The impetus to reduce costs and improve quality of care is calling the traditional skilled nursing facility (SNF) provider coverage model into question. Local primary care physicians in the community serve as attending physicians in the traditional SNF model, which presents several recurring concerns that impact both care quality and hospital finances. Specifically, it creates avoidable scenarios in which patients are sent to the emergency department, admitted to the hospital, and sometimes readmitted.
To illustrate the need for this program, consider this SNF patient scenario:
89-year-old Ms. Anderson resides in an SNF. She has moderately advanced Alzheimer’s disease. One morning, the nursing staff notices she hasn’t eaten her breakfast, she’s more confused than usual, and she has a temperature of 99.7oF. However, the nurse feels there’s no specific reason to call the physician.
She eats little lunch or dinner too, and her confusion and mental status progressively worsens. At 8 PM the night nurse notes she has a temperature 101.6oF. At this time, the nurse calls the patient’s physician, who requests that the patient be sent to the emergency department (ED) at the local hospital for evaluation.
In the ED, Ms. Anderson has decreased responsiveness, a temperature of 101.2oF, a slightly elevated WBC count, and a urinalysis with many WBCs and bacteria. The ED physician feels that she has a urinary tract infection. However, due to the time of night, and the fact that the ED physician doesn’t feel comfortable that the patient will be followed up closely, he recommends she be admitted to the hospital for IV fluids and antibiotics.
In this scenario, the patient is sent to the ED because the SNF nurse did not feel comfortable calling the attending physician when the patient’s condition initially changed, and the ED physician didn’t feel the patient would receive sufficient follow-up care at the SNF. This is because local primary care physicians in the community traditionally serve as the SNF patients’ attending physician. Per Medicare guidelines, the patient is seen by the physician within 30 days of admission, and at least every 30 days subsequently. They are available on call for emergencies between visits, and in theory, will come in to see a patient if he or she is ill, and the nurse calls the physician and asks him/her to come in. However, these providers are often busy throughout the day with their office practice. At night, they are home trying to get some sleep before their next busy office day. If a patient is ill, it is often far easier to send the patient to the ED for evaluation and treatment rather than coming in to see one patient. Additionally, nurses are often uncomfortable calling the doctor. They don’t want to “bother” the physician, or risk reporting something that the doctor does not feel is critical. Therefore, in too many cases, patients are not seen when they are “starting” to become ill or unstable, and when they worsen, they are sent to the emergency department. The result of this system is avoidable ED visits and hospitalizations.
In FY 2011,SNF’s transferred one quarter of their Medicare residents (825,765) to hospitals for inpatient admissions, and Medicare spent $14.3 billion on these hospitalizations. (1) These costs represent 11.4 percent of Medicare Part A spending on all hospital admissions ($126 billion) in the same year. Hospital readmission is associated with an increased mortality rate, even after adjusting for demographic variables and clinical comorbidities. (2)
Of larger concern is that many ED visits and readmissions from SNFs are avoidable. One study identified 23% of transfers out to a SNF as being potentially preventable. (3) The most common reasons identified included a recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers. Another study examining the frequency of potentially avoidable hospitalizations identified an even higher rate (67%), and cited the reasons identified were lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, and problems with quality of care in assessing acute changes. (4) Many other studies have found similar results. The recurring theme in all these studies is the impact of the lack of consistent availability of primary care providers to manage ongoing issues and to intervene early on urgent/emergent problems. An additional observation is the SNF’s lack of an emergency plan other than transfer to the ED if a provider is not available.
In October 2018, CMS will begin a SNF value-based purchasing program that focuses on the cost of these readmissions. It will specifically focus on avoiding unnecessary ED visits and hospitalizations, which will put 2% of SNF’s Medicare payments at risk based on reducing 30-day readmissions from any cause or condition.
In future blogs, I will explore methods that can significantly improve the quality of care at SNFs, decrease readmissions, and reduce costs. These include the presence of on-site advanced practice providers, facility staffing as part of an acute care hospitalist program, and the use of telemedicine when no providers are on-site.
- Office of Inspector General, DHSS. Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring OEI-06-11-00040. Nov. 2013
- Burke, RE et al. Hospital readmission from post-acute facilities: Risk Factors, timing, and outcomes.
- Ouslander, JG, et al. Root Cause Analyses of transfers of skilled nursing facility patients to acute hospitals: Lessons learned for reducing unnecessary hospitalizations. J Am Med Dir Assoc 2016. 17(3): 2576-62.
- Ouslander, JG et al. Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriatr Soc 2010. 58: 627-635.