Hospital systems and skilled nursing facilities are redefining their relationships in response to manifold challenges and changes affecting the continuum of care.
One example: In the midst of the Covid-19 public health emergency, NorthShore University HealthSystem — which became the third-largest health care delivery system in Illinois after a 2022 merger with Edward-Elmhurst Health — established a new way of assessing which patients should be discharged to SNFs.
This new approach has led to an overall reduction in SNF use while improving readmission rates, Dr. Christopher Boyle, chief of stewardship and physician advisor services for the north region of the health system, said at Skilled Nursing News’ recent RETHINK conference in Chicago.
Luther Manor, a senior housing and skilled nursing provider in the Milwaukee area, offers another example of how hospital relationships are being redefined. The nonprofit organization created a bed lease program in partnership with a health system in its market, to provide care for clinically complex patients, Luther Manor CEO Stephanie Chedid explained at RETHINK.
Such efforts are taking on additional importance as post-acute bed shortages continue to strain providers across the continuum, leading to some patients spending long periods of time in the hospital when they could otherwise be discharged.
The evolution of payment systems likewise makes such efforts more critical, as providers increasingly have their financial strength tied to their ability to deliver care in the lowest-cost setting that is appropriate for patients — while providers also are sometimes at odds with the limitations imposed by Medicare Advantage plans.
A multidisciplinary committee at NorthShore
NorthShore’s new process for determining which patients should be discharged to a SNF involves a multidisciplinary committee that includes therapy providers, care management, social workers, physician leaders and other clinicians. The team looks at each individual case and determines what care setting would be most appropriate following the hospital stay. This approach originated in the midst of the public health emergency, to limit patients’ potential Covid-19 exposure and limit outbreaks in facilities.
Committee review of patient placement led to a “significant reduction” in discharge to the SNF, Boyle said. The hospital system ended up conducting a study into the matter a couple years ago and found a 50%-plus reduction in SNF discharges with the committee review process, considering both new and returning residents.
“Along with that, one of the concerns was around sending more folks into the community; if they aren’t supported, we might see increases in our readmission rates … that is not something we’ve seen,” said Boyle.
In fact, readmission rates overall have improved, he said.
Most of the patients who might previously have transitioned to a SNF now are going back to their own home, with necessary services rendered there, Boyle said.
With SNF referrals down overall, being a part of the hospital’s preferred provider network becomes especially important for facilities to maintain referral streams. The hospital system continues to look at quality scores in determining what SNFs are preferred providers, Boyle noted, with the CMS star ratings considered an “anchor point” as networks evolve and shift with quality feedback.
Other factors in determining preferred provider status include a SNF operator’s geographic distribution of facilities, current utilization patterns and community reputation, according to Boyle.
Improved communication is always huge too, he said, especially when it comes to what specialities the SNF can provide, which can play a role in preventing a subsequent trip back to the hospital.
Chedid agreed that communication and education together made for a better partnership, but the conversation needs to be mutually respectful. She believes hospitals should view SNFs as a “vital cog” in transitional care, in helping people get to where they need to go.
“I don’t know if any of you folks have ever felt like you were the lesser of the two in the room in a hospital conversation … treat us as equals and recognize the value and the experience and the care we provide, that’s vital in a partnership,” said Chedid.
Leased beds at Luther Manor
Luther Manor’s bed lease program also was developed in response to the needs of the Covid-19 era, Chedid said.
The organization worked with its hospital partner to focus on “outlier patients” – those who were essentially living at the hospital, even if they were not older adults or transitional long-term care or rehabilitation patients, she said.
The program took a year-and-a-half to put together, and involves the hospital essentially paying the SNF to reserve beds through the program, with a split in revenue for patients who receive care at Luther Manor through the initiative.
“These were folks that just didn’t have a place to go. We spent a lot of our time on the psychosocial elements, and we spent a lot of our time on safe discharges,” Chedid said of the program, in which half of patients are under the age of 64.
But, the financial equation for providing care to this population is difficult, she acknowledged. Psychosocial needs are often required for this population but adequate payment streams are not available for these expenses, and only 30% of the patients in the porgram even have a payer in place when they arrive at Luther Manor. Meanwhile, their clinical needs also can be complex and costly. Wound care is among the top 3 diagnoses.
Luther Manor does a lot of work to get these patients on the Medicaid system or Wisconsin’s managed care program. Chedid calls the Medicaid program “precarious,” although the team has been trying to work with the state of Wisconsin to recognize the cost related to this patient population.
“It’s not just high acuity clinical care, it’s not just the psychosocial aspect. We work with families, we work with individuals on guardianship … to help them get the paperwork together, get on Medicaid; none of that is reimbursed,” she said.
The provider finds candidates for the program through weekly calls with a physician, medical director and nurse practitioner from the nearby hospital system.
“We do a lot of nurse to nurse conversations for this group of folks. We have dedicated social workers, we work very closely with their case managers,” noted Chedid. “That said, we’re starting to see a lot of inappropriate referrals coming through. One of the things that we’ve recognized is that once you get a reputation for dealing with the tough stuff, you get all the tough stuff, even if they’re not appropriate.”
She said Luther Manor staff have applied a stoplight tactic of sorts with admissions to try to be more discerning, and get people to the right care setting.
Despite all the operational and financial challenges involved, such a program contributes enormous value to the health care system writ large, in Boyle’s perspective. He said this type of program could help alleviate an “enormous challenge” for hospitals, when a patient doesn’t have traditional skilled needs but it’s not entirely safe for them to go home.
He and Chedid agreed on the need for more creativity and attempts at innovation along these lines. In fact, Chedid has been sharing Luther Manor’s story and advocating for support from the state of Wisconsin for further initiatives. She and other health care leaders in the state put together a proposal for a pilot, in which the state would fund hospitals and SNF providers that put forward promising innovative care solutions.
“So, we had asked for more money, we got at least a bit in the budget, and that’s been successful,” she said. “We’re working with the Department of Health and with the Speaker of the House to try and negotiate on what exactly that’s going to mean. But we’ve got to do things differently.”
Medicare Advantage constraints and expectations
Hospital systems are having conversations about restrictive Medicare Advantage plans and policies affecting their referral pipeline to skilled nursing facilities, just as SNF operators are struggling with coverage requirements prior to and once these beneficiaries are in the facility.
Similar to SNF operators, Boyle said NorthShore is in a wait-and-see mode regarding the Centers for Medicare & Medicaid Services (CMS) plan to stop MA companies from inappropriately diverting beneficiaries away from SNFs in favor of home health.
“What we’ve heard from the Medicare Advantage plans themselves is not a whole lot in terms of what their plans are come Jan. 1, 2024, which is when [the policy] goes into effect,” said Boyle. “I think we’ve been looking at it a lot and not from the SNF lens, but through the hospital lens, around patient status determinations, observation, inpatient.”
Boyle is particularly worried about the potential for MA plans to start denying SNF stays because of the three-day stay requirement, if insurers interpret the coming CMS rule to be more restrictive in terms of the latitude allowed. He refers to a Medicare beneficiary needing to stay at the hospital for three nights before they are covered for SNF services, which MA plans along with other managed care plans can waive under the right circumstances.
Chedid said Wisconsin in general is a high MA state, and the county that Luther Manor operates in has about 69% of total residents on MA plans. Luther Manor’s issues with MA plans are the same as what Skilled Nursing News has been hearing across the country, including coverage denials that curtail length of stay and prior authorization issues.
“We even have situations where patients come to us with an authorization and they’re denied when they arrive. Some organizations we won’t work with, because we were burned one too many times, or their length of stay is unrealistic,” Chedid said.
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