SNFs Continue to Battle Depressed Referrals as Hospital Inpatient Volumes Recover

Occupancy recovery in skilled nursing facilities will depend on a variety of factors: COVID-19 vaccination uptake among staff and residents, visitation policies of nursing homes, the willingness of family members to place their loved ones in the SNF setting, and acute care’s return to normal.

At least, that was the theory.

One of the looming questions emerging from COVID-19 is whether or not hospitals will continue to discharge patients to home health at the rate they did during the pandemic. One study from September last year found that while hospital discharges were climbing back to normal after hitting lows during the spring of 2020, discharges to the skilled nursing setting hit a low with little to no sign of recovery.


More recent data from CarePort Health, a care coordination software provider under the WellSky umbrella, shows that hospital inpatient volume as of March 2021 had almost recovered. Data from 44 hospitals in 13 states show that inpatient volume reached 98% of calendar year 2019’s weekly baseline volume.

But CarePort also found that, of patient referrals from 398 hospitals across 37 states, referrals to the SNF setting had reached 91% of calendar year 2019’s baseline. Home health referrals, on the other hand, were at 116% of the 2019 baseline.

Chart showing trends in CarePort Care Management patients by referral setting through March 2021 as a percentage of calendar 2019. Settings include home health and skilled nursing. CarePort Health
Source: CarePort Health

“What this tells me is that – a little bit speculating here in the future – we’re starting to reach maybe what is normal,” Tom Martin, CarePort’s director of post-acute analytics, told Skilled Nursing News. “As in: I’m seeing referrals returned to normal, I’m seeing inpatients volumes return to normal, I’m seeing less patients being referred with COVID.”


But crucially for SNFs trying to get a sense of when occupancy will return to normal, acute care referrals to the SNF setting do not appear to be returning to what they were in March of 2019, where referrals were roughly split 50-50 between the SNF setting and the home health setting, Martin said.

“In March of 2021, if you believe that we’re approaching a new normal, we’re at like 60-40,” he said. “Amongst a lot of our customers – and certainly patients are going to want this as well – if it’s possible to send the patient home, you’re going to want to send them home. They prefer to go home, it’s less costly. It’s kind of better for everybody that they go home if they can.”

The new findings add onto an earlier set of data from CarePort in January that strongly suggested a return to the old normal is unlikely, at least any time soon. At that time, SNF discharges had only reached 83% of their historic volume.

Major home health players such as LHC Group (Nasdaq: LHC) and Amedisys (Nasdaq: AMED) have seen opportunity in this phenomenon, looking to capitalize on capturing a greater share of patients from institutional settings amid COVID-19 concerns.

Martin noted that CarePort tracks referrals, but not necessarily patient admissions to the next setting. So a SNF referral tracked by CarePort might not necessarily be a SNF admission, even though “the vast majority of the time, that is going to be the case.”

Another set of data, albeit through only the end of August 2020, indicates that discharges to the SNF setting are significantly outpaced by discharges to home health. In a preliminary analysis of all Medicare fee-for-service (FFS) claims from March to August of last year, the consulting firm ATI Advisory found a considerable decrease in discharges from short-term acute care hospitals (STACHs).

“While total STACH discharges were lower in March through August of 2020 than in 2019, SNFs were receiving disproportionally less volume from STACHs in these months,” the firm wrote. “In April 2020, STACH discharges to SNFs declined by 50% as compared to April 2019. In August 2020, that number was still 33% lower than August 2019 levels.”

Anne Tumlinson, the founder and CEO of ATI Advisory, told SNN that some of her clients in the skilled nursing field do feel they are seeing a measure of recovery in terms of referral numbers.

“They’re kind of getting back to – not normal, maybe in terms of volume recovery, but directionally, it’s going in the right direction,” she explained. “I think they’re feeling a little bit more optimistic. Now, the challenge is that the referrals that they are getting, the uptick is in more complicated, more complex patients.”

CarePort has also noticed this phenomenon, but with patients being discharged to home health, Martin told SNN. One of the measures of acuity among patients that CarePort tracks, for instance, is showing an increase in acuity scores for the patients that go home.

That means that outcomes will be the crucial metric to watch to assess the effect on the increase in discharges to home health, he told SNN, even though the answers on that front won’t become clear for several months, if not a year.

“That’s telling us we’re seeing a sicker patient population starting to go to home health than anything we’ve seen in the past,” Martin said. “What has happened to these patients?”

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