Recently released research affirmed what skilled nursing operators know all too well: Medicare Advantage requirements are creating impediments to patients’ timely care transitions.

That’s according to SNF provider leaders who spoke with Skilled Nursing News (SNN) in the wake of a JAMA study outlining how Medicare Advantage patients averaged longer pre-SNF hospital stays than traditional Medicare patients. 

There are some possible mitigating factors at play in the data, but the findings reflect a serious threat to patient wellbeing and SNFs’ operational and financial soundness. But there are steps that skilled nursing providers can take to address this issue – namely, working more closely with hospital partners, as well as making sure they are ready both clinically and in terms of payer processes to move expeditiously on admissions.

Approval process delaying care

The JAMA study looked at data on hospital discharges to skilled nursing for Medicare Advantage and Medicare beneficiaries from 2017 to 2023. A large chunk of that time was during the COVID-19 pandemic, which may have affected discharge rates, said Brian Ellsworth, VP for public policy and payment transformation for Health Dimensions Group (HDG).

“After the onset of the pandemic, there was a 14% drop in the per Medicare beneficiary use rate of nursing homes nationally,” Ellsworth explained. “In some markets, such as Wisconsin, it was even more pronounced. During that time, HDG worked with several health systems who were experiencing significant problems with hard-to-place patients to develop a deeper partnership with post-acute providers. The increase in avoidable days in hospitals was very pervasive.”

HDG provides management services to more than 50 senior living and care communities in nine states, including independent living, assisted living, memory care, skilled nursing facilities and life plan communities.

Ellsworth proposed another factor in the increased length of stay may be due to a shift in discharge patterns, with home health being the first option.

“In Western Pennsylvania, for example, there was a pronounced shift to home health care driven by a shift to Medicare Advantage as well as to managed long-term care,” he explained. “The upshot of this trend means that more acutely ill patients were being sent to SNFs, which in turn leads to longer stays in hospitals prior to entering skilled nursing.”

The study’s authors did point out capacity issues the pandemic caused, but they also looked at Medicare Advantage requirements, which can make discharge difficult.

The patient may be ready to transfer to a new level of care before an approval comes in, Holly Bowen, chief clinical officer for Idaho-based Cascadia Healthcare, told Skilled Nursing News. She pushed back on the idea that SNF capacity was the cause for delayed discharge, citing the administrative burden of MA plans.

“Hospitals are holding patients longer while waiting for Medicare Advantage authorizations or in-network placement,” she said. “This is especially common with higher-acuity residents who clearly need skilled care — wound management, IV antibiotics, or respiratory support. By the time those patients reach us, they’ve often lost strength and function, and the window for recovery is smaller.”

Cascadia operates skilled nursing and senior living communities across Arizona, Idaho, Montana, Oregon and Washington.

In a worst-case scenario, a patient might enter into what the researchers described as a “rehabbed to death” cycle. Bowen has seen that this pattern is all too possible, noting that unnecessarily extending a hospital stay creates serious threats to patient health and wellbeing, including infection, deconditioning and delirium.

“In some cases, they also fall into that ‘rehab to death’ cycle … where care intensity continues past what’s clinically appropriate simply because transitions are delayed,” she said.

Ellsworth concurred with this assessment, explaining the issue affects routine discharges more than hard-to-place patients.

“We have consistently seen an extra one to three days in the hospital for Medicare Advantage patients discharged to SNFs vs. traditional Medicare,” he said.

Moving at ‘clinical speed’

SNFs, managed care plans and hospitals must work together to ensure patients receive the right kind of care at the right time, Bowen and Ellsworth agreed. SNF providers can take the lead on that effort with communication efforts.

Many SNFs are already implementing processes that allow for faster care coordination, Bowen explained. In terms of best practices, she cited rapid-response admission teams that can accept and categorize a new patient the same day the physician sends orders.

Providers who standardize their documentation so admission packets are ready to go when an admission comes in, as well as have authorization specialists to coordinate with MA case managers on a daily basis, also see improved results.

Ellsworth advocates for close relationships with referral partners, noting it is especially important that the hospital knows exactly what level of acuity a facility can accept.

“With the adoption of PDPM [the Patient Driven Payment Model] by many state Medicaid programs, it should be more attractive for SNFs to take heavier care patients from hospitals. The closer the partnership is with hospitals, the more the barriers to SNF admission will be addressed,” he said.

Bowen explained that ultimately, change will come from additional Centers for Medicaid & Medicare Services (CMS) oversight into how managed care plans are approving skilled nursing. She said providers should partner with hospitals and state and national associations “to push for standardized, expedited authorization pathways. We need the policy and payer structures to let us do what we do best — restore function, preserve dignity, and deliver value-based care.”

Ellsworth conveyed a similar message.

“This is a longstanding problem that Congress and CMS are attempting to chip away at, but the jury is out on how effective public policy solutions will be,” he said.

Solving this issue is of paramount importance, given the problems that inappropriately delayed hospital discharges create. Patients are at risk of complications and poor outcomes, hospitals experience bed shortages and emergency departments get backed up, while SNF providers experience more unpredictable admissions, harming census, staffing and care flow, according to Bowen.

“When care aligns with a patient’s goals and moves at clinical speed, everyone wins,” she said. “Skilled nursing facilities aren’t the bottleneck; we’re the bridge. We just need the policy and payer structures to let us do what we do best — restore function, preserve dignity and deliver value-based care.”