I want to build on my conversation from last month and discuss how emerging payment and delivery models continue to drive efficiencies across the continuum of care, and how SNFs must demonstrate their value relative to competitors. One area where many SNFs have room to improve is medication management. Medication errors are common during transitions from the hospital to the SNF and SNF to home. Optimizing medication management services during care transitions will position SNFs as high-value partners in the preferred referral networks of hospitals and health systems.
Innovative SNFs have already begun to reduce medication errors by facilitating the transfer of medication information from the hospital, administering appropriate medications and supporting medication adherence once patients return home. Enhancing this communication ensures accurate and timely transference of a patient’s medication information. The successful SNFs use three key communication strategies:
1. Employ tools to coordinate admissions to the SNF with hospitals and other providers.
2. Engage pharmacists to dispense the most appropriate medications to patients.
3. Implement comprehensive education processes for discharge and follow-up.
If these steps were easy, all SNFs would employ such tactics. Unfortunately, however, medication management very easily breaks down during care transitions. Nineteen percent of all Medicare patients have an adverse event within 30 days of a hospital discharge, and two-thirds of those events are adverse drug events (Hines, 2010). In addition, according to the American Society of Clinical Pharmacists, 28% of total hospitalizations for seniors are due to adverse drug reactions. Medication error data from North Carolina SNFs suggest that from 2010 to 2011, 10 drug classes constituted more than 50% of all errors. For the 10 most commonly involved drug classes, nearly 50% were due to improper dosage.
The SNF is not always at fault though. A number of factors make medication management challenging for patients who transfer to a SNF following an acute care stay. SNF patients have a complex set of clinical needs, receive a high number of medications and experience multiple transitions across different sites of care. To manage medications safely, these transitions require effective and comprehensive communication across care teams — something that, as discussed, is not yet omnipresent. In fact, a recent survey of SNF-based nurses in Wisconsin (King B., et al) revealed that poor communication and transitions from acute to post-acute is the norm. The surveyed nurses highlighted three main communication breakdowns:
1. SNFs often receive multiple medication lists with missing and/or conflicting information.
2. Hospitals neglect to send signed prescriptions for controlled substances.
3. Care summaries are missing contact information for relevant personnel.
In response to these issues, SNFs often delay care and rush to coordinate with offsite long-term care pharmacies to acquire different medications, creating sub-optimal and error-prone care. When returning home, these patients are often unprepared to manage their medications. Discussing medications before discharge would go a long way toward adherence once patients arrive home. However, the Health and Human Services Office of Inspector General has found that SNFs did not meet discharge planning requirements for 31 percent of stays.
Emerging hospital-based payment and delivery models also are making SNFs’ jobs more difficult. These new models drive hospitals to discriminate among SNFs based on quality. Successful SNFs will position themselves by improving quality of care and providing superior medication management. Only recently have quality and reputation become competitive differentiators for SNFs. In the past, hospitals discharged patients to SNFs based primarily on bed availability and whether the SNF had the basic capabilities to manage the patient’s care. Now, stakeholders are seeking value-based partnerships.
Under the Hospital Inpatient Value-Based Purchasing and the Hospital Readmissions Reduction Programs, Congress and CMS have implemented payment penalties for hospitals that exceed benchmark episode costs and readmission rates. As hospitals attempt to narrow their networks of post-acute referral partners, they will pay closer attention to SNF performance on readmission rates and other quality indicators affected by these and other programs. That information is increasingly transparent, with resources such as Nursing Home Compare including measures related to medication management.
As a whole, these processes will come easily for some SNFs, while others will fall even further out of favor with acute care providers. If SNFs follow the three proven communications steps listed above, they will be on the right path toward success.
Anne Tumlinson is Senior Vice President at Avalere Health.