By BRIAN HOLZER MD, MBA
Leaders in hospitals and health systems as well as post-acute care providers such as skilled nursing facilities (SNFs) and Home Health Care (HHC) agencies operate in a complex environment. Currently, the health care reimbursement environment is largely dominated by fee-for-service models. However, acute and post-acute leaders must increasingly position their organizations to prepare for, and participate in, evolving value-based care programs—without losing sight of the current fee-for-service reimbursement structure.
With that said, the call to action for acute and post-acute providers working at both ends of the reimbursement spectrum is real. The time is now to innovate, test and adopt new post-acute care models to support each patient’s transition from hospital to post-acute settings, and eventually home to enable a better care experience for patients and their care teams.
This is especially relevant for Skilled Nursing Facilities (SNFs) and chains that meet the current Medicare requirements for Part A coverage. Increasingly, the SNF industry is under pressure from the Medicare program to improve coordination and outcomes. Medicare’s hospital readmission policy and value-based purchasing program (VBP), bundled payments, and ACOs encourage SNFs, and other post-acute settings, to avoid readmissions. In addition, earlier this year, the Centers for Medicare and Medicaid Services (CMS) finalized a new patient-driven payment model (PDPM) for SNFs, which will go into effect on October 1, 2019. The overhaul of the entire system will require significant staff focus and operational changes.
Care management solutions will be particularly helpful as SNFs operate under the recently imposed SNF VBP. Specifically, models that assist SNFs in reducing their 30-day hospital readmission measure and better manage performance scores, which may increase the facility’s Medicare incentive payments. This will undoubtedly require investments in internally developed and/or outsourced solutions that engage patients after discharge from the facility for a period of at least 30 days, whether or not the patient is under the care of a home health company. Telephonic patient engagement, in particular, with clinically trained resources during this 30-day period of time can serve to efficiently:
- Screen for fall risk and depression, and identify common gaps including concerns related to medications, home medical equipment, physician appointments, and necessary medical services such as home health
- Assess for site of care needs with coordination for patients who may be better served back in a SNF for a shorter therapy stay, which does not require another three-day hospital qualifying stay
- Assess for site of care needs with coordination for patients who may be better served in Home Health Care or assisted living or independent living residences, which can serve as appropriate alternatives to unnecessary emergency room visits or hospital readmissions
There’s an urgent need for additional post-acute care management services supporting holistic patient transitions and operations, and providers need to take actions now or run the risk that the decisions will be made for them. The time is now for acute and post-acute care providers to consider solutions that help deliver effective care management and improve patient engagement across the post-acute care continuum.
MedPAC recently highlighted drops in readmit rates from SNF back to the hospital, but an increase from SNF to home, back to SNF. Facilities will have to weigh the lite-ish CMS penalty over hiring new personnel (difficult in PAC space) along with the costs of putting programs together.
SNFs are unable to even afford 30-50K/yr for off-hours telemedicine support; add that to costs of regulatory burdens, and I think the time it will take to focus the industry on this problem will be prolonged. Follow up calls, however, do have merit–both to troubleshoot and as a patient/family engagement tool.
The PDMP will change the mix of SNF patients (“cost neutral”), and perhaps, by refocusing what happens inside SNFs, good things will happen outside them by dint of altering their angle of care for the longer game (>30 days out).
I don’t disagree with the thrust of the article, but I fail to see any evidence that it is talking about anything REMOTELY related to patient engagement. It talks about develping systems to better assess patient risks and needs. It reminds me of Inigo Montoya’s comment in The Princess Bride: “You keep using that word. I do not think it means what you think it means.”
Engagement, along with quality, transformation and patient-centered, is one of those words that means nothing, everything, and anything – all depends on who’s using it.
Well, I think what you say about enhancing patient engagement after post acute care is right. It seems a truism. But I’m not sure this is the time to start trying to find packages of services so that value-based purchasing can occur. The reason is that after acute care, the range of services needed seems to be higher than before acute care…because at this later time you have all the unpredictable health problems like delirium, drug reactions, pulmonary emboli and DVTs, frailty and all its problems, slow wound healing, infections, UTIs, bronchopneumonia, diabetic complications, worsening of angina, asthma and copd, skin problems from stasis…you know the endless list.
In other words, it seems the wrong time to be searching for packages that will enable value-based health care.
Theoretically, you could have the hospital offer a price for all these possible services that might be needed say for three months after an acute care episode, but then the hospital would have to own the SNF’s etc. Impractical at this time.
It’s probably better to shift the financial risks to the purchaser–who is so dominant anyway. In other words make the purchaser say, after it collects all the fee-for-service claims: “this is what we are going to pay”. And let it take the political heat if the coverage is blatently inadequate.
I’m afraid if we start insisting on VBP from SNFs etc that we are going to put a lot of these firms out of business. They are not risk underwriters or actuaries.
Well and good, but there is no nationally and locally supported strategy to assure that enhanced Primary Healthcare is equitably available and ecologically accessible, community by community and neighborhood by neighborhood. Engagement should begin with a high degree of Trust that exists between the healthcare team and each person/family unit regarding their healthcare plan, aka Personal Survival Plan. I offer a “trail head” reference that connects Trust with Health along with its reverse causality.
Giordano and Martin “Trust and Health: testing the reverse causality hypothesis” http://dx.doi.org/10.1136/jech-2015-205822
So, the future of successful SNF financing and health spending generally will be related to how we solve the requirements for available and accessible ENHANCED Primary Healthcare that is offered to each citizen within every community?