Framing the issue:

Value-based payments are prompting hospitals to work more closely with post-acute providers.

Hospitals face Medicare penalties for high readmission rates.

Establishing narrow networks of post-acute partners can encourage providers to improve quality of care.

Tactics for improving care between acute and post-acute partners include “warm handoffs” that involve actual conversations, not just the exchange of paperwork, between clinicians on both sites.

New staffing models, including the use of SNFists and nurse care navigators, are gaining ground.


Until recently, hospitals had little reason to consider how local nursing homes might affect their performance. The introduction of value-based payment initiatives changed that.

Hospitals that participate in accountable care organizations or bundled payment initiatives have a powerful incentive to work closely with nursing homes to improve patient care, control costs and reduce readmissions. Nationally, about 18 percent of all patients discharged from hospitals to nursing homes are readmitted within 30 days.

In October 2012, Medicare began penalizing hospitals that have high readmission rates. The ante was upped with the 2013 announcement of an efficiency score — Medicare spending per beneficiary. The efficiency score was added into the value-based payment formula used to calculate hospital payments beginning this year. The MSPB includes all spending for a patient care episode, starting three days before an inpatient admission and ending 30 days after discharge. That means hospitals are held directly responsible for the costs incurred by Medicare to patients discharged to nursing homes.

About 40 percent of Medicare patients discharged from the hospital require some type of post-acute care, says Kathleen Griffin, president and CEO of Care Management Innovations LLC, a consulting firm in Scottsdale, Ariz., that assists ACOs and health systems to develop post-acute continuing care networks. Depending on the region of the country, between 20 and 24 percent go to nursing homes.

“There has been a strong movement on the part of health systems to recognize that if they’re not at financial risk today, they will be tomorrow,” she says. “They want to have some control over both the expenditure and the quality of the entire care continuum.”

Regional variations

Nursing home-hospital relationships are playing out differently in different areas of the country, and while the goal of better quality is shared, agreeing on the strategies to get there is a complex process.

In Massachusetts, for example, ACOs are looking for nursing home partners. Paul J. O’Connell, R.N., administrator of Beaumont Rehabilitation and Skilled Nursing Center at Westborough (Mass.), said none of the five nursing homes in the Beaumont group are in risk-sharing contracts with hospitals yet. But, Beaumont leaders are preparing to be attractive partners.

“As a company, we are on three or maybe four different cross-continuum teams in the central Massachusetts area,” he says. “We are sharing data and setting up standards. I think these cross-continuum teams will eventually evolve into ACOs.”

Brooks Rehabilitation, a nonprofit organization in Jacksonville, Fla., is in two risk-based arrangements through the Centers for Medicare & Medicaid Services’ Bundled Payments for Care Improvement Initiative. Brooks is the sole provider at risk in a bundled payment program for post-acute care only, and it is a partner with a hospital in a program that includes both hospital inpatient and post-acute care.

First-year performance exceeded expectations in all ways, and President and Chief Operating Officer Michael Spigel says Brooks is just getting started. “As we get more into it, it amazes us how many more opportunities there are to improve care,” he says.

Meanwhile, Catholic Health Initiatives, which includes 105 hospitals in 18 states, is engaging post-acute partners in many of its markets. CHI owns seven skilled nursing facilities and several other post-acute services, but it is aggressively forming partnerships with many other providers.

CHI’s first post-acute care continuing care network, or PAC-CCN, was created in Tacoma, Wash., in late 2013. Since then, PAC-CCNs have formed in Des Moines, Iowa, and Lincoln, Neb., with plans to organize in five other markets by the end of this year. Already, CHI has found that redesigning care processes and some staff roles are important steps in building these networks.

‘Speaking a different language’

Forward-thinking nursing home leaders know that the federal government’s march to value-based purchasing eventually will reach their doorsteps, so they are eager to prove they can collaborate with hospitals to deliver high-quality, cost-conscious care.

That does not mean it is easy. Agreeing on priorities, metrics and protocols can be challenging, in part, because the two types of facilities are so different.

“One of the things we have found is that hospitals and skilled nursing facilities speak different languages,” Beaumont’s O’Connell says.

For example, everyone agrees that a “warm handoff” — a telephone call in which a hospital nurse and a nursing home staff member discuss the pertinent information about a patient being discharged to the nursing home — is a good practice. However, there is no agreed-upon standard for when that conversation should happen and the exact information that needs to be shared. Some hospitals have developed their own tools to guide the warm handoff, while others send paperwork without any phone call.

That’s why a committee of the Massachusetts Senior Care Association, which includes more than 500 nursing homes and other post-acute care organizations, is developing a standardized warm handoff script and other protocols. “We are working to come up with consistent language that everyone is comfortable with,” O’Connell says. “It’s crucial for all of us to agree on what is most important and, ultimately, what’s going to provide the best care for the patient.”

Another challenge is that nursing homes serve two distinct populations — patients who need help recuperating before they return home and extremely frail patients who will live in a nursing home until they die. While many elements of good care apply equally to both types of patients, some of the tenets of high-value care — for example, short lengths of stay and successful transitions to home — do not apply to long-term care residents.

The sidebar, “Four Domains of Clinical Transformation,” facing page, explains how Brooks Rehabilitation met those challenges.

Finding the right fit

ACOs and health systems that are accepting financial risk for a population of patients benefit from selecting a group of preferred post-acute providers to work together as a PAC-CCN, Griffin says.

Medicare patients are allowed to choose any nursing home, home health agency or other provider they wish, but patients approaching discharge often look to hospital staff for guidance, and the hospital can explain why some post-acute choices may be better than others.

A narrow network of post-acute providers — one that offers geographic coverage and adequate capacity while weeding out poor performers — increases the occupancy rates for the facilities in the network. That provides a financial incentive to work with hospitals to lower costs and improve quality.

“A big part of developing a post-acute care continuing care network is not just selecting the right partners, but it’s making the partnership work so that the patient outcomes are improved overall throughout the continuum,” Griffin says.

The sidebar, “How CHI aligns with post-acute partners” details one system’s strategy. Lola Butcher is a contributing writer to H&HN.


The four major domains of clinical transformation

Brooks Rehabilitation, Jacksonville, Fla., was prompted to make big changes in the way care is delivered when it entered into bundled payment arrangements that put the organization financially at risk for the care of Medicare patients for 60 days after hospital discharge. “That really allowed us to think through a care redesign that — bundled payment or not — has become the basis for our clinical transformation,” says Michael Spigel, president and chief operating officer.

Within the first six months of a bundled payment arrangement, Brooks reduced hospital readmissions by nearly 15 percent. Patient assessments of their own improvement in functional performance put Brooks in the top decile of facilities that use the same measurement tool. And more than 90 percent of patients reported high satisfaction with site-of-care transitions and the nurse navigator.

While he is optimistic that improvements will continue, Spigel says hospitals should expect that achieving full alignment with post-acute providers will be a difficult journey. “I don’t want to downplay how hard this stuff is,” he says. “This is a peak of change management — trying to get a team across multiple settings to collaborate, work together and standardize. It’s very hard work.”

Selection of the right “first setting”

For the patient being discharged from the hospital, choosing the right first setting is crucial. Inpatient rehabilitation is the most expensive setting, followed by a skilled nursing facility and then home health. Patients should be placed in the least expensive setting only if the clinical services are there to meet their needs, but the bundled payment approach incentivizes post-acute care providers to make the necessary adjustment. “Many of our patients used to start in a much higher-cost setting,” Spigel says.

Standardization across the continuum of care

“For a given diagnosis, if we’re at risk, we standardize all the tests and assessments so that our clinicians can really speak the same language and monitor the patient against the same assessments no matter where they are,” Spigel says.

Longitudinal CARE planning

Instead of thinking about a patient’s care only until discharge from the skilled nursing facility, Brooks staff prepare a 60-day care plan for every patient in the bundled payment program. “That makes us really think about: What will these people need over the next 60 days? Where are they going to need it? And how much of it are they going to need?” Spigel says. “Taking into consideration the things that are unique about that person — his or her physical condition, social, emotional and family support — what’s the right recovery path?”

Nurse care navigators

Nurse care navigators help patients transition successfully from one care setting to another. “If they’re in skilled nursing, home health, at home with outpatient care or in the hospital, the care navigator is the glue that holds everything together for that 60-day period,” Spigel says.


How CHI aligns with post-acute partners

When Catholic Health Initiatives creates a post-acute care continuing care network, the post-acute providers become participants in CHI’s clinically integrated networks, which allows them to share in any financial gains from bundled payment or other risk-oriented arrangements. The PAC-CNNs led to CHI working in many new ways, including:

Assigning skilled nursing facility specialists, known as SNFists, to work directly with post-acute care providers. In one market, CHI hired midlevel providers to do that work; in another, an internal medicine practice assumed the responsibility; and in yet another, CHI hospitalists covered the post-acute network.

Rethinking staff roles. In some markets, hospital-based care managers have become transition coaches. “We’re looking at a redeployment of resources because we know today’s health care environment is becoming leaner,” says CHI’s Dee Miller..

Redesigning care in collaboration with post-acute providers. If a nursing home has a high rate of pressure ulcers or infections, a root cause analysis is conducted to identify what changes in practice need to occur. Likewise, CHI hospitals adjust their work to allow nursing homes to succeed. “In one of our markets, we heard, ‘You’re not discharging patients until after 3 p.m. to our facilities, and it’s very hard for us to actually deliver physical therapy services when we only have a few hours left in the day. Can we look at revising that?’ ” says Miller.

Training nursing home staff members. Many nursing homes need to improve clinical services to avoid sending patients to the hospital unnecessarily. In one case, CHI invited PAC-CCN staff members for an all-day educational session about cardiac care — from EKG reading to the use of a defibrillator to understanding blood pressure management.

“We provide them with the education so that they can give our patients the best care,” Miller says. “By doing that for all of our facilities, we also raise the quality of care in the whole post-acute community.”

Although CHI is aggressively developing PAC-CCNs, it also owns and operates many post-acute facilities. Miller works closely with the director of quality for CHI’s owned facilities, who attends a monthly meeting with the PAC-CCN directors.

“We are continually staying in touch, and we often collaborate,” Miller says. “For instance, if CHI is putting on a seminar for our owned assets on, say, the use of [quality improvement] tools, all my CCN directors are asked to attend so that they can disseminate that information to the partnerships as well.”


Executive Corner

The Centers for Medicare & Medicaid Services maintains the Five-Star quality ratings on the Nursing Home Compare website, based on health inspections, staffing reports and quality measures. However, the ratings should be just one tool for hospitals evaluating post-acute partnerships.

One reason: Most hospitals’ main priority for nursing homes is to reduce avoidable readmissions; experts say readmissions often reflect factors other than the quality of care as measured by CMS.

Here are factors hospitals might consider to avoid unnecessary readmissions:

The nursing home should know residents’ end-of-life preferences for care.

On-call physicians should be familiar with a patient and the nursing home’s ability to handle his or her medical condition so they don’t order an unnecessary transfer to the hospital.

Hospitals should check nurse staffing ratios, nurse training and employee turnover.

Does the facility have SNFists on staff?

Can the organization establish proper communication so that “warm handoffs” are routine? Sending paperwork is one thing, but a phone conversation between a hospital caregiver and a nursing home nurse is also essential.

Does the nursing home use information technology intelligently to collect and share information and interface with hospitals?

Dee Miller, director of acute/post-acute care management at Catholic Health Initiatives, says a review of quality measures is just one step in evaluating a nursing home’s quality. “We also do a series of interviews. The RFIs give us a paper understanding of the facilities, but really going in and visiting with the teams at those facilities is essential.”