Research, Ability and Track Record: How SNFs Have to Help Referrers Under PDPM

With the Medicare reimbursement overhaul taking place in a few short months, skilled nursing facilities — ideally — are moving into the last stages of preparation and training for staff and workflow procedures.

But according to post-acute care partnership strategist Mike Wetula of therapy company TMC, SNFs can’t ignore their referral partners in the process.

After all, there is precedent for value-based payment models — such as the Patient-Driven Payment Model (PDPM) — in the form of accountable care organizations (ACOs) and Bundled Payments for Care Improvement (BPCI), Wetula said July 24 during a TMC webinar. And the predictions of how those models would pay out for SNFs didn’t end up matching the reality.


“Essentially we were promised that our census would increase because our SNF model was a much less expensive model than hospitals, inpatient rehab facilities (IRFs), and our long-term acute care hospitals (LTACs),” he said during “Census: Best Practices for PDPM,” part of TMC’s PDPM webinar series. “That’s what we were promised, but what have we experienced? Well, in 2018, our industry experienced continuous occupancy declines.”

Part of that occupancy decline was because of reductions of length of stay (LOS) in SNFs and because of what SNFs perceived to be an increase in home health referrals, though the latter belief might not be borne out by referral patterns, Wetula said.

Either way, improving outcomes while lowering costs will lead to value, and outcomes are being tracked, he emphasized.


To build lasting referral partnerships under PDPM, there are three key steps for SNF providers to execute:

  1. Develop a comprehensive understanding of the hospitals, ACOs and BPCIs that refer patients to a SNF.
  2. Demonstrate capacity and ability through patient-specific, individualized, high-quality care.
  3. Provide a consistent track record of that care.

For the first step, SNFs must understand what is important to the referral sources, Wetula said. This can include determining whether referrers are part of an alternative payment model such as an ACO or bundled payment program. SNFs also must identify the decision-makers, and be aware of the diagnosis categories that the referrer typically sends to the SNF.

“We’ve seen a big change in the pattern of referrals to SNFs,” Wetula noted. “So [think about] not only what type of diagnosis category are they going to be considering for a SNF, but also what does that diagnosis category look like in terms of the volume of the referrals that they have the potential to send you?”

SNFs should also check on whether their referrers have specific clinical protocols or downstream referral protocols, such as preferred home health providers. Specific outcomes, such as average LOS in the SNF and readmissions percentages, are also important to know.

SNFs should also be aware of the pain points of their referring hospitals, defined in the webinar as the diagnosis related groups (DRG) that have high readmission percentages.

Yet Wetula warns against providers getting lost in the information-gathering stage.

“I caution all of you not to stay here for too long,” Wetula said. “You can’t sit in Step 1 … forever because your competition is going to move past you.”

That means providers must execute the second stage, “where the rubber hits the road,” by demonstrating the capacity and ability to take good care of patients, Wetula said. To do that, SNFs have to adhere to their upstream referral sources’ protocols, attend all collaboration and care update meetings, and monitor patient outcomes and satisfaction.

Once this step happens, SNFs have to repeat it, to establish a track record and share it with the referral partner. This is the promotional phase; some of the common tools for that include outcome reports, quarterly facility report cards that might incorporate outcomes, patient success stories and patient satisfaction surveys.

One thing is certain: Come PDPM’s October 1 start date, SNFs need to be ready for what their referral partners send them.

“PDPM will drive more clinically complex patients to SNFs — there’s no doubt about that,” Wetula said. “Value-based models are here to stay. I think we should all embrace PDPM as a major opportunity, not only to become better providers, but also to enhance our referrals.”

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