5 BIG Barriers SNFs Can Overcome with Value-Based Relationships

By August 31, 2021 November 9th, 2021 No Comments
Value-based care models have great potential to succeed but require smart partnerships. In this article, Integrated Care Solutions (ICS) discusses how care coordination closes the gaps in care to enable risk-bearing partnerships to thrive.

Care Coordination Closes the Gaps in Care to Enable ‘Value’ Partnerships to Thrive

Skilled nursing facilities (SNFs) are often operating alone—like a ship in a storm—braving the incessant waves of financial and regulatory pressure, census squeeze, and staffing strain, all the while trying to create positive patient experiences.

August 31, 2021

Now pained by the pandemic, SNF operators are beginning to reconsider their traditional silos and join forces with risk-bearing organizations to help calm the water. 

Meanwhile, value-based care entities such as accountable care organizations (ACOs) and direct contracting entities (DCEs) are motivated to drive down costs and improve their performance metrics, and they are looking to SNFs. After all, a significant portion of the Medicare population utilizes SNF services annually, making SNFs pivotal partners in lowering total cost of care. 

“I will say regardless of a pandemic or not, post-acute partners are instrumental in the success of an ACO, and hopefully you don’t hear anything different,” MJ Tran, ACO Executive Director for HCA Healthcare, told attendees at the Synergy Summit, sponsored by Synergy HCA and SRX, over the summer. 

However, as in any relationship, there can be misalignment. From the perspective of ACOs, figuring out how to work with SNFs remains a challenge. Whether it is SNF length of stay (LOS), utilization, or readmissions, 40 percent of ACOs had a SNF per member per year (PMPY) over $700, according to a CareJourney report. 

Reducing those numbers and ensuring a successful journey for organizations working with SNFs in these value-based care models require a master mariner to steer the ship. 

That captain is care coordination. 

In the following article, Integrated Care Solutions’ (ICS) CEO Brian Fuller and VP of Clinical Integration and Operations Andrea Rizik (RN) identify five of the most significant barriers facing SNFs and how care coordination closes the gaps in value-based partnerships.

Barrier #1: Misaligned Incentives

We know this to be true in healthcare: Incentives are inconsistent.

Skilled nursing is the only per diem paid Medicare service, which can encourage longer stays than medically necessary. Alternatively, value-based organizations are incentivized to transition patients efficiently and remove barriers to discharge. 

“An entity like an ACO or DCE has a fixed payment,” Fuller explains. “So the more days their patients are in SNF, the more that’s eating away at that fixed payment. I think that’s a big barrier. However, SNFs have the choice to take on risk, and a gateway for them to do so is re-evaluating their risk-agnostic approach to patient care through value-based partnerships.”

“If a [skilled nursing] facility is willing to take risk as we continue on this arc from fee-for-service to value, if we can find partners on the post-acute side that want to take some risk with us or embed themselves in a different kind of relationship with us … that signals to us that facility’s overall alignment with what we’re trying to do.”

Dr. Nihar R. Desai, Medical Director for Value Innovation at Yale-New Haven Health (Synergy Summit 2021)

Barrier #2: Fragmented Process & Discharge Planning

Unlike care coordination teams, SNFs are not hard-wired to think about processes nor hyper-focused on mapping out the most efficient pathway to achieve patients’ goals and reduce SNF LOS. 

SNFs often view discharge planning as a process for patients on their way out of a care setting. It’s more than that—it’s dynamic and evolving and customized for every patient. Many care settings have their own processes for discharge planning, but not all are created equal. 

“Discharge planning ideally should begin immediately upon admission,” Rizik says. ”It’s a misconception that hospitals or skilled nursing facilities feel they don’t have to address discharge planning until patients are ‘ready to go home.’ Our mantra is that ‘discharge planning starts on day one upon admission.’ Every aspect of the patient’s needs—physical, social, and emotional—should be taken into account through the transition.”

Barrier #3: Constrained Coverage & Quality of Care

The domino effect of the pandemic (population loss, fewer patients discharged to SNFs, and burnt-out staff) has reduced the quality of care.  

“The average size of a SNF in the U.S. is 120 beds often with an RN-to-patient ratio of more than 20-to-1 and could be much higher on nights and weekends,” says Fuller. “An average hospital medical-surgical unit has one nurse for every five patients. That’s an impossible load to carry to provide high-quality care given the increasing acuity and needs of patients admitted to an SNF.” 

In fact, Rizik has heard of social workers being in charge of discharge for hundreds of patients. It’s another impossible clinical reality where the patient ultimately suffers from a lack of quality care. 

“Many readmissions occur during second-or-third shift or over the weekend,” Rizik says, “Mid-level providers or physicians may not be on-site to evaluate patients before they are sent to the hospital. Additionally, due to limited nursing resources, aggressive clinical interventions may not mitigate an emergency room visit.”

“There are many SNFs that share personnel,” Rizik continues. “We work with several SNFs that share social workers between different buildings. They may not even be in the building when needed. We work with several SNFs that also share therapy resources.”

Quality also is reliant on consistency, but a wide range of inconsistencies take place at SNFs. Rizik notes that while one SNF may routinely schedule blood work for a patient with sepsis, another SNF may only do it every two weeks, leading to a decline in a patient’s clinical status and resulting in an emergent situation. 

Barrier #4: Inexperience in Advanced Care Planning

Another barrier that SNFs have is inexperience in identifying patients near end-of-life and communicating their needs to providers and loved ones. As a culture, broaching the topic of death is unapproachable or considered taboo.

“Advanced care planning is often not discussed—what the patient’s code status is or what the patient’s desires are,” Rizik says. “We can be the agents of conversation by identifying those patients who may have had redundant readmissions and may be approaching end-of-life. We also have the specialty to handle these conversations sensitively for patients and families, and the ability to communicate their needs to the care providers.”


Disconnected Clinical, Operational, Financial, and Reimbursement Knowledge

The biggest benefit of care coordination is creating a “connector” that integrates clinical, operational, and financial goals for SNFs and the ACOs or DCEs that partner with them. Both are separately working within constantly changing regulatory policies that affect operations, reimbursement, and patient care. All of the “gaps” discussed here boil down to this point. 

“Entities struggle to coordinate care and the SNF relationship because they don’t understand the very complex and unique clinical, operational, financial, and reimbursement environment,” Fuller says. “They may understand the clinical, but they don’t understand what operationally makes it work or not work. They may understand the operations, but they don’t understand the reimbursement environment that’s driving decisions. The other important point is that even if you learn it all today, you can’t necessarily apply it tomorrow because the regulatory environment is constantly changing. It’s really hard for value-based organizations to be effective in coordinating care in that evolving environment without additional support from a knowledgeable care coordination partner.”

Care coordination teams truly coordinate all tangibles and intangibles through boots-on-the-ground patient micromanagement, constant communication, and regulatory expertise to ensure all those in the relationship maximize their results for success. 

“For care transformation to occur, skilled nursing teams have to have the right mindset,” Fuller says. “They have to be a downstream provider that organizations like ACOs and DCEs have confidence in to manage the patient’s needs. Even then, to close all gaps in care, the partnership must include care coordination to continually make sure there is a high-clinical acuity and optimal regulatory understanding to succeed in a value-based model.”

“If you don’t have a team member who understands all of these dynamics, it’s really hard to influence change in care,” he says.  

ICS helps organizations transform from fee-for-service to value-based care and delivers ongoing care coordination, consulting, and expertise in data-driven processes necessary to achieve quality care and financial success. If you are an ACO, DCE, hospital, or payer in need of a partner with expertise in value-based care and proven results working with risk-bearing organizations, contact ICS today for a free consultation.

ICS has built a Transition and Throughput Expectations (TTE) Checklist to ensure the highest standard of care while making transitional care seamless for patients and providers. Some of the highlights include:

  • Ensure communication with ICS Clinical Integration Nurse (CIN) within 24 business hours of notification of the patient.
  • Establish Anticipated Date of Discharge (ADOD) based on established nursing and therapy goals.
  • Identify patient/care partner education and training to be completed prior to transition/discharge.
  • If home health is the anticipated next level of care, initiate referral.
  • After discussion with patient and care partner, make appointment with primary community provider for approximately 5-7 days after discharge.
  • Final medication reconciliation and all teaching with repeat demonstration completed and share list with ICS and post-discharge providers.

Though this list only includes a few bullets, the actual checklist has nearly 30 to-do’s—within defined timelines of the patient stay—that cover process, quality, and patient oversight throughout the continuum, preventing any gaps in care.


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