Steven Littlehale
Steven Littlehale

The recent publication of the SNF PPS Proposed rule for FY 2017 contains regulations that seek to unite post-acute providers by aligning payment incentives and overlapping value-based penalties.

It might be trickier than it looks to many.

As we have seen with the hospital readmission reduction program (HRRP), events that occur after leaving one care center have an impact on the reimbursement of the discharging care provider. Hospitals responded by narrowing their network of post-acute providers to increase likelihood of success, and now skilled nursing centers face a similar need to get smart about their post SNF referral network.

The PAMA regulation resulted in a promise to withhold 2% of SNF payments in FY 2019 and return a portion of those monies to providers with better rehospitalization outcomes, thus operationalizing the Centers for Medicare & Medicaid Services requirement of value-based payments.

The regulations require CMS to introduce only one rehospitalization quality measure at a time; they will begin with Skilled Nursing Facility Rehospitalization Measure (SNFRM NQF 2510). In the FY 2017 proposed rule they introduced a new measure Skilled Nursing Facility 30-day Potentially Preventable Readmission Measure (SNFPPR).  This new measure is a result of harmonizing the previously proposed SNF penalty (NQF 2510) with the currently in use hospital penalty (NQF 1789).

Now SNF providers will see firsthand the impact of having “too many” rehospitalizations not only within their care, but also anytime in the first 30 days after leaving a hospital, which often includes days post-discharge from the SNF. While these penalty payments won’t go into effect until fiscal 2019, it is based upon SNF performance now. In order to establish payment penalties, CMS has to understand past performance of the industry as a whole, determine what it means to be “good”, “better” or “worse” than others, and then measure both SNF performance and improvement over time.

The SNF baseline performance is being established from CY 2015, and CMS will use most of 2016 to calculate SNF performance and improvement models. By no later than August 2017, SNF providers will find out their performance improvement over 2015 baseline rates, and how PPS payments for all of fiscal 2019 will be impacted.

What can you do today? You’ve likely been tracking your 30-day rehospitalization rate but limiting your calculations to activity while the person is in residency at the SNF.

If your new Five-Star Rehospitalization QM appears much higher than your calculations, it could be due to rehospitalizations post-discharge from the SNF yet within 30 days of hospital discharge.

Knowing how to evaluate Home Health Agencies (HHAs) is a critical first step. Look at the performance of your HHA partners: How well do they perform compared to other HHAs? The data found on Home Health Compare offers insights to build a ‘smart network’ for downstream referral. While beneficiaries have a choice when selecting providers, you can help them make an informed decision by using then online Five Star Scores listed on Home Health Compare.

The Five Star Rating for HHAs includes a Quality of Patient Care domain, which looks at quality process measures including care transition concerns such as timely initiation of care, medication education and pain assessment. The patient experience of care survey provides insight into satisfaction with care, communication between their providers, and other specific care issues. When used properly, these data serve as the cornerstone of your referral strategy.   

In many ways, your goals are aligned with those of the home health agencies, as they are also held accountable for acute-care hospitalizations, ED use and rehospitalization.

Invite your local home health leadership to your facility to discuss successful care transitions, talk with them about best practices for high-risk discharges and jointly conduct root-cause analysis on cases that have failed. Through process improvement and continuous collaboration you will set yourself and your HHA partners up for success — all well ahead of the IMPACT Act’s timelines for these very activities.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.