For Winston-Salem, N.C.-based health system, Novant Health, which includes 15 hospitals, 800 clinics and hundreds of outpatient facilities, admissions have started to return to pre-COVID-19 numbers but referrals to SNFs are still down.
While some of that has been lost to home-based care, Andrea Areskog, senior director of value-based care operations at Novant Health says the challenge has been finding the right facility to take the patients they need.
“For us a good partner is someone who cares for a patient in the skilled nursing home for just the right amount of time so the patient is there for as long as they need to be,” Areskog said.
As Novant Health looks to build and modify its post-acute care network, Areskog said it looks to build one that’s not too narrow but that also serves the needs of a more clinically complex patient mix.
One challenge in building that network can be finding facilities that accept all patients, including bariatric patients, and finding facilities that align with Novant Health’s mission, regardless of whether it’s not-for-profit or for profit.
“We want all of our patients to be able to have a good place to go that’s high quality and that’s regardless of payor source,” she said.
She sat down with Skilled Nursing News to discuss what she sees as the role of SNFs in post-acute care coming out of COVID-19 in an interview that’s been edited for length and clarity.
Have referrals started to bounce back to SNFs?
The referrals are definitely starting to bounce back some, but I think you’re right that is probably not exactly where it was before, in terms of number of referrals. Some of that is patient-driven. I don’t know that all of it is because the hospital is not sending the same number of patients to SNFs, however, a lot of our admissions have come back up so in our hospitals we’re starting to see similar [pre-pandemic] numbers.
I think because of everything that happened through the pandemic some patients and patient families are more hesitant to go to SNFs and might prefer or consider bringing a family member home and rearranging for home health when they weren’t before.
The other thing that I think has changed [is that] so many families are able to work from home.
Now if you’re working from home, maybe you could bring an older family member home that previously would have had to go to a nursing home.
Are you looking to expand your at home services?
We are seeing it start to increase. We are not currently doing hospital-at-home. We have recently gotten the CMS waivers for it at all of our acute care facilities and are building out and evaluating what that might look like in the future, but we’re not currently doing hospital-at-home or SNF-at-home.
What do you have to do to get those services up and running?
We’re looking at which would be the right patients to go to that program. We’re looking at what the right algorithm is to identify them and how we would make sure that they have the right support network to be able to do that.
From our side it would be building some infrastructure to be able to see patients virtually and have the whole care team and interdisciplinary rounds, where someone is going to see the patient every day but there’s some team that is virtually checking in on them. Remote patient monitoring would be a big piece of that.
What do you look for in SNF partners when building out your network?
We have a lot of really good partnerships with skilled nursing facilities. We have a network of facilities that we’ve built really good relationships with and we work closely with them.
In addition to being a good partner, some of how you would define that I guess is willingness to take patients and consider patients 24/7 and having a smooth discharge process.
We also look at quality metrics. For us that would be length of stay and total spend while in skilled nursing facilities. We also try to balance that by looking at patient complexity. If you only look at length of stay then that doesn’t account for the nursing homes that are taking really complex patients.
Readmissions once they’re in a skilled nursing facility [is another metric we follow]. Are they bouncing back to our emergency departments or inpatient units?
Do you think SNFs need to specialize to take on higher acuity patients?
The specialties that we are looking for help with are sometimes the more medically complex patients.
For us that could mean very bariatric patients. A lot of skilled nursing facilities are only able to care for patients up to a certain weight limit and so we’re trying to identify those who can accept bariatric patients from those who can’t. What would it take for them to be able to do that and could we help them with that.
We also have sometimes a challenge with patients who need IV antibiotics. Patients who need dialysis can also be a challenge.
Another challenge, partly just because they’re not as many facilities that are able to do this, would be SNFs who have a locked unit that are able to care for patients who have dementia and need to be in a locked unit.
How does the SNF operator prove to you that they’re ready to take on some of those clinically complex patients that you were talking about?
A lot of times it’s willingness. Many SNFs are hesitant to take some of those more challenging patients. So for those who have a willingness, we are willing to partner with them.
What about in-house dialysis?
We’re not doing that, and don’t have a ton of SNFs in the area who are doing that today. We’re looking into it and talking, because there are some patients who are in the hospital just because of dialysis who otherwise would be ready to discharge. So we’re looking at what that would look like for them in the future, where’s the best place for those patients to be and that could be a nursing home.
What about transportation to and from the hospital?
That has been a huge challenge in both our Charlotte and Winston markets. I think there’s a lack of transportation. A transportation organization recently closed its doors in Winston. Perhaps they’re struggling with staffing, but transportation is definitely a challenge.
What do you see as the role of SNFs in a value-based world?
It definitely has changed because we’re looking at a balanced list of metrics. I think previously we maybe were looking at readmission rates as one of the main indicators but now in a value-based world we’re able to see length of stay for patients in certain skilled nursing facilities. We’re also able to see what the total spend is there.
Do you think there’s still a place for SNFs in post-acute care?
I do think there’s going to be a place for SNFs no matter what because some patients will always need that higher level of care and may not be able to be cared for at home. I think there’s a growing desire for patients and families to have their loved one at home with home health. I would just identify a current challenge today for that industry is staffing, which we see across all of healthcare.
How are you looking to build your post-acute care network?
We have a post-acute care network that we work with. We’ve had one for about five years now.
We want just the right amount of facilities in it so that we have enough for our patients who need to go to a skilled nursing facility, there’s somewhere for them to go in-network that we consider to be high quality. But we’re not trying to make it too narrow either.
What are some challenges with that?
Really complex patients can be a challenge for us. Another challenge can be payer source I think because a lot of skilled nursing facilities are for profit. They’re looking to have a certain payer mix within their patient panels and we serve all patients. We have been fairly transparent about how the patients that we have coming into our facilities are changing and that we’re looking for partners who are willing to serve the same patients that we do.
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