Nursing homes are facing greater pressure to prove their value as the Centers for Medicare and Medicaid Services (CMS) holds hospitals and ACOs more accountable for post-discharge costs, readmissions, length of stay and patient outcomes – factors that can influence which facilities hospitals end up choosing as referral partners. 

The changes mean SNFs should be prepared to demonstrate their ability to control costs and reduce rehospitalizations, according to Jennifer Edwards, census specialist at Therapy Management Corporation, who led a webinar on the impact of value-based care models, particularly the Transforming Episode Accountability Model (TEAM), on skilled nursing facilities (SNFs).

“Hospitals will face high pressure to partner with high-quality post-discharge partners. Hospitals will look for SNFs to help manage post-acute care costs,” she said. 

Traditional Medicare beneficiaries undergoing one of five surgical episode categories are participants in the TEAM model, with currently 720 hospitals participating, Edwards said.

This means SNFs should identify TEAM patients as early as possible and begin discharge planning on the first day of admission, she noted. And given that hospitals may not always identify a patient as part of a TEAM episode when making a referral, the facility will need to recognize the relevant diagnoses themselves, she advised. 

Providers should be aware of the five episode categories, which are coronary artery bypass graft, major bowel procedure, lower extremity joint replacement, surgical hip and femur fracture treatment and spinal fusion, Edwards said.

“This is important because we need to be on the lookout for these five diagnoses. Whether the team, whether the hospital is a TEAM model or not, the reason being is that not all hospitals will notify us upon referral or admission that they are a mandated TEAM hospital or that the patient that they’re referring to us falls within the TEAM model,” Edwards said. 

Moreover, AI is going to be key in helping SNFs measure future performance, Edwards said.  

“AI can assist us with exploration of missed opportunities based on trends, recommendations for improved reimbursement, identification of the need for clinical services expansion, and. and the big picture overall,” she said. 

SNFs should certainly be using their EMRs to track outcomes, length of stay, rehospitalizations and quality measures while identifying areas for improvement, Edwards said.

Future models affecting referrals 

Providers also need to accommodate for future models that will affect SNFs.

“So positioning ourselves for the launch of future models, as well as knowing where we’re positioned right now, will have a high impact on our referrals and our SNF skilled census,” Edwards said.

The ACO LEAD Model, for example, is scheduled to begin January 1, 2027, and will run for 10 years. It is intended to support smaller, independent, rural, and high-need practices and includes an SNF three-day waiver.

Meanwhile, the Comprehensive Care for Joint Replacement Expanded (CJR-X) model is scheduled to launch January 1, 2028. It will cover hip, knee, and inpatient ankle replacements and use a 90-day episode, compared with TEAM’s 30-day episode.

“The hospitals and physician groups that oversee these models will monitor our outcomes regularly and compare them to the competitors in our market,” Edwards said. “It’s plain and simple: if we don’t achieve these outcomes, we will not grow our skilled census.”

Edwards suggests SNFs should start by first identifying TEAM model hospitals.

“Reach out to the hospital team coordinator or post-acute care manager, … obtain the hospital’s expectations and maintain regular communication,” she said. “Discharge planning should start on the day of admission.”

Next, facilities should leverage existing technology or AI tools in place to track outcomes and stay current on value-based care changes. And last, she advises providers to remember that the goal is to discharge skilled patients to the next level of care as quickly and safely as possible. 

The TEAM Model also includes a three-day SNF waiver for qualifying facilities. However, a SNF must have a CMS rating of three stars or higher for at least seven of the previous 12 months. CMS updates the qualifying SNF list quarterly, she noted.  

Providers need to understand that TEAM could both create referral opportunities but also reduce certain sources of SNF census. Qualifying SNFs may be able to receive certain TEAM patients who otherwise might not meet the traditional three-day inpatient requirement. However, the shift to outpatient joint replacements and spinal procedures could mean that SNFs see fewer patients from these diagnoses because some patients may bypass inpatient hospitalization and receive post-acute care through home health or outpatient therapy instead.