The value-based care payment model, Transforming Episode Accountability Model (TEAM), is confronting challenges related to communication and interoperability across hospitals and nursing homes, including the timely identification of potential TEAM-eligible patients.
Moreover, some clinical leaders believe the three-day inpatient stay waiver for TEAM could use a revamp to include additional episodes of care to account for shorter hospital stays for many procedures for which patients should still be able staying a nursing home to recover after the surgery.
As part of the Centers for Medicare and Medicaid Services’ (CMS) broader push toward value-based care, TEAM creates financial incentives for providers to coordinate care, manage costs, and improve outcomes across an episode of care. Given this, it makes sense for hospitals and SNFs to be on the same page. And yet, according to experts, this is not the case because providers do not have timely access to the same patient information or clear communication about a patient’s TEAM status.
“The biggest challenge is lack of communication,” Michelle Stuercke, chief clinical officer at TCM Consulting and Management, told Skilled Nursing News. “Often times the facilities are not aware the resident is a TEAM patient.”
And there continues to be issues with data exchange between hospitals and nursing homes, she said.
“There is not always seamless interoperability between hospital and post-acute care providers medical record systems,” Stuercke noted.
Skilled nursing facilities (SNFs) need to identify potential TEAM patients early and communicate with the hospital because the hospital’s TEAM accountability can make the decision about inpatient days, the three-day requirement, and use of the waiver financially important to both organizations, said Jennifer Edwards, census specialist at Therapy Management Corporation.
For TEAM episodes – currently five types of surgical procedures – the Medicare three-day hospital stay requirement is waived.
“If we get a referral for someone who looks or appears to be in one of those five surgical or procedure episodes, that’s when we need to put up our radar,” Edwards said. “Sometimes we can make assumptions that they’re a TEAM patient, but where it gets a little tricky is with the three-day waiver. If we’re going to utilize the waiver, we really need to get concrete information from the hospital.”
The five episodes are lower extremity joint replacement, primarily hip and knee replacements; major bowel procedures, involving certain major surgeries of the bowel; major lower extremity fracture treatment, involving surgical treatment of certain major fractures of the lower extremities; spinal fusion, involving certain spinal fusion procedures; and coronary artery bypass graft (CABG), which is bypass surgery for coronary artery disease.
Clinical reality is changing
CMS needs to broaden the scope of the three-day stay waiver to more fully incorporate the improvements in surgical methods made over a decade. Some procedures can now result in a same-day discharge but could still need a SNF stay. Currently, for many such procedures, SNF stays aren’t covered.
Lisa Chubb, chief nursing officer for Venza Care, argues that the three-day stay rule is increasingly misaligned with how care is delivered these days. As hospitals shorten stays and shift procedures such as hip replacements to outpatient or observation status, due to more minimally invasive surgical procedures and improvements in recovery time for processes that used to typically require SNF stay, patients who could benefit from skilled nursing rehabilitation may never meet the inpatient requirement for SNF coverage. That creates a disconnect between the hospital’s increasingly compressed episode and the SNF’s ability to participate in the patient’s recovery.
“We all know the length of stay at a hospital is becoming shorter and shorter,” Chubb told SNN. “For a hip replacement, I would say five to 10 years ago we were taking care of those patients in skilled nursing, and they were having a short rehab stay and going back home, and now these folks are literally almost having an outpatient stay for a hip replacement and going home that evening or the next day. So, there are very little inpatient stays that require a three-midnight stay.”
For a model like TEAM, which emphasizes accountability and coordination across an episode of care, the three-midnight rule could limit SNFs’ ability to participate in the episode even when post-acute skilled care is clinically appropriate. In other words, the payment-eligibility rule may work against the model’s goal of coordinating care across settings because patients can be discharged from the hospital before they satisfy the threshold for SNF coverage.
CMS needs to conceptualize the three-day rule to reflect today’s shorter hospital stays and evolving care pathways, rather than relying on an inpatient-stay threshold that may no longer match clinical reality, she said.
“And so it might be something that CMS needs to look at, and we need to challenge the process as operators to say, ‘this doesn’t really work anymore.’ We’re changing things all the time internally. We’re changing from the external forces … but it’s definitely something that CMS needs to look at and rethink,” Chubb said.
Inpatient versus observational stay hiccups
And as for those surgeries not covered by TEAM and the three-day stay waiver, it seems that hospitals are placing SNF-destined patients mostly correctly into the “inpatient status” versus the “observational stay.”
That said, there may be a small portion placed into an observational stay, which would then cause them to not qualify for a SNF stay.
“The observational period is definitely a pain point for us. As far as the three-day rule goes relative to the TEAM model, that’s pretty well defined so we shouldn’t come up against that observation period,” Edwards said, adding however, “It’s something that we definitely need to continue to make sure and monitor and communicate with the hospital.”
Some hospitals can at times discharge to SNFs even when the patient doesn’t have a qualifying stay and is not covered by the three-day waiver.
“We are still seeing that most of the individuals are meeting the three-day rule. Unfortunately, often times when the three-day rule is not met, [it is because] the individual does not have a qualifying diagnosis,” Stuercke told SNN.
And that means SNFs can miss out on revenue.
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