Stemming the Tide of Hospital Readmissions from SNFs

About 25 percent of patients admitted to skilled nursing facilities (SNFs) from hospitals will land back in the hospital within 30 days. Hospital readmissions among SNFs are costly, expose patients to additional health risks, and exact a toll on patients and families.
Many of these admissions and readmissions are avoidable because the condition could have been prevented or treated outside of the inpatient setting. A report by the Kaiser Family Foundation highlighted studies indicating that 30 to 67 percent of hospitalizations among SNF residents could be prevented with well-targeted interventions.    
Reducing readmissions is a high priority for hospitals and SNFs, as a provision of the Protecting Access to Medicare Act kicks in next year penalizing both the skilled nursing facility and hospital for 30-day readmissions. Besides bottom line improvements, reducing readmissions improves patient satisfaction and provider reputations.
Thanks to a statewide effort to operate hospitals on fixed budgets for five years, a Maryland hospital and long-term care facility successfully reduced readmissions through closer management of high-risk patients.

Operating on a Fixed Budget

In Baltimore, Saint Agnes Hospital and a nearby long-term care facility, FutureCare Irvington, sought to decrease preventable hospital admissions and readmissions through improved integration and collaboration. The effort was spurred by a five-year budgeting experiment between the state of Maryland and the Centers for Medicare and Medicaid Services (CMS). Under the experiment, all Maryland hospitals volunteered to operate on global budgets through 2019.
As Saint Agnes’ ED management partner, Vituity was eager to help them succeed on a fixed income. The organization focused its efforts on a couple of high-risk patient populations, one of them being chronic respiratory patients from FutureCare’s 50-bed ventilator unit.
The ventilator unit patients are a particularly fragile and complex patient population. Most have been at the facility for six to 12 months following a complicated hospital course. Tracheotomies and feeding tubes are common in these patients.
Previously, the ventilator patients were cared for by individual internists, who were also juggling office and hospital visits. As a result, ventilator unit nursing staff had difficulty communicating with the physicians.
During the first half of 2015, the ventilator unit had an above average number of readmissions per month, averaging about seven patients each month. Many of these patients were sent back to the hospital for fairly routine issues, such as fever, abnormal labs, or diarrhea. These problems might have been managed at FutureCare had the right expertise been available.
Later that year, Vituity proposed providing medical direction to FutureCare, Irvington’s ventilator unit. Being familiar with my (Dr. Frizner’s) work as hospitalist medical director at Saint Agnes, they asked me if I might be interested in heading up this practice, and I agreed.

A Medical Home

Having a dedicated medical director on-site enables us to provide a true medical home. Before each patient arrives at the SNF, we work with the hospital to ensure a smooth transition. For example, we follow a protocol around catheter removal to ensure that the patient will be able to void independently within the first three days of admission.
Once the patient arrives, they receive consistent day-to-day care, including frequent rounding to examine tracheotomy sites, central lines and IV catheters.

Touring the SNF

We felt it was important for our Vituity ED physician colleagues to have a strong understanding of the suite of services available at FutureCare Irvington. To that end, we invited the physicians to come out for a site visit, to actually walk the halls and learn directly from senior leadership and front line staff about how they care for these often complex and fragile patients.

Seeing our clinical capabilities, e.g., the ability to administer IV antibiotics and fluids and read routine X-rays and EKGs, has provided a level of comfort with our ability to provide advanced care to these patients. The ED physicians discovered that the SNF looks very much like a med-surg unit.
There are times we still have to send a patient to the ED, when a patient needs advanced tests or treatments during the night or over the weekend, for example. But, we can often work together to avoid an inpatient admission.
This is where our collaborative relationship and the site visits are bearing fruit. The ED physician is now comfortable providing care and sending the patient back to the SNF, knowing that I (Dr. Frizner) will follow up with the patient the next day. We’ve been able to achieve some really good outcomes through that level of trust.

Collaboration Delivers Results

That high level of collaboration and communication between FutureCare and the Saint Agnes ED has paid off. Together the team can make decisions about when a patient requires an inpatient hospitalization or can be treated at the SNF. Among our successes:
  • Hospital admissions from FutureCare are have decreased from seven patients per month to just one.
  • 30-day readmission rates from the post-acute unit are down 22 percent.
  • Across Maryland, reduced inpatient utilization has saved hospitals $300 million.
When a FutureCare ventilator patient does need to be hospitalized, Dr. Frizner works with the hospitalist team to coordinate care. Because he's a former Saint Agnes Hospitalist himself, the doors of communication are already open. Working together, we can often reduce length of stay – and get the patient back to FutureCare before their Medicare inpatient coverage runs out.
As a final thought, simply bringing different service lines under the same management umbrella is not sufficient to achieving meaningful integration. Aligning the SNF and ED teams toward common goals and changing the culture to put the patient at the center of all decisions has made the difference.
As we continue the journey toward payment for value, that high level of collaboration across care settings is critical in improving the patient experience and utilizing resources more appropriately.
Interested in learning more about SNF-hospital collaboration? The authors will be presenting a poster the subject at the American Association for Physician Leadership 2017 Annual Meeting meeting on April 21–23. Stop by our poster to have your questions answered in person!