‘The Safe Discharge’: Challenges Behind Balancing Care and Cost in Value-Based Care at Nursing Homes

Reimbursement issues at nursing homes are pushing operators to adapt their payment models to increase reliance on Institutional Special Needs Plans (I-SNPs) and Accountable Care Organizations (ACOs). But while these models aim to enhance care quality even as they control costs, they also bring on unique challenges, including requiring extra oversight with discharges and related administrative burdens.

Operators said these value-based care options can be difficult to manage sometimes, and require strategic planning and clinical team coordination right from the admissions stage. But if done well, the payoff can be big.

Julie Britton, chief clinical officer at Genesis HealthCare, said I-SNP and ACO participation has overall added efficiencies and cost-effectiveness to care at her organization, but such value-based care can be difficult to manage at times.


“Our centers follow the triple aim: safe, efficient, cost-effective care,” Britton told Skilled Nursing News. “Operationalizing I-SNPs and ACO memberships has streamlined processes for our staff.”

Genesis HealthCare subsidiaries include more than 200 skilled nursing centers and senior living communities in 19 states nationwide. Genesis also supplies rehabilitation therapy to more than 1,400 locations in 43 states and the District of Columbia.

Delena Stortz, chief nursing officer at Consulate Health Care, said that while there are benefits with ACOs and I-SNPs, the challenges in managing care under these models require extra vigilance. And in striving to ensure safe and appropriate discharges, her organization is habitually needing to negotiate for more time to achieve optimal outcomes.


“We are definitely involved in these types of ACO and I-SNPs in our buildings [but] it is difficult sometimes to manage because [these programs] are wanting residents to stay in shorter and shorter time frames. So it’s a struggle because we want to make sure that the discharge is safe and appropriate,” Stortz told SNN. “And we find ourselves having to really go back to that provider and say, ‘Wait, we need more time.’ And so, yeah, it’s definitely a struggle.”

Consulate Health Care is a leading national provider of senior healthcare services, specializing in post-acute care. With operations in Pennsylvania, Virginia, North Carolina, Mississippi and Louisiana, it offers services ranging from comprehensive short-term rehabilitation and transitional care to Alzheimer’s and dementia care.

Total care from the get go

Meanwhile, at Ignite Medical Resorts, Chief Medical Officer John McFarlane, said that under these plans, it is critical to provide a full clinical picture to support successful outcomes, right from the outset because missing pieces can impact the resident’s length of stay at a facility.

“We try to just do our best when working with I-SNPs and ACOs, especially in providing a really comprehensive clinical picture of what is going on with that resident so that they have the best chance of success,” McFarlane told SNN.

Discharging too early from the SNF increases the risk of readmission, perpetuating a costly cycle, he said.

“Our facilities go by the hospital’s goal that this resident doesn’t go home just to return back to the hospital and go through the whole cycle again and again,” McFarlane said.

Ignite Medical Resorts combines advanced medical rehabilitation with the high-end hospitality of a 5-star luxury resort. The Park Ridge, Ill.-based company has 20 facilities spread over seven states, including Illinois and Texas.

Interdisciplinary care a key to success

Executives said that the transition to value-based care models can be tricky in balancing cost with quality. However, Ignite and Genesis have a process in place, right from the start of a resident’s journey through their facilities.

“It’s challenging. We focus on comprehensive, interdisciplinary care planning upon admission, ensuring residents and families are well-informed about their conditions and care options,” McFarlane said.

Meanwhile at Genesis, in order to avert problems with care in pursuing VBC, Britton said that proactive measures to align care goals with patient needs early on are an absolute must – something Genesis does in an intricate fashion.

“We review medications, equipment needs, and appointment schedules upfront,” Britton said. “It’s crucial for our staff to understand how to deliver safe, efficient, and cost-effective care.”

As for Consulate Health’s recipe for success with VBC, Stortz also stressed the interdisciplinary approach to discharge planning, aiming for consensus among care providers as well as families.

“Aligning goals ensures safe transitions to home,” Stortz said. “Cost considerations are important, but they should never compromise clinical judgment or patient outcomes.”

These strategies reflect a broader industry shift towards integrated care models that prioritize patient outcomes and cost containment.

However, challenges persist. The pressure to shorten stays under these models demands careful management to avoid premature discharges.

At the end of the day, a proactive approach with planning can really maximize the gains from value-based care, according to Justin Di Rezze, CEO of Theoria Medical, which offers technology-based solutions to value-based care management.

“While it may seem like ACO and I-SNP models push for quicker discharges, the focus is really on treating long-term care patients in place and effectively,” Di Rezze said. “The administrative burden of renegotiating for optimal care time is a key challenge if you do not have a provider group that is engaged and familiar with both I-SNP and ACO [programs].”

Advanced discharge planning with interdisciplinary teams and cutting-edge technology can streamline processes and reduce administrative loads, allowing more focus on patient care, he said.

“Joining an ACO or I-SNP plan should make the operator and patient’s life easier, not more difficult,” he said.

And as nursing homes adapt to these new payment models, better collaboration with hospitals and community providers may also become pivotal. 

McFarlane noted the importance of aligning with hospital systems to facilitate seamless transitions and reduce unnecessary readmissions.

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