Hospitals Also Face Length of Stay Pressures — and Skilled Nursing Can Help Ease The Burden

The relationship between skilled nursing facilities and their referring hospital partnerships can be a rocky one for both sides. But in an ideal world, it should be a partnership, with each willing to work together to achieve top patient and resident outcomes.

For Sue Craft, the vice president of inpatient case management and post-acute services at the Detroit-based Henry Ford Health System, that’s the goal of creating preferred networks of post-acute providers. She oversees the six-hospital system’s post-acute services, including the preferred SNF network and a home health network that Henry Ford is building. Her responsibilities also include post-acute care surveillance programs for patients under accountable care organizations (ACO) and payers that have risk-based contracts with the system.

Craft joined SNN’s “Rethink” podcast to talk about how the health system’s relationship to post-acute care has evolved — and why even hospitals are worried about the Patient-Driven Payment Model (PDPM), the upcoming Medicare overhaul for SNFs. Excerpts from the interview, condensed and edited, are below.


And if you like what you read, be sure to check out the full podcast episode on the platform of your choice: iTunes/Apple, Google Play or SoundCloud.

What are some of the pressures hospitals face financially, and how does that shape the way you approach your post-acute partners?

A lot of the identification of the need for change was related to readmission penalties, when those were first implemented for hospitals. As we looked at our own data, we realized that readmission rates for patients that were being discharged to skilled nursing were incredibly high. It was very clearly an area where we could develop partnerships and interventions to improve those. That’s probably the number-one reason we found all of this so incredibly important.

We’ve also seen that as patients are readmitted, some of the reasons are the result of something that maybe we missed in the hospital, or didn’t quite communicate what needed to be done at that next level of care. Sometimes it was related to something that occurred in the SNF.


But we really identified that the only way to solve those issues was to partner together.

I think the third piece of that has really been around cost of care; hospitals are really held accountable for Medicare spend per beneficiary, and that also includes those post-acute care costs. So even though a patient has been discharged from the hospital, if those costs in that post-acute setting are high, that impacts the hospitals as well, and it impacts our star rating. Looking at value-based care, all those things impact us.

Can you talk about some of the data challenges for hospitals?

Data is always a challenge. We tend to be data-rich but information-poor, so we have all these pieces of data out there, but until someone can take all of that and make sense out of it — and help us understand where our opportunities are — it is a lot of data.

The biggest challenge for the hospitals related to post-acute care is no access to that information. Although we have [the Centers for Medicare & Medicaid Services’] Nursing Home Compare, Hospital Compare, there’s all those government sites where you can get information — the data lag there is pretty significant. That really becomes problematic as you’re looking at some of those patient outcomes that are two years old, and so the ability to get real-time information is one of our biggest barriers.

What we’ve done, and what we’ve started doing, was kind of pulling our own information. We created our own scorecard for our SNF partners based on information that we had access to, so we knew which patients went to which SNF, and we knew which patients came back.

We’ve also looked at payer information; many of the payers will share specific information about our post-acute care costs and those specific SNFs for that payer group. We can look at readmission rates, length of stay, cost of care, but again, it’s one piece of that payer mix. We have lots of areas where we have pieces of information, but it’s very tough to get a very clear, overarching picture of all the patients — where they go and what the patient outcomes are.

When SNFs come in with their outcomes data, what do you want to see?

We like to see readmission rates, obviously; length of stay. Ideally, we would like to see patient satisfaction information, and one of the challenges from an industry perspective is that there’s been no standardization and no requirement, really, to standardize within post-acute care.

We have Henry Ford Medical Group geriatricians embedded in many of our SNFs, and we expect that as Henry Ford patients are being discharged to those facilities, that they’re being assigned to our physicians that are there in most facilities. So that’s one of the things that we ask our SNFs to report.

Some of our SNFs take obviously more complex patients, so we do look oftentimes at readmission rates by [diagnosis-related group].

When a patient is getting ready for discharge, what are the top priorities?

I’m not sure that we are sophisticated enough yet to be able to drive patients to specific facilities that are expert in certain things. I think we need to get there and figure that out — and that’s where that information is so helpful to us, based on a particular type of patient.

The concern, from the hospital perspective, that’s coming to light right now is the changes that are going to be occurring in skilled nursing, and actually the whole post-acute care world, related to the new payment model that’s going to be starting October 1. We have a lot of concern, I guess, about facilities that have historically taken very specific types of patients, and their ability to manage those more complex patients that are going to be reimbursed at a higher rate.

Until we see how things fall out from that, we do our best to educate patients and families on our preferred network and so that’s something we ask case managers to really think about. They struggle a little bit with patient freedom of choice, and exactly what they should and shouldn’t say — which has really taken a lot of education for them to feel comfortable in having conversations with patients about where the best place for them might be.

How can SNFs improve their relationship with acute-care providers to make those transitions easier?

We recognize that insurance authorizations have to occur for a facility to be able to accept a patient, but we also ask that [SNFs] very quickly determine if — based on the level of the medical needs of that patient — their facility [is] able to accept them, pending that insurance authorization?

We’re under incredible pressure related to length of stay, and we’ve had situations where sometimes it’s days before we have a clear answer to where a patient is going to go next at that transition point. It is very difficult from the hospital perspective. Many of our SNF partners don’t have staff in on weekends to be able to review and accept a patient, and so that becomes problematic, because we often will have patients sitting in an observation unit waiting for placement — and they’re waiting upwards of 96 hours if they happen to come in on a Friday afternoon.

So the more a SNF can streamline and help us get patients out of the hospital quicker, those are really good partners for us, and that’s one of the things that we really look at.

And I will tell you from a case-management perspective, our case managers know which facilities are easier to work with, are very responsive, respond quickly, and will go the extra mile to accept a patient that maybe is more complex or maybe has some difficult needs.

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