When skilled nursing providers seek to lower their readmission rates, they increasingly use data to do so. In fact, TeamHealth, which provides physicians and advanced practice clinicians across a range of both hospital-based clinical services and services in the post-acute setting, recommends following three datapoints in particular: antipsychotic use, fall risk and overall risk of readmissions.
Following those three points is just one of three big steps SNFs can take today to use data aggregation to lower their readmissions.
“Readmissions are multifactorial — lots of literature shows that there’s not one direct cause for readmission,” says Dr. Darren Swenson of TeamHealth. “Causes can be communication between the facility and the provider. It can be medications involving polypharmacy. Readmission can be related to a fall. It can be related to a family’s request and desire to have further evaluation. What we’re saying at TeamHealth is, how do we try to anticipate the risk factors from a population health-based approach that would determine that a patient is at high risk or moderate risk for readmission?”
According to the CDC, about 60% of U.S. adults suffer from at least one chronic condition, a problem that contributes 90% of the nation’s annual $4.1 trillion health care spend. SNFs can proactively address these challenges by using data aggregation. Here are three ways.
Study the in-between time: Know what’s happening to your patients in the 59 days between visits
TeamHealth uses its chronic care management (CCM) program to provide services to both Medicare patients and dual-eligible Medicare-Medicaid patients. The program, Swenson says, is designed to anticipate a multitude of factors that affect a patient’s health, and to assess the patient holistically. That means taking a psychosocial perspective, viewing activities of daily living, following his or her polypharmacy experience and then his or her chronic disease state, and bringing that all together every 60 days, per federal government requirements.
But, as Swenson notes, “A lot happens in 59 and a half days from the time I saw a patient last to the minimum federal requirement.”
When there is a medical necessity, clinicians can see a patient more often, but when there is not, the clinician is liable to miss important insights into the patient’s wellbeing.
“The chronic care management program is a way to be involved with a patient through data aggregation, vital signs, the evidence-based structure, and to give a clinician a report on a monthly basis to intervene and to improve the patient’s outcome in a proactive way,” he says.
The alternative, of course, is simply rounding every 60 days, and returning to learn that your patient is back in the hospital — and has been for weeks.
“We want to do better than that at TeamHealth,” Swenson says. “We want to be proactive in the engagement.”
Use QAPI meetings to drive performance improvement
Like any tool, the CCM program is only as valuable as the SNF that wields it. Taking a proactive approach to care and patient engagement also means being proactive with your data, Swenson says.
“We encourage all of our facilities and clinicians to use the CCM outcome data at the Quality Assurance and Performance Improvement Committee (QAPI) meetings to drive performance improvement activities to improve the systems of care delivery,” he says. “For example, the falls risk indicator and 12-month mortality indicators focus our clinicians on proactively reducing polypharmacy, increasing goals of care conversations from a facility perspective, but also allow us to drill down to the unique patient level.”
The headwinds today for SNF operators are numerous and create ongoing risks for reimbursement reduction. The data aggregation associated with a CCM program in the long-term care facilities supports the clinicians to make more informed decisions proactively while remaining patient-centric.
Follow the three key datapoints
It bears repeating: SNF operators should be aware of the three key datapoints that can make or break a patient’s ability to stay out of the hospital. Tracking those three pieces of data — antipsychotic use, fall risk and overall risk of readmissions — are yet another way that the CCM program can mitigate some of the challenges that SNFs face, thus creating ways for the facility to differentiate itself from others in the community.
“Educating skilled nursing facilities about chronic care management and the patient population of the long-term care patients that it applies to is the first step SNFs can take to best change their chronic care management,” Swenson says. “Number two is helping the skilled nursing facilities to define the value proposition. Chronic care management not only improves patient outcomes, but from a skilled facility perspective, chronic care management and data from it can be applied to the QAPI process as a proactive performance improvement.”
This article is sponsored by TeamHealth. To learn more about how TeamHealth can help you manage the complex chronic conditions of your patients, visit TeamHealth.com and download the CCM brochure.