In a healthcare system perpetually challenged with care coordination, older patients – especially those admitted to skilled nursing facilities – represent the biggest challenge of all.

Many of these patients have multiple chronic conditions, treated by multiple providers and are on complex regimens. They also often have memory or mobility issues that limit their ability to manage their own care. These factors leave them especially vulnerable to adverse events and too frequent hospital readmissions. A 2010 report found that 23.5% of Medicare beneficiaries discharged from a hospital to an SNF were readmitted within 30 days.

And those hospital readmissions continue to drive up healthcare costs substantially. More recent figures from CMS show only slight improvement over the 2010 report, with current estimates of nearly 20% of Medicare patients discharged from a hospital readmitted within 30 days — at a cost of more than $26 billion per year.

In the face of CMS penalties designed to reduce excessive readmissions, SNFs have begun relying on hospital liaisons or skilled care coordinators to improve patient outcomes. While an important step, it is still challenging as not all SNFs have the ability to add personnel and, perhaps more importantly, has not been shown to reduce readmission rates as much as needed. 

One essential problem: SNFs rarely have visibility into patient medical records outside their own operations and can’t easily follow patient activity once they leave.

Putting the SNF patient at the center of care

This situation calls for new tools that track clinical events by patients rather than by facilities, with more complete patient histories and the means to track patients through care transitions. In effect, such tools enable better care coordination by addressing an inherent problem in healthcare’s patchwork of disparate and dissimilar EMRs.

EMRs have always been built around the needs of a specific setting, whether primary care, specialty, outpatient, inpatient, post-acute or long-term. For SNF patients, this can mean separate medical records housed at a half-dozen or more facilities.

Consonus, a nationwide provider of rehab, pharmacy and post-acute care transformation services in over 300 SNFs, recently addressed this challenge by partnering with the Collective Medical care collaboration network. Collective’s risk-adjusted and real-time event notification platform, which tracks clinical events by patients rather than by facilities, now provides Consonus SNFs with patient records of clinical events and histories across their care communities, issuing real-time provider notifications with every transition.

By receiving clinical insights that put patients rather than providers and facilities at the center of medical records, SNFs can realize far greater care continuity, and ultimately reduce readmissions.

Improving continuity of care

Providers at Consonus-sponsored SNFs can now collaborate more closely with hospitals, health systems and community providers, regardless of technology infrastructure. These SNFs who used to receive only the patient’s record from the referring facility (or less) now have more comprehensive patient histories. In many cases, this includes information regarding care guidelines and plans, care team, ED utilization patterns and advance directives and prescription histories—all of which provide insights into a patient’s readmission risks and help SNFs make better care decisions.

Having a much more insightful patient record enables greater care coordination that can eliminate unnecessary tests and duplicative treatments, increase patient safety in medication management, inform care generally within the SNF, streamline transitions of care through a strengthened referral network and even better estimated lengths of stay helping to manage discharge planning more efficiently.

Reducing readmissions

Having a more complete view of patients will help SNFs to reduce readmissions and associated penalties. This confidence rests in part on being able to provide better-informed care during a patient’s SNF stay. It also provides an opportunity for collaboration outside the walls of the SNFs so care managers associated with ACOs and health plans can also assist during these transitions.

With a view into the patient’s continuing care in and out of their four walls, a care manager can then oversee the transition from a SNF to a home environment, remain apprised of ongoing care and even arrange to directly readmit the patient to the SNF if appropriate to avoid hospital readmission. When a patient does need hospital readmission, the SNF knows the patient’s activity immediately after discharge, enabling outreach for care collaboration and reengagement, including a return to the SNF if necessary for their health.

The digitization of patient information ushered in by EMRs is unquestionably valuable. But the unintentional creation of silos of information not easily shared across facilities is a shortcoming that most impacts older patients with multiple chronic conditions. When providers have only partial insight into these patients’ histories and conditions, their care can be compromised within a SNF and post-discharge, increasing their chances of hospital readmission.

By adopting automation tools designed specifically to address this issue along with adding skilled care coordinators, SNFs can take a highly productive step toward improving the lives of their patients — and put a more serious dent in the current $26 million in annual readmission costs for Medicare patients.

Benjamin Zaniello, M.D., is a Seattle-based practicing physician and chief medical officer of Collective Medical.