The Good, the Bad and the Ugly: What Nursing Homes Should Consider When Diving into SNF-at-Home

Nursing home executives are increasingly exploring what it would take to start a SNF-at-home program, at a time when it has become apparent after the height of a global pandemic that patients would rather be cared for in the home when at all possible.

For many skilled nursing providers it becomes part of a bigger strategy to get and stay ahead of the curve as the long-term care industry moves toward a value-based payment world.

SNF-at-home can also have considerable benefits, including a better patient experience and lower costs.

But these conversations bring some challenges to the forefront — namely already debilitating staffing shortages and a murky reimbursement path.

National HealthCare Corporation, the oldest publicly traded senior care company, is no stranger to thinking outside of the traditional nursing home box.

Although the genesis of the company began when its founder purchased 14 nursing homes in distress, the senior care operator has long recognized that there can be better ways to provide care, according to CEO Stephen Flatt.

Murfreesboro, Tenn.-based National HealthCare Corporation currently operates 75 SNFs, 25 assisted living communities, 28 home care agencies, six continuing care retirement centers and 37 hospice agencies.

National HealthCare Corporation plans to roll out its SNF-at-home pilot program in this year’s fourth financial quarter — a decision that was made about 18 months ago.

“We think that it is a great place for SNF-at-home, much like what managed care is already doing through this by shortening the length of stay, to say, ‘this is a high acuity patient, he or she is going to need X amount of time in the SNF but we think they can step down more quickly, but maybe to something a little more robust than traditional home care,’” Flatt said during a panel at the Synergy Summit conference in San Diego earlier this month.

And National HealthCare Corporation is certainly not alone in its endeavor. PruittHealth CEO Neil Pruitt Jr. told Skilled Nursing News at the beginning of this year that the operator would launch its own SNF-at-home type of service, dubbed PruittHealth Family First, in its home state of Georgia.

Pruitt sees expanding at-home services as a must for skilled nursing operators moving forward as it continues to adapt to the modern patient.

Flatt said this step down concept would be National HealthCare’s “first pass” at the program this year.

“From that we think as the model evolves, we’ll be able to grow and evolve with it,” he added.

Staffing realities

As National HealthCare works to prepare its three test locations for the rollout later this year, persistent staffing challenges remain front of mind.

While the health care industry added an estimated 34,300 jobs in April — only 900 of those jobs were in the skilled nursing sector. Since the start of the pandemic, the nursing home sector has lost 241,000 workers, or 15.2% of its total workforce.

Flatt called the current skilled nursing staffing environment “uncharted territory” and expressed concern over where additional staffing would come from to get their SNF-at-home program off the ground.

While having an institutional special needs plan (I-SNP), which was started in 2014, will be “instrumental” in helping to be able to follow patients once they return home, it doesn’t completely eliminate labor concerns.

“Our first pass at modeling how many hours per patient day is needed to do the SNF-at-home … It was 50% more than my hours per patient day in that institutional setting. Now where are those people going to come from,” Flatt said during the panel.

That number also only included hands-on staff — not even taking into account what it would look like when social workers or administrative staff were factored into the equation, he added.

“I’m not afraid of new models of care, I’m just trying to think how widely can you spread the health care workforce,” Flatt said.

Constellation Health Services has utilized telemedicine visits in the home as one way to provide SNF-at-home care — and in some ways to get around the current labor constraints, according to Judy Walsh, regional director of population health.

She stressed during the conversation that it cannot be underestimated how important virtual care is going to be.

Constellation Health Services offers community-based home health, palliative home health, hospice and personal care, among other services.

And without partnership across the entire health care continuum, SNF-at-home success will be difficult, she added.

“The reason this has been able to work it’s because we work very closely with our SNF partners, we work very closely with that nurse practitioner group who becomes sort of the glue and the connection for that patient across their journey so they stay in touch with their patients … help them to have access to care, collaborate with their primary doctors, and then we’re able to ideally service as our SNF partners by allowing them to stay in touch with the patient,” she said.

Dr. Robert Moskowitz, Contessa Health’s corporate medical officer, also highlighted the importance of getting those involved in the care team on the same page when it comes to patient care.

“You have to have the alignment of the physicians, of the nurse practitioners because if you don’t have everybody pedal in the same direction you’re not going to be able to accomplish this,” Moskowitz said during the panel.

In the meantime, while resources continue to be slim, operators who are interested in getting involved in SNF-at-home — and even those who aren’t — will need to make some sensible decisions as to exactly what care is needed in person versus virtually.

“We need to get to a place where we’re being judicious about our resources and really only doing hands on that’s needed to be hands on and finding other ways to leverage technology and recognize that otherwise our reach will run out,” Walsh said.

Moskowitz added that staffing challenges will likely always be a “constraint,” but there can be different ways to look at that.

Contessa is a home-based care provider dedicated to shifting higher-acuity care into the home.

“We talk about this attrition from the workforce in nursing, or moving from one position to another, but we found that … sometimes this is what someone’s looking for in their career,” Moskowitz said, referring to working in a home versus a brick and mortar setting.

At-home care giant Amedisys, Inc. (Nasdaq: AMED) acquired Contessa last summer with plans to expand its capabilities to reflect growing market demands and evolving patient preference for higher acuity in-home services.

Overall, there have been 520 admissions for Contessa since the completion of the acquisition, as Amedisys has seen growing interest in its SNF-at-home model, according to Christopher Gerard, Amedisys president and COO of Amedisys.

Moskowitz said during the panel that the company’s SNF-at-home program is expected to be in five of its markets by the end of the summer.

But as skilled nursing operators are looking for ways to diversify and innovate to stay ahead of the pack, some in the industry wonder if efforts to pivot may be coming at the wrong time.

It may be better to go back to the basics, according to Pamela Pelizzari, a principal and senior health care consultant at Milliman, and recognize that the patient who is going into a SNF-at-home program is likely not the patient that needs to be in a traditional skilled nursing setting long-term.

Especially when, once reimbursement is determined for the service, more home health agencies are going to become interested in starting their own SNF-at-home programs, she added.

“To the extent that you can go back to basics and say, ‘there is this thing that we do and we do it well, and we are offering value for these patients,” Pelizzari said during a separate panel at the conference. “Worrying about that first part and sort of ignoring some of these things that are going on and saying, ‘you can buy whatever home health agency you want, but that’s not the same patient as the one I’m taking care of.'”