Post-Acute Care is provided to patients after an acute hospital stay. There are many types of post-acute care settings for patients to receive continued care such as long-term care hospitals, inpatient rehabilitation facilities, skilled nursing facilities (SNFs) and home health or residential agencies. Partners Population Health post-acute care programs are focused on leveraging Skilled Nursing Facilities (SNFs). Skilled Nursing Facilities provide short-term care for patients recovering from an illness or injury who require skilled nursing and/or skilled rehabilitation services. Once patients are medically stable, no longer need to be in the hospital, and meet admission criteria, they may transition to a SNF to continue their recovery under continued professional care. There are a wide range of rehabilitation and medical services offered at SNFs that are tailored to meet each patient’s needs.
Skilled Nursing Facilities also provide long-term care for patients who require 24-hour care in a residential setting. This care is considered non-skilled or custodial, and Medicare does not cover this type of care. The SNF and the patient’s care team can assist in investigating options for this type of care.
Patients with Medicare insurance coverage are required to meet standard regulations when seeking care. Patients may be required to spend three nights in the hospital before their Medicare insurance will cover care at a Skilled Nursing Facility (SNF). This regulation is called the “Three-Day Rule.” However, an inpatient hospitalization is not always the best way to care for a patient as hospitalization may be unnecessary and inefficient for patients and healthcare providers. To better serve our Medicare population, Partners HealthCare was granted the ability to participate in the CMS 3-Day Waiver Program. This waiver allows us to send patients who require skilled nursing and/or rehabilitation care directly to nursing facilities; bypassing the required three-overnight rule. Patients can be admitted to a Skilled Nursing Facility using the 3-Day Waiver from the emergency department (ED), short inpatient stays, primary care physician’s office, or other community settings. The waiver leads to reductions in the overall cost of care due to decreased hospital admissions and length of stay. Most importantly, the waiver gets patients to the right level-of-care faster and increases patient satisfaction. Each year, approximately 450 Partners patients are transferred to a Skilled Nursing Facility on the 3-Day Waiver program. To be an eligible Skilled Nursing Facility (SNF) Waiver facility, a site must maintain at least a 3-star rating in Overall Quality from CMS. Partners HealthCare has a network of eligible Skilled Nursing Facility waiver facilities that collaborate closely with Partners organizations and participate in the Transitional Care Management Program to care for Partners patients.
The Skilled Nursing Facility (SNF) Transitional Care Management program aims to optimize SNF utilization for the Medicare Accountable Care Organization (ACO) population through use of an evidence-based decision support tool and Transitional Care Managers. Patient functional status information is put into the tool which uses data to predict the ideal post-acute care setting for the patient. The tool also provides an expected length of stay, anticipated therapy needs, estimated functional improvement, and readmission risk for the patient. Our providers and SNF Transitional Care Managers use this data to create personalized and patient centered care plans for our patients. The Transitional Care Manager works closely with the Skilled Nursing Facility care team to ensure high quality and efficient post-acute care. This collaboration results in improved functional gains for the patients. The goal of the Skilled Nursing Facility Transitional Care program is to achieve quality post-acute outcomes for our patients, and decrease unnecessary SNF utilization and practice variation by using proven evidenced-based technology. This program has been proven to reduce the number of days patients spend at the Skilled Nursing Facility. On average, Transitional Care Management patients had a four-day shorter length of stay at the Skilled Nursing Facility. Participating patients have successfully meet their goals and are not more likely to be readmitted to the hospital—patients have similar 30-day readmission rates to patients not enrolled in the program.