Why SNF-at-Home Programs Could Provide a Path Forward for Traditional Nursing Home Operators

Even before the pandemic, executives at onehome saw opportunity in developing a robust rehab program that could provide a skilled nursing facility level of care at home.

The Miramar, Fla.-based home health provider and convener partners primarily with managed Medicare insurers, with limited traditional fee-for-service Medicare or Medicaid business lines; instead, onehome opts for risk-sharing agreements with Medicare Advantage plans.

That strategy lent itself perfectly to the idea of SNF-at-home services, onehome president Dr. Joseph Mayer told SNN: Instead of seeing itself as simply a home health provider that looks to collect fees for providing services, the company has instead tried to position itself as more of a whole-health management service.


While patients and their families have increasingly demanded at-home options instead of institutional post-acute care, significant hurdles have always impeded progress — there may not be a regular caregiver available at home, Mayer noted, or traditional home health providers in the area might not offer the same therapy intensity as a traditional SNF.

“What we realized is that if we were able to solve for some of those problems, we could take those patients directly home,” Mayer said. “And then COVID obviously lit a fire under that, and made it just even more urgent.”

SNF at home isn’t as simple as rolling out an existing home health product into the post-acute space, however. The onehome program provides up to two hours per day of physical therapy and three hours per day of skilled nursing care in some cases, vice president of home health operations Jennifer Southwell said, along with home health aides that perform more familiar tasks such as bathing, dressing, and meal preparation.


“We really try to mirror, as much as possible, in the home what they would receive on that SNF level,” Southwell said.

The home setting even could have post-acute advantages over traditional SNFs. Southwell noted that many rehab facilities offer full-scale simulations of bedrooms, kitchens, and cars to help patients prepare for a return to their daily lives. But at home, therapists can work with patients on navigating their actual beds, vehicles, and living spaces, and offer real-world training on how to avoid falls.

“There are a couple of things that I feel — I’m an occupational therapist by trade — like we do even better than SNFs,” she said.

Though operators of traditional SNFs might immediately see a service like onehome’s SNF-at-home program as a threat, Mayer and Southwell pointed to significant opportunities for the two care settings to collaborate. Providing higher-level rehab services in the home doesn’t necessarily need to mean replacing SNFs entirely — it could allow, for instance, a shorter length of institutional stay and a smoother transition from the hospital to normal life, Southwell said.

As the post-pandemic efforts to move more older and disabled Americans out of institutions and into the community gain steam, partnering with high-caliber home health providers may also provide a key strategy for traditional nursing home operators struggling to remain relevant in a changing marketplace.

The year began with an analysis showing that home health providers had achieved 109% of their 2019 patient volume by last fall, compared to just 83% of prior-year referrals for SNFs. That number was in line with various home health industry projections that 10% to 15% of post-acute patients, even prior to the pandemic, could safely receive care either at home or in an institution.

“I think the number is bigger than we think,” Mayer said of the diversion potential. “And things like remote patient monitoring, telehealth are only making that even more, in my opinion, likely — that we will be able to chip away at that number.”

Like many other post-acute and long-term care observers, Mayer asserted that there will always be a place for some type of institutional skilled nursing services in the future. But joining forces with a SNF-at-home option could give a nursing home provider the edge when dealing with Medicare Advantage plans, which are eating up an increasing share of the typical SNF’s revenues in many markets.

This has typically been seen as an existential threat within the nursing home world, given the significantly lower per-day rates that managed care plans pay for post-acute services. But operators may not have a choice: MA could account for more than half of all Medicare enrollment by 2025, according to a projection cited by ATI Advisory founder Anne Tumlinson during a presentation last week, rising to 64% by 2028.

“If your organization does not have a Medicare Advantage strategy that goes beyond just arguing over contracts, you need one,” Tumlinson said of skilled nursing providers.

SNF-at-home provides a logical area where operators on both sides of the institutional-home health divide can strike novel risk-sharing agreements with MA plans, Mayer noted. Not only could the two parties pitch the collaboration as a way to reduce institutional length of stay while potentially improving the journey home, they could also cite the ability for the SNF to readmit directly from home health if a patient requires more intensive services — bypassing the hospital and reducing the overall episodic cost.

“The nursing home universe is probably contracting a little bit with COVID, because not everybody is going to make it through once the government incentive payments dry up,” Mayer said. “It will make it easier to partner, because the more well-run and the more clinically-minded skilled nursing facilities will remain.”

And it’s not just a matter of financial strategy: It’s about meeting consumer demands and potentially providing better care.

“It’s not about driving volume; it’s about matching the patient to the right site of care,” he said.

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