The “rapid” adoption of SNFists, or clinicians specializing in skilled nursing care, has increased Medicare referrals for facilities that use them. But it has not led to reduced rehospitalizations, a new study finds.
“Facilities that adopted SNFists were able to shift the case mix to postacute care without an increase in rehospitalization rates, which may incentivize facilities to adopt models of care based on SNFists,” researchers with the Perelman School of Medicine at the University of Pennsylvania and the Division of Health Policy and Economics at Weill Cornell Medical College reported in JAMA Network Open Wednesday.
“The absence of increases in rehospitalization rates suggests that SNFist adoption may reflect facility investments in care models better suited to managing patients receiving postacute care,” they added. “This may be attractive to [nursing homes] because Medicare payments for postacute care are more profitable than Medicaid payments for long-term care.”
In the study of nearly 4,500 nursing homes, the presence of SNFists — defined as physicians, nurse practitioners and physician assistants who concentrate their practices in the nursing home — increased from 13.5% of facilities in 2013 to 52.9% in 2018.
While the number of post-acute admissions increased after SNFists started working in facilities, the researchers found there was “no statistically significant change” in the acuity index of patients. Nor was there any lowering of the 30-day hospital readmission rate.
The hospitalization metric has been commonly used by federal regulators to measure care quality, but it’s not the only way to show the impact of advanced practitioners in the skilled nursing setting, said Karl Steinberg, MD, a long-time nursing home medical director and chief medical officer and past board president of AMDA — The Society for Post-Acute and Long-Term Care Medicine.
He took exception to the idea that nursing homes were just bringing in experts to drive up profit margins, noting that most SNFists are placed by health systems or hospitalist groups that want to track and continue to care for their patients.
“I don’t see how anyone would see how it’s a bad idea to have their presence in the building, whether or not that correlated to a reduced 30-day rehospitalization rate,” Steinberg told McKnight’s Long-Term Care News on Wednesday. ”There’s every reason to believe that it would improve other aspects of the quality of care, whether or not there’s any kind of finances associated with it.”
He said that, historically, a nursing home patient’s community-based primary care physician was usually the one to look after them in the facility. But few still do nursing home care and when they do, they may only provide the regulatorily required visit once shortly after admission and then not see them again before discharge.
“Clearly, it’s better for everyone to have a doctor or nurse practitioner seeing the patient more frequently when they are right out of the hospital,” Steinberg added.
He said other tangible benefits of a SNFist or medical director regularly onsite would include better ability to assess patients routinely and with a change of condition that could precipitate a return to hospital; rounding to cover wound or other specialty care needs; and having a clinician ready and able to serve as an additional resource or mentor to frontline staff.
The researchers identified several facility characteristics associated with nursing homes that had SNFists versus those that never did.They were larger on average, more likely to be for-profit, and more likely to be affiliated with a chain, they wrote. Nurse staffing also was generally lower in facilities that adopted a SNFist, while occupancy was higher.
Steinberg said it made good business sense for nursing homes to adopt clinical care strategies that bring in more Medicare patients, a population that facilities have been pursuing for decades.
