Hospitals in bundled payment initiatives steering patients away from SNFs: study

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t’s clear from the results that hospitals are looking to reduce SNF use, said lead author Jane Zhu.
t’s clear from the results that hospitals are looking to reduce SNF use, said lead author Jane Zhu.

Hospitals participating in bundled payment efforts are actively reducing the use of skilled nursing care in their respective areas. That's one of the key takeaways from a new study out of the University of Pennsylvania, published Monday in Health Affairs.

Skilled care is a big driver of cost growth and variation in Medicare, the authors note. In 2015 alone, about 20% of Medicare fee-for-service hospital admissions went to a SNF, despite scant evidence that this is the optimal post-acute setting, or that a nursing home helps improve quality, Penn researchers wrote.

For those reasons, the Centers for Medicare & Medicaid Services has undertaken both the Bundled Payments for Care Improvement initiative and the Comprehensive Care for Joint Replacement model in an effort to eradicate some of that cost variation. Wanting to better understand how hospitals are navigating these waters, researchers interviewed leaders at 22 institutions taking part in those two CMS bundled pay efforts.

It's clear from the results that hospitals are looking to reduce SNF use, said Jane Zhu, lead author and a national clinician scholar and fellow in the Division of General Internal Medicine at Penn's Perelman School of Medicine.

“For the past couple of decades, we've had a persistent increase in SNF utilization across the country, but it's still very unclear what the benefit ultimately is for patients, and what the optimal post-acute setting is,” she told McKnight's. “As bundled payment incentives force hospitals to think along the lines of total cost of care, they're starting to see that, for certain patients, skilled nursing facilities offer no greater benefit and are more expensive than other venues.”

Often, hospitals are reducing SNF referrals by using risk-stratification tools, better educating patients, providing care support at home, and better linking up with home health agencies to smooth out any discharge hiccups.

Other hospitals, meanwhile, are strengthening bonds with nursing homes, researchers found. Fifteen institutions formed networks of preferred SNFs, aiming to exert influence over cost and quality. Typical tactics found included linking electronic medical records, embedding a hospital provider in the nursing home and hiring dedicated care coordination staffers.

Most often, hospitals are partnering with SNFs with which they are familiar and have trust, rather than reaching out to new partners, authors added.

Zhu's three key takeaways for skilled nursing operators:

  1. Payment really matters. Hospitals have been “really conscientiously and in a very collective manner reorganizing the way that they are thinking about post-acute care, and specifically trying to save costs, along those lines.” The payment structure is having a distinct effect on hospitals' behavior.
  2. The extent to which these practices have been disseminated is unclear. Some of the things hospitals are doing have “enormous implications” for skilled nursing facilities. Hospitals are really trying to move away from SNF use, particularly for joint replacement patients. They are trying to then integrate and coordinate care with skilled nursing facilities through a variety of different structures.
  3. There's uncertainty over what the ultimate implications are for SNFs. There is a question of what sorts of pressures SNFs will face, given these hospital practices.
“SNFs are not only under heavy pressure to work more closely with hospitals and to compete to be the desired referral partner,” Zhu said, “but they're also facing downward referral pressures as hospitals try to send their patients, more and more frequently, home.” Future research may expand on how nursing homes are responding to this trend, she added.