Nursing homes and hospitals are developing closer ties and improving communication, and with this trend, admissions into nursing homes are expected to increase as rehospitalizations and excessive lengths of stay are also seen as declining.

With rising acuity and staffing shortages of recent years, nursing homes have often been reluctant in admitting challenging cases that are referred to them from a nearby hospital if their staff are unable to meet medically complex needs ranging from behavioral health issues to those requiring more collaboration and sharing of resources.

But that seems to be changing, experts said.

Matt Nieukirk, director of skilled nursing facility practice at OSF Healthcare, and DeeAndra Sandgren, chief nursing officer for Evangelical Good Samaritan Society, discussed what factors are at play as the nursing home-hospital relationship continues to evolve. They spoke at Skilled Nursing News’ RETHINK conference in Chicago recently.

Overall, communication and collaboration can be refined further to manage patient flow between the hospital and nursing home setting, and ensure high quality patient care, they said, particularly for complex cases and those with behavioral health needs.

While OSF no longer owns nursing homes, the 17-hospital system has cultivated a partnership with 67 skilled nursing facilities, emphasizing the importance of quality and safety standards as criteria for its network.

OSF, which has health facilities across Illinois and Michigan, partnered with physiatry and care coordination group Puzzle Healthcare to deliver a care transition program to more than 50 of its SNF partners. OSF’s skilled nursing partners were able to cut readmission rates from 29% to 9% if they had Puzzle physiatrists in their facilities.

As for Good Samaritan, when it merged with Sanford Health in 2019, it drastically changed its SNF-hospital relationship, Sandgren said. That relationship, five years later is a “blossoming relationship” and has helped clinical teams move people out of hospitals and coordinate care with access to more than 1,000 doctors.

Higher acuity and the evolving SNF-hospital relationship

Closer partnerships with hospitals carry numerous benefits, and these make nursing homes less reluctant to admit more acute cases. That’s because nursing home staff can more easily get a specialist to review a certain issue with a patient, something they didn’t have access to before.

For certain complex cases, nursing home staff might even be sent to the hospital for training, or use a virtual care system to get training and support.

“That helps us, especially when you have [residents needing] wound care or behavioral health services, it can get really tricky,” she said. In areas where there isn’t a Sanford hospital nearby, Good Sam works with other hospital partners to try to make sure they can take the more challenging referrals.

For each of its hospitals, OSF looks at three to six nursing home partners in the immediate area. To Sandgren’s point, most operators in OSF’s preferred network already have liaisons in the hospital to help with complex cases.

“We’re working on readmission rates and trying to build a better relationship with those facilities. We’ve partnered with an organization that has allowed us to have that footprint in those nursing homes,” said Nieukirk, referring to Puzzle.

Puzzle physiatrists round sometimes five days a week, depending on complexity of cases and number of patients, he noted.

OSF looks for nursing homes that residents want to go to, rather than relying more so on the Five-Star Rating System, Nieukirk said. OSF, much like other hospital systems across the country, understand that five stars is tough to get, and was made even more difficult to obtain after the pandemic.

Nieukirk said hospital systems need to be ready to support their nursing home partners as well with resources, considering the acuity level of most nursing home residents being discharged from the hospital.

Accountability and results

Accountability when it comes to readmission metrics for both entities will help that relationship evolve as well, said Nieukirk. For OSF, those on the hospital end, Puzzle and SNFs in the preferred network meet regularly to review readmission numbers.

“The big focus for us was, we now have accountability in the skilled facilities. They’re reporting back to us, they’re reporting metrics,” Nieukirk said of preferred network nursing homes that have Puzzle physiatrists on hand. “They have a care management team that follows those patients post 90-day discharge from the skilled facilities.”

Physiatrists are sometimes calling patients every day post discharge, to make sure they have everything they need to be successful at home.

“We do readmission calls with a lot of our [nursing home partners], and we’ll actually have Puzzle on those calls giving those post-discharge metrics back to the facility so they see where they’re at as well.”

As for Good Sam, it has leaned a lot on its integrated electronic health records to help reduce readmissions. A lot of information shifts over to the right person much easier, including labs and other documentation.

“Our drug regimen review is much more robust because of [integrated electronic health records]. We’ve done some deep dives and found that mis-medication is often the root cause of a readmission. So that’s where we’re leaning toward,” said Sandgren.

There’s a lot of communication between nursing home staff and home health workers under the Sanford umbrella, she said, focusing on post-discharge metrics and re-hospitalization rates. On the other end of the care continuum, when a patient is getting ready to discharge from the hospital, a palliative care team may be brought in depending on the patient, to have that conversation about goals of care.

One area that still needs improvement: Prior authorization and denials of care. These still seem to be a big issue, said Nieukirk, but that issue is more connected to Medicare Advantage. The nonprofit hospital system works weekly with managed care organizations (MAOs) and nursing homes to improve prior authorizations, sometimes starting the authorization process themselves.