Hospitals Update, Refine Discharge Processes to Meet New Skilled Nursing Data Rules

Nov 1, 2019

The new federal guidelines mandating that hospitals offer patients detailed information about available post-acute providers is prompting their acute-care counterparts to solidify and deepen their discharge policies.

The rule, finalized last month, calls for hospitals to provide information about residents’ SNF options — with detailed data on quality measures — to help patients make the most informed decision possible during the vulnerable transfer period.

This new rule does not affect anti-steering regulations that prevent hospitals from recommending particular skilled nursing facilities, Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma said last month. But the grey area between “steering” a patient and offering in-depth information about SNF ratings has created confusion for staff, and at times, a roadblock for helping patients understand all of their post-acute options.


In response, hospitals around the country are working to clarify their communication procedures when connecting patients with SNFs to ensure they are in the right place — and that they know what they can expect in terms of quality measures — in accordance with the new regulations.

Jason Grundstrom, executive director of continuum of care at the University of Kansas Health System, is in charge of the Kansas City, Kan.- based hospital’s post-acute landscape. Grundstrom’s team of caseworkers and social workers has been working closely with post-acute providers, with both the new discharge rules and the Patient-Driven Payment Model (PDPM) in mind.

“We are ahead of the curve, and have case managers and social workers trained in both of these new models,” said Grundstrom, whose unit has been attending PDPM seminars and studying patient health profiles several months prior to the shift.

So far, Grundstrom hasn’t noted any particular changes in discharge patterns to the hospital’s regular post-acute partners. He continues to stay informed about the various specialization efforts at skilled nursing facilities that take University of Kansas Hospital patients — including those that have particular tracheostomy or wound care programs — to ensure that individual patients go to the best possible provider based on their needs.

“We’ve had a lot of frank conversations, and I personally traveled many miles to speak to providers in person about protocols for patient care. This is not an e-mail conversation,” Grundstrom said.

At the University of Kansas Hospital, patients are handed a comprehensive paper list of potential facilities twice upon admission, and are able to go onto CMS’s Nursing Home Compare website or Google Reviews before leaving. Social workers also have a conversation with the physician, who writes the orders for the right skilled nursing facility and other essential information for discharge.

“We are required by law to provide all of the options for categories of care in the provider network that we’ve created. Fortunately, we meet with them for quality and safety on a regular process,” Grundstrom said.

Because of generally high demand for the university system’s services, Grundstrom takes a proactive approach with its network; if a SNF is no longer accepting a certain type of patient, he prefers to deal with it immediately to “remove friction in a given day.”

Placentia-Linda Hospital, an 114-bed acute care facility in Placentia, Calif., has also been tweaking its discharge procedures for depth and breadth.

Karen Wilkerson, case management director at Placentia, explained that the hospital has been working with naviHealth, a third-party agency, to help streamline its transition process since last November. naviHealth gathers relevant quality metrics and organizes the data on a spreadsheet; Wilkerson then chooses the highest quality providers and meets with them on site at the nursing homes. If both sides agree on expectations, the new provider earns a place on the hospital’s preferred list.

“Working with a third party makes it easier to organize the data into four- or five-star ratings,” Wilkerson said. “It’s also good for the patients because they don’t have to do much research.”

Wilkerson admitted that ultimately, regardless of quality measures, it’s the patient’s choice in terms of choosing a facility, and that sometimes patients choose facilities with lesser quality metrics — but better intangible factors.

“They don’t only choose based on high metrics. Some Korean patients, for example, might want Korean-speaking clinicians and traditional food options. We need to only ensure patients are making an informed choice,” Wilkerson said.

Rhonda Sausedo, chief nursing officer at Placentia, said that the hardest part of discharge is coordinating all the needed resources for a patient as he or she moves through the system.

“They might need parenteral nutrition, known as PPN, or intravenous feeding. Certain IVs are very costly and more difficult to locate. A patient with respiratory problems may mean moving someone from skilled nursing to sub-acute care, and only some facilities have dual facilities,” Sausedo said. “It’s a challenge to ensure insurance will cover it all.”

Sandra Jenkins, director of post-acute care at Baptist Health System in Jacksonville, Fla., said that the hospital’s discharge processes are already “hard-wired” with a tool called Patient Choice. Hosted on the acute-care provider’s internal intranet, Patient Choice allows hospital discharge planners to pull up information about residents’ potential options.[

“We update Patient Choice monthly for skilled nursing providers as Medicare also creates a monthly update,” Jenkins said.

Baptist Health’s care coordinator supports the inpatient team, assisting patients as they transition to their desired locations.

Since the new rule came out, Jenkins recognizes the team needs to take a closer look at “a more formal way to include long-term care hospitals on the tool, like we have SNFs and inpatient rehabilitation centers. The long-term care option is not on our tool yet.”

The staff hosts regular collaborative calls with stakeholders along the continuum of care in order to improve patient care and quality outcomes. More specifically, the team speaks to their skilled nursing partners regularly — once or twice a week — to look for early gaps in care in order to prevent hospital readmissions after a patient has transitioned to the new facility.

The coordination team is also creating a patient-friendly flyer to illustrate the trajectory from the hospital to skilled nursing or the hospital to home health.

Mary Leen, executive director of care coordination at Baptist Health, stressed that the real work is in the care coordination across the continuum, and that “skilled nursing is just a stop along the route. We need to keep collaborating with partners along a patient’s road to recovery.”

“We are adjusting to the new rule to ensure the measures we already have in place are working, and to see what we can expand,” Leen said. “We offer detailed information for providers and patients so we are fully informed about their care. We make sure it’s relevant, and also the information in a way that the clinical viewer can access it.”


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