How Three Skilled Nursing Facilities Cut Hospital Admissions by a Third

A new model for reducing unnecessary transfers from skilled nursing facilities to hospital emergency departments (ED) drastically cut hospitalizations and ED use — albeit with a very small sample size.

Three SNFs made use of the Reducing Avoidable Facility Transfers (RAFT) model from January 1, 2016 and June 30, 2017, as detailed in a study published in JAMDA: The Journal of Post-Acute and Long-Term Care Medicine.

The model included several components: a team of providers managing longitudinal care and after-hours calls; a clear, systematic discussion of advance care plans, including acute-care preferences; increased engagement of providers during an acute-care episode; and biweekly meetings for case review.

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The result was that average monthly ED transfers fell by 35.8% across all three SNFs, while average monthly hospitalizations fell by 30.5%.

These reductions came among the long-term care residents of SNFs, without a related effect on quality measures, the researchers noted.

“Like other models, RAFT provides evidence that much of the acute care provided to SNF residents can be provided more safely, more effectively, and more inexpensively than is currently the norm,” they wrote in the study.

The study limitations, beyond small sample size, included the fact that hospitalization rates among SNF patients have declined modestly on the national level, which could account for some of the drop; the fact that the study used hospital-based charges as a cost indicator and was not designed with cost as a primary outcome; and a non-randomized design.

But the model of care is worth future study, as the findings indicate, the researchers argued.

In particular, adding “do not hospitalize — treat in place” as a formal option was essential to the results in the study, the researchers said. This was because even though many patients and their families were interested in limiting aggressive interventions, many wanted “some interventions taken to prolong life, particularly if those interventions offered limited risk of distress,” they wrote.

They also noted the importance of actively engaging the on-call provider early, as well as the regular review of all ED transfers.

“Unsure of the patient’s condition, the nurse’s reliability, or the family’s litigiousness, transfer represented the safest path that few would question,” the researchers wrote. “With RAFT, though providers were free to make any decision they thought best, that decision was made with the knowledge that they would soon be called upon to explain their actions to their peers.”