SNF skilled length of stay: Where's my cookie?
While reviewing the CMS document on Five-Star changes recently, I suddenly had a hankering for some cookies.
These cookies are the ones that everyone can make! There's no recipe needed. Of course, you may want to share these cookies with your friends. That means one batch needs to be gluten-free for Cheryl with celiac disease. And don't forget about Julia's walnut allergies, so her cookies need to be nut-free. Of course, Joe is watching his weight, so let's make his cookies sugar-free.
All of the sudden, I don't want to make cookies anymore, because my magic recipe doesn't work for everyone's needs.
So how are a SNF Length of Stay and discharge measurements related to cookies? Grab a glass a milk and let's dive in.
The “successful” Discharge to Community measure has created a lot of debate.
Let's look at the recipe (definition) for this Percentage of Short-Stay Residents Who Were Successfully Discharged to the Community measure: “An episode-based measure that looks at whether resident is successfully discharged within 100 days of admission and a successful discharge defined as those for which the beneficiary was not hospitalized, was not readmitted to a nursing home, and did not die in the 30 days after discharge.”
If i'm a provider, here are the questions I'm asking:
Does this mean my discharge-to-the-community resident cannot choose to have elective surgery OR require hospitalization for any reason including reasons completely unrelated to why they were in the SNF to begin with?
What if my discharge-to-the-community resident has a change in caregiver situation at home, or decides they actually liked the culture and care they received in a SNF, thus wanting to live there?
Do I need a crystal ball to know this resident will not pass from this life to the next?
CMS reviewed these concerns, but dismissed them because these scenarios of “unsuccessful” discharge-to-the community situations should be “few and far between.”
My takeaway is that either CMS wants this measure to have a cookie-cutter approach to care, or they want one cookie recipe to satisfy all beneficiaries.
But not only is this not true, it's not going to work. Until the measure becomes a “responsible” discharge-to-the-community versus a “successful” one, we will not truly see the value in this measure.
The LOS recipe needs variations. Skilled nursing facilities need to be given flexibility in the ingredients needed to make the recipe work for each individual beneficiary. SNFs need managed Medicare plans held accountable to this flexibility so that a discharge-to-the-community is a responsible discharge FIRST. After that, we can evaluate a “successful” discharge.
What does success mean? Well, much like a cookie recipe that sounds odd, the recipe for this “unsuccessful” discharge-to-the-community may not be bad after-all.
For example, let's review these factors:
Why would we want to create a path to infringing on the beneficiaries right to choose or modify their situation in the name of measurement?
Why would we NOT want a beneficiary to seek care in a less expensive situation if their home situation changes? What if their condition becomes complicated enough that could result in an expensive and unnecessary re-hospitalization related or unrelated to recent discharge?
Where is the balance of good clinical pathways and responsible and informed discharge planning with reasonable length of stays? There is a race to reduce LOS to 14 days, 7 days, 4 days - will there be actual healthcare savings?
I still want those cookies - but, like many providers, I think it's necessary to evaluate the recipe each time, to make sure those who are eating the baked goods are satisfied.
Tara Roberts, PT, is the Vice President of Rehabilitation and Wound Care Services at Nexion Health.