Competing Incentives: How Improving the Transition to Home Can Pay Off for Nursing Homes

Some skilled nursing providers have looked to improve transitions to the home as one way to build back hospital referrals, but without much direct financial incentive to do so, things like patient education and discharge planning may remain in the periphery for most operators.

Value-based payment methodologies, especially for Medicare patients, provide some financial incentives for SNFs with low rates of rehospitalization; however, coordination with the primary care community continues to be a difficult proposition for under-resourced and overutilized nursing homes, especially as staffing challenges persist.

SNFs with limited staff are likely unable to devote scarce resources to the ongoing management of patients’ complex needs after discharge.

Joan Guzik, director of quality and efficiency for United Hospital Fund, said that while problems with care transitions are ‘systemic in nature’, it’s still important for SNFs to take the lead and do appropriate follow up post-discharge as there are financial incentives in preventing readmissions.

Likewise, some in the industry see improving patient transitions and discharge planning as an investment that will pay off in the long run.

“Being the referral provider of choice is more critical than ever because what we usually considered ‘simpler cases’ no longer come to nursing homes,” Stuart Almer, president and CEO of Gurwin Healthcare System, told Skilled Nursing News. “So we’ve got to work harder, smarter and better to be more attractive to hospitals to get those cases, which by the way, are more complex.”

He considered improving transitions a “worthwhile investment” for the New York-based health system.

Gurwin Jewish Nursing & Rehabilitation Center, which includes 80 short-stay skilled nursing beds, was one of eight skilled nursing facilities to participate in a two-year learning collaborative with the United Hospital Fund – which culminated in a report that highlighted different interventions that could be implemented by the facilities to improve transitions to the home.

SNFs can make big difference during ‘risky time’ for patients

Transitions of care – especially for those with multiple chronic conditions – can be a risky time for seniors. According to the Centers for Medicare & Medicaid Services (CMS), less than 53% of patients successfully return to their home or a community-based service following a short stay in a SNF.

In order to ensure a successful transition, SNFs need to play a bigger role in facilitating care transitions, according to Guzik, the lead researcher of the report.

Different interventions, such as improving medication education, were shown to have a positive impact for the facility as patient understanding of their prescriptions increased from 57% to 98% when those educational steps were taken, while patient understanding of symptoms and problems they may experience once home increased from 70%to 93%, according to the report.

“There needs to be greater coordination between the SNF, community based providers and primary care,” Guzik told Skilled Nursing News. “The problem is that given the current reimbursement structure and the small margins SNFs operate under, it’s very difficult for SNFs to take on those problems.”

Focused on finding interventions that would improve discharge planning, patient education and post-discharge follow up after a short stay in a SNF, the UHF project aimed to enhance care transitions.

Improving discharge education for nurses and follow-up phone calls conducted within 72 hours of discharge were also shown to improve transitions for participants.

Mary Jean McKeveny, director of clinical innovation at Gurwin Healthcare System, said the nursing home leveraged technology and used nursing students as “transitional educators” to make the process smoother for the patients and care staff.

Nursing students were used to help patients tackle any barriers to their transition back home, and followed up with weekly calls.

McKeveny said the students conducted 60 individualized sessions in a matter of two months with 70 post discharge calls, and documented it all on electronic medical records.

She said that when a nursing home can demonstrate it made certain investments that others don’t, it pays off the long run.

For Jeffrey Farber, M.D., President and CEO of the New Jewish Home, the report showed him how important it was to take an active rather than a passive approach to the discharge process. 

“What we’ve learned is a strengthened confirmation that transitions are a very risky time, and it’s probably more so as time has moved on, because of a more fragmented health care system,” he said.

Farber added that the more nursing homes can take an active role in medication management and helping a patient understand what they are taking and why, the better off the patient will be.

SNFs still ‘not include’ in value-based care

While investing in what happens to patients after they leave a SNF may not be at the top of an operator’s priority list, especially at a time when census is still down, incentivizing operators more to do so could prove beneficial to the system as a whole.

I-SNPs (institutional special needs plans) have frequently been SNFs payment model of choice in value-based care, but the Centers for Medicare & Medicaid Services announced a redesign to the direct contracting to a provider-led Accountable Care Organization (ACO) Model last month, which could garner more SNF interest.

Farber hopes to see incentives better aligned as the industry moves towards more of a value-based, integrated healthcare system.

For some, like Jamaica Hospital Nursing Home, which is a 228-bed four-story nursing center found on the Jamaica Hospital campus in Queens, moving to more of a value-based approach made sense, according to Thomas Younghans, vice president and administrator at the nursing home.

“The hospital itself has a very high Medicaid population and for us to take full capitated risk on those 172,000 healthcare members made financial sense being that the nursing home is part of the network and we see many of those patients that our system is at risk for,” he said.

Younghans said that while it made sense for the nursing home to manage their stay more closely, he thinks there needs to be more skin in the game for nursing homes to get involved in a value-based care arrangement.

“For us, it’s to try to get more patients to refer to us and being that our system has the risk for the 172,000 members, many patients do come to us,” he said.

However, he doesn’t think there’s going to be much movement on value-based care for the post-acute care sector because the industry “isn’t ready for it.”

Almer said that it isn’t that nursing homes have been slower to adapt to value-based care methodologies, it’s that they haven’t been included or embraced.

“Whatever new initiatives are announced in the value based payment world, we often have to wait to be contracted with the payers, meaning managed care organizations or with the hospital,” he said. “Our position is we haven’t been slow, once there are opportunities, I believe we quickly embrace. It’s just where we stand.”