Health care organizations must consider relevant structure, process and outcome measures − and not just CMS ratings or geography − before selecting post-acute care facilities.
Reducing readmissions is a primary goal for hospitals and accountable care organizations. The good news is readmission rates are improving.
Yet, these figures do not tell the entire story.
Embedded within these rates are various “stories.” For example, some readmitted patients were originally transferred to skilled nursing facilities for post-acute care, where they were discharged successfully to a lesser-care setting. When assessing where “the ball was dropped” and ultimately reducing the occurrence, it is crucial for hospitals and ACOs to conduct a comprehensive scan of the entire post-acute care ecosystem to identify the best partners that meet the needs of the hospital’s patient base. A vital component of this scan is evaluating a skilled nursing facility’s performance using key metrics, including readmission rates.
If skilled nursing care is required, the vital next step is deciding which facility best fits the patient. When making this determination, acute care providers sometimes use an inaccurate metric to guide their decision.
This commonly used metric for evaluating facilities is the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System. While many hospitals and ACOs use this measure to compare facilities and predict a patient’s experience, there is minimal statistical relationship between Five-Star and a facility’s rehospitalization rates.
Many hospitals and ACOs make skilled nursing facility selections based on Five-Star or geographic convenience. Unfortunately, the rehospitalization rate is not reduced only because a facility is rated three stars or better, or that the facility happens to be close to the hospital or has an available bed.
The quality of the care provided by the facility, and what happens with the patient during and after the transition to a lesser-care setting, affect rehospitalization rates. Again, this has little to do with Five-Star. A more effective practice when discharging patients to skilled nursing facilities is for hospitals and ACOs to partner with facilities specializing in post-acute care delivery who meet thresholds on key structure, process and outcome measures, as evidenced by a comprehensive evaluation.
This is accomplished by creating “smart preferred-provider networks,” where real-time facility data is aggregated and viewed by all stakeholders. Focusing on how these facilities formalize care transition and their associated metrics is essential in achieving shared goals and savings, and far exceed the benefits of Five-Star alone.
It is important for these structure, process and outcome metrics to be well-supported in scientific literature, evidence-based, reliable and valid, and appropriately benchmarked to the hospital’s specific market. This concept of creating unique benchmarks that are sensitive to the hospital’s and skilled nursing facility ecosystem is a requirement for making important partnership decisions. For instance, one facility might have a 20 percent rehospitalization rate, which may be considered a poor rate in some markets but average for others.
Health care metrics endorsed by the National Quality Forum are considered the gold standard in the United States. These metrics are transparent and often actionable, meaning hospitals and ACOs easily can understand how the metric is created. With additional data, analytics allow hospitals and ACOs to discharge patients to the most appropriate skilled nursing facilities, matching the patient’s unique needs to the facility’s strengths, thus reducing the likelihood of readmission or rehospitalization.
Here are some additional suggestions to positively influence readmission/rehospitalization rates for patients discharged to skilled nursing facilities.
Provide warm handoffs. Ensure both person-to-person and data-to-data handoffs occur before patients are transferred. Sending over the patient’s medical report during the transfer, or even providing access to the electronic medical record, is not as valuable as the hospital provider initiating a brief conversation with the new provider about that patient. An even-better scenario is if providers from the nursing facility meet transfer patients before they leave the hospital.
Ensure similarity of care protocols. Encourage both the hospital and nursing facility to match care protocols, wherever possible. Similar and tailored protocols and formularies benefit a patient’s recovery.
Perform medication reconciliation. One of the biggest drivers for readmission is a constantly changing medication protocol. Confirm that the nursing facility has the patient’s updated medication list during the transfer. This list should include the medicines taken by the patient at home (before the hospital visit) and those prescribed during the hospital stay. It is crucial for patients to understand their new medication regime. Otherwise, they might revert to their original medication routine before going to the hospital — a routine that might have contributed to the original hospital visit.
Consider this example from the field:
An ACO group based in the Northeast and representing 85,000 lives recognized its skilled nursing facility expenses were higher than those of their peer groups. The group also understood there was little collaboration between the ACO and facility. Using many of the strategies described above, including monitoring specific metrics, the ACO realized a 2.3 percent medical costs savings, which translated to $6.6 million. There was a 13 percent decrease in nursing facility costs and a significant reduction in its per-beneficiary costs. Because of this collaboration, the nursing facility received more referrals from the ACO, as well as more traditional fee-for-service patients from the hospital. Additionally, the nursing facility improved its CMS Five-Star Quality Rating through the collaboration and use of actionable NQF-endorsed metrics.
Today’s skilled nursing facilities are radically different from what they were 10 years ago. Many specialize in caring for special populations such as mental illness, dementia or complex orthopedic issues. They play a critical role in a patient’s rehabilitation and should be recognized by hospitals and ACOs as partners in their patients’ health care.
Evaluating facilities using meaningful metrics allows the facilities to demonstrate their competencies. By knowing which data to use to ascertain the strengths and weaknesses of a facility, hospitals and ACOs can identify precisely which facilities are the best fit for their patients while monitoring the performance of these facilities to reduce hospital readmissions.
Steven Littlehale is executive vice president and chief clinical officer for Massachusetts-based PointRight, which provides data analytic services nationwide to skilled nursing facilities, hospital systems and others who are responsible for post-acute care. This article was written exclusively for the American Association for Physician Leadership.