Nursing Homes Post-COVID Must Prove Themselves to Hospitals Through Communication, Clinical Ability

For AdventHealth, COVID-19 didn’t remake its relationships with skilled nursing facilities as much as it intensified all the factors the Florida-based health system considered important.

And as hospital patient volumes start to rise back to their pre-pandemic levels, SNFs need to know what hospitals are looking for and what matters to them. With hospital referrals a major factor in how quickly SNF occupancy recovers, the long-term viability of a SNF depends in large part on its ability to secure a significant portion of discharges from its acute care partners.

The health care continuum’s movement to value-based care also makes it critical that SNFs enhance their relationships with their hospital partners, according to Dr. Ben Zaniello, the chief medical officer of post-acute software developer PointClickCare.

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“In particular for post-acute facilities, it it meant that there was renewed interest into what happened within their walls, because hospitals are both ultimately on the hook for the quality and the cost of the care that occurs in a ‘non-affiliated’ post-acute facility,” he told Skilled Nursing News. “They’re on the hook for that care, but secondarily, they are still the channel for that discharge of patients. … They want to ensure that [patients] go to the best facility possible.”

Hospitals are taking more risks with their care in the form of setting up accountable care organizations (ACOS) and other value-based entities that take on financial risk to improve patient outcomes, he pointed out. That is driving hospital questions about quality metrics in ways that “go well beyond the traditional kind of five-star quality rating.”

Amid COVID-19, SNFs needed to be ready to answer those questions and more, one acute care provider told SNN.

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“We held weekly meetings with our facilities to talk about what was changing,” Lisa Musgrave, the vice president of home care administration and post-acute services for the Altamonte Springs, Fla.-based AdventHealth, told SNN.

Those meeting focused on rapidly changing regulations, visitation policies, communication protocols, personal protective equipment (PPE) procurement and more, she explained.

As a result of that constant exchange of information, COVID-19 reinforced AdventHealth’s relationships with facilities in its community. It also put a new spotlight on patient needs, with the post-pandemic goal of “keeping the patient at the center” of care transitions, Musgrave said.

Being the right partner

Even before the pandemic put nursing homes in a harsh spotlight, AdventHealth was trying to move more patients to the home setting when that was possible, Musgrave said.

“That had been a preference of our patients, and it was a goal to help people heal in the setting where they could be the most independent, if that was appropriate,” she said. “But we also know that sometimes a facility is the right place for people to be.”

With this in mind, AdventHealth focused on finding the right post-acute partners for its preferred provider networks, what it terms the “Post-Acute Care Collaborative.” The goal was to ensure there was a group of high-quality SNFs and home health providers available to provide support, Musgrave explained.

“For skilled nursing specifically, we were really looking for a narrow network of providers that were ready for something like the pandemic … [and were] able to take on high-acuity patients,” she said.

This became particularly critical during COVID-19, even if – as Musgrave noted – acute care hadn’t necessarily had a pandemic in mind.

In the early months of the pandemic, hospitals were full, Zaniello said. In turn, patients needed to be discharged rapidly to SNF environments, including patients who might have stayed longer in a hospital and then gone home in more normal times.

When hospital volumes were down due to the suspension of elective procedures, the referrals to the SNF setting became the “very, very sick or clinically complex,” according to Keith Boyce, president and CEO of the AdventHealth Care Centers, the acute care system’s region of SNFs. Considerations for SNFs in this context became the rules around isolation units within a facility, given the CMS and Centers for Disease Control and Prevention (CDC) guidelines, he said.

AdventHealth has 10 SNFs in the Care Centers organization. At different times, it ran multiple buildings with COVID-19 units through 2020 and into this year. And the capacity of a SNF to take on COVID-19 patients, or handle high clinical complexity, or both, was what drove most hospital decision-making, Boyce told SNN.

“That drove a lot of the discussion of those [patients] that actually did go to the SNF,” he said. “But of course more and more people went directly home, if that was at all possible.”

That was consistent through last year and has continued into this year, Boyce said. And Musgrave pointed out that even as fewer patients went to SNFs, those that did were far more medically complex.

This was a phenomenon that PointClickCare also observed.

“If there was one particular spike, it was that one, which was simply creating more hospital space,” Zaniello said. “And fortunately we saw that SNFs were really able to meet the need, given the frankly absolute need across the care continuum for better care settings for high-risk patients.”

Thriving under the microscope

But the pandemic also brought significant scrutiny for nursing homes, coming “very much under the microscope,” especially given that one of the earliest outbreaks of significance was in a nursing home in Washington, Zaniello pointed out.

“There was much more interest in the care that SNFs provided, the data that they could provide about that care, and then, ultimately, their protocols for managing not only COVID-19 needs and protection of their residents, but also how they were managing their staff,” he told SNN. “Recognizing … that nurses, doctors, nurse practitioners, etc., that were actively working in the SNF were going to be in the community and therefore at risk for bringing COVID-19 into those facilities.”

That increased scrutiny led to several changes, he said. PointClickCare has an infection prevention module, which had seen increased interest even before the pandemic due to the quality metrics related to tracking infection, Zaniello explained. When COVID hit, there was “a massive spike in interest in that module, and use of that module,” he said.

“From an organizational standpoint, we saw a lot of post-acute facilities shift from tracking not only their residents within our software, but also their staff,” he told SNN.

Pre-pandemic, AdventHealth would examine a SNF’s quality of care and global star rating, as well as staffing metrics, cost of care, length of stay, and rehospitalization rates – the last metric was particularly important, Musgrave said.

During the pandemic, when facility ratings were not being updated on CMS’ Care Compare website, AdventHealth was using inspection ratings and state information, she told SNN. But fundamentally, the health system was using information provided by post-acute care, making communication a critical component of the COVID-19-era partnerships with SNFs – hence the weekly meetings.

“I think readmission rates were the consistent [metric],” Musgrave told SNN. “We developed a bed board with bed availability in our regions, just so we could see where the beds were and which beds were COVID beds, versus which ones weren’t. But it was just that frequent communication and touching base with how each facility is doing and what their capacity is, that helped us get patients to the right setting, so they were able to get the care they needed at the right time.”

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