SNF-at-Home Model Becoming ‘Critical Player’ For Success

Several factors continue to push patient care inside the home including health care waivers, patient preference, proposed legislation and an incentive to keep patients out of hospitals during the pandemic, as 32 states now offer hospital care at-home services as of July 27.

While the clinical capabilities of in-home care remain limited, some operators are already looking to grow skilled nursing at-home programs alongside their acute care models.

But with staffing shortages continuing to be an issue and no clear reimbursement path beyond 2021, some question the long-term viability of the program.

South Carolina-based Prisma Health, one of 68 health systems approved by the Centers for Medicare and Medicaid (CMS) thus far under the care at home waiver, recently expanded its home recovery care program to its post-acute facility, Lila Doyle.

“I think what we’re learning on the acute side, which is our primary model … as we continue to increase our capabilities on our acute model, we certainly see that translating over into our skilled nursing model as well,” Angela Orsky, vice president of post-acute services for Prisma Health, told Skilled Nursing News. “Our clinical team continues on a daily basis to add more robust capabilities around clinical care delivery.”

As one of the largest health care systems in South Carolina, Orsky sees Prisma Health’s home recovery care program expanding its capabilities with better technology and resources that can be brought into the home and supplemented with its nursing staff, such as advancements with ultrasounds.

“We continue to build those capabilities in the clinical care model to support the needs of our patients,” she said. “We’ve seen, in a combination of our acute and skilled nursing model, over 300 patients and on the acute side that’s avoiding close to 1,000 hospital days.”

Hospitals without walls

Operators have traditionally steered away from care at-home programs due to low CMS reimbursement options, but the CMS hospitals without walls program, announced in March 2020, combined with the pandemic sparked new life in care at home.

CMS expanded the program in November 2020 with the acute hospital care at-home waiver. The waiver provided hospitals with unprecedented regulatory flexibility to treat eligible patients in the home and supported at-home hospital care models throughout the country.

Hospital-at-home is now seeing renewed activity with pilot programs across the U.S., including in New York, Los Angeles, Philadelphia, New Orleans, Portland, Cincinnati and Minneapolis, Chicago-based specialty investment bank Ziegler noted in a report released earlier this year.

In South Carolina, Prisma Health was one of the first health systems approved under the waiver with its home recovery care programs. It has since expanded to Lila Doyle, a nursing and short-term rehabilitation center that specializes in treating individuals transitioning between the hospital and home.

“We launched Prisma Health home recovery in partnership with Contessa in May 2020,” Orsky explained. “There’s also the skilled nursing component that we were able to leverage for some of our patients who have an interest in going home with services at home.”

Since the announcement of the CMS initiative in November 2020, over 90 hospitals across 24 states have received the waiver and joined the program to offer hospital-at-home services, according to the Ziegler report, which focuses on the emergence of acute care home-based models.

Advancements in telemedicine have made these models more feasible moving forward as many health care companies are looking to take advantage and see how their own hospital-at-home programs would stand on their own.

“Home health is definitely getting a lot of interest these days. Everyone would rather convalesce at home than in a skilled nursing facility (SNF),” Wendy Simpson, CEO of LTC Properties (NYSE: LTC) told SNN’s sister publication Senior Housing News during a SHN+ TALKS appearance

She felt SNF providers would be “well served” to look into providing home health services.

“It connects them more with the whole health care continuum in their cities,” she said.

Choose Home could change landscape for operators

Renewed federal support could push care to the home even further as the Choose Home Care Act of 2021 received support from both sides of the aisle when it was introduced last Thursday.

The bill looks to reimagine and reshape where seniors can receive care, giving them more choice to stay at home rather than going to a long-term care facility to recover following a hospital stay.

LeadingAge, which represents more than 5,000 non-profit senior housing and care providers, is among those in support of the bill and sees it as meeting the current needs of older Americans.

“It takes important steps toward increasing choice by supplementing the existing Medicare home health benefit and expanding the services providers can offer at home for hospital discharged Medicare recipients,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement released last week.

The act seeks to enable Medicare patients to receive extended care services as an add-on to the existing Medicare home health benefit for 30 days following a hospital stay.

While the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) adamantly opposed the bill, with higher acuity patients heading to SNFs anyway, it remains to be seen how much of the skilled nursing patient population will actually be lost to the home.

Respiratory treatments, labs, imaging, continuous IV fluids are all being done inside the home in currently used models, however, clinically complex treatments such as cardiac and insulin drips, blood transfusions and frequent neuro checks are still generally not used in the home, researchers with Ziegler noted.

Ziegler researchers found that pneumonia was shown to be the most frequent diagnosis for hospital-at-home programs, at 16%, followed by cellulitis, at 14% and congestive heart failure, at 13%. Though renal failure was shown to be much lower at 2%, growing in-house dialysis service provider Concerto Renal Services is among those following the industry trend and is looking to make a greater play inside the home.

Though the skilled nursing dialysis service company only provides true home residential services in its Maryland market, Concerto Executive Vice President Kyle Stone admitted to Skilled Nursing News that adding home-based services is something that is constantly on his radar.

“Our Maryland market stands alone because we do not offer any residential home services currently in any other market,” he explained. “For a clinically complex patient, one of the reasons why I remain bullish about the skilled nursing community’s future is that whether we like it or not, these clinically complex patients aren’t going anywhere. And these are clinically the sorts of patients who it would be unusual and unique for them to be able to care at-home in a residential setting.”

DispatchHealth, an in-home medical care company that has grown to 18 states and 33 markets since 2013, plans to expand its SNF-at-home model to six additional markets in the second half of the year as one of its priorities is to continue to grow the program.

The same could be said for Prisma Health.

“I don’t think it slows down,” Orsky added. “I think as we continue across the health system to look at more value-based models and when you have health systems that are moving more toward at-risk, the SNF-at-home model is a critical player for our success.”