The transition from hospital to SNF is a phase change point in a patient’s continuum of care plan. However, traditionally, there have been issues in this transition, such as poor communication, problems with sharing data, delays in discharges, and issues with payment models.
This article looks into the future possibilities and current technologies and payments to enhance coordination between acute and post-acute care.
The Challenges With Current Care Transitions
When patients are discharged from the hospital to an SNF, they are at high risk of adverse events. Studies indicate that almost one-quarter of Medicare SNF patients are re-hospitalized within 30 days. These poor outcomes arise from various issues, including:
- Information Gaps: Missing or incomplete information on medical history, treatment plans, and medications can jeopardize patient safety.
- Lack of Interoperability: Health records and communications systems frequently do not interconnect effectively across hospitals and SNFs. This data fragmentation leads to impaired continuity of care.
- Rushed Discharges: Pressures to free up hospital beds, coupled with inadequate SNF capacity, often result in patients being discharged to SNFs without complete arrangements in place for follow-up care.
Improving Care Transitions Through Enhanced Coordination
In order to address these transition challenges, new approaches are being developed that will facilitate better integration, cooperation, and information sharing between hospitals and SNFs. These next-generation strategies include:
Data Integration Systems
Ensuring that medical record information is interoperable and that insurance eligibility verification can be done in real-time across care venues is basic. Having complete information about the patient’s medical history on the first day of an SNF stay provides the staff with critical information to ensure safe and individualized care is provided to meet the patient’s needs.
Care Transition Teams
The care transition staff act as coordinating centers before, during, and after transfer to SNF. They coordinate transportation, contact families, balance medications, coordinate record sharing, clarify follow-up needs, and confirm that the receiving facility can address the needs of the patient.
These transition coordinators are essential for ensuring proper patient hand-off from one level of care to another.
Remote Patient Monitoring
New technology allows for monitoring of health indicators as soon as the patients get to SNFs and relays data to hospitals. Telemonitoring helps hospitals identify potential complications early enough and address them before they result in ER admissions or readmissions.
Optimizing Care Transitions Through Payment Adjustments
In addition to care delivery innovations, the shift towards value-based payment models provides financial incentives that are more aligned with coordination and positive health outcomes.
Bundled Payments
Bundled payments compensate hospitals and SNFs under one ‘episode of care’ payment encompassing both the acute and post-acute stay. This motivates tighter care connections between settings to deliver comprehensive rehabilitation efficiently. Providers share financial accountability for achieving positive results.
Accountable Care Organizations (ACOs)
ACOs are groups of hospitals, physicians, and SNFs that voluntarily join an accountability contract to deliver coordinated care to a defined patient population. By linking payments to quality metrics, ACOs reward providers based on patient outcomes and cost efficiencies rather than service volume, spurring cross-continuum teamwork.
Hospital Readmission Penalties
Medicare now reduces skilled nursing billing payments to hospitals with excess readmissions for common conditions like heart failure or pneumonia. This counteracts incentives for premature discharges and stimulates investments in robust SNF coordination to prevent unnecessary bounce-backs.
Advancing Coordination Through Unified Post-Acute Networks
The most transformational approach combines clinical integration, shared accountability, and technological interoperability through unified post-acute care networks.
Post-acute networks align hospitals, SNFs, home health agencies, rehab centers, and other support services under one umbrella organization. This enables end-to-end care continuity, leveraging common data platforms and care protocols.
Unified post-acute networks usher in a new era of cross-continuum coordination. They provide the clinical and technological infrastructure to offer each patient a customized sequence of cost-effective post-acute support matched to their health status and recovery goals. This simultaneously improves outcomes and reduces avoidable hospital utilization.
The critical ingredients for successful post-acute networks include:
- Regional Alignment: Networks with geographic clustering allow for localized care transitions within adjoining catchment areas. This enables greater in-person collaboration and lower transport burdens for patients.
- Interoperable EHR Systems: Integrated electronic records provide immediate access to health histories, treatment plans, and diagnostic tests across different providers. Shared platforms help eliminate barriers in sharing health information.
- Standardized Assessments: Common patient assessment frameworks used across the network streamline care transitions and continuity. Uniform assessments facilitate placement in the optimal post-acute setting.
While launching large-scale clinical integration networks entails significant investment and culture change, the returns through enhanced coordination are equally substantial. Post-acute networks exemplify the infrastructure needed to actualize improved hospital-to-SNF transitions and patient-centered continuity.
The Future Vision
The old, disconnected transitions need to be replaced with smooth, fully integrated coordination between hospitals and skilled nursing facilities (SNFs). We have the necessary tools—like networks that work together, clinical integration, and payment improvements.
Leaders in post-acute care need to unite around a shared vision and deliberately build this advanced infrastructure. The technology is ready, and the financial incentives are in place. With strong leadership focus, we can achieve better coordination. Patients deserve this improved approach.
