking for high-quality facilities that are willing to partner with us,” she told SNN. “And it’s not that they come in with great and perfect data or quality metrics, but are willing to look at where their opportunities are, and being willing to work to try to fix them.”