By Melinda Young


Coordinating post-acute services for patients has been an ongoing challenge during the COVID-19 pandemic.

  • One solution is for hospitals to form partnerships with local skilled nursing facilities.
  • Partnerships with post-acute organizations can help hospitals find adequate care for complex patients.
  • Hospital case managers and other staff can help the skilled nursing facility with difficult problem-solving and care coordination.

An ongoing problem that was made much worse during the COVID-19 pandemic was coordinating post-acute services for patients.

Sometimes, case managers struggled to match patients’ apparent needs with what their insurer or Medicare would pay. When the pandemic hit, many providers stopped accepting patients, reduced available bed space, or would turn away patients who had recovered from COVID-19. This problem led to people going home or to post-acute care without access to services they needed.

For example, patients with continuing acute needs might be best served in a long-term acute care (LTAC) facility, but they might not receive Medicare reimbursement if patients did not meet the requirements for transition from an intensive care unit (ICU), says Jenn Leitch, MN, RN, CCM, CGS, nurse manager in the department of care management at Oregon Health & Science University (OHSU).

Since the Centers for Medicare & Medicaid Services (CMS) revised its hospital inpatient prospective payment system (IPPS) for acute care and long-term care hospitals in 2015, transitioning patients to LTACs has been more challenging.

“We saw a decline in the number of patients we could send over there,” Leitch says. “We’re sending half the patients over there that we were.”

Complex Patients Need Post-Discharge Services

Vulnerable, complex patients need services after they are discharged from the hospital, but transitions can be challenging. One potential tactic is a partnership with a local skilled nursing facility (SNF), Leitch says. Such a partnership can help the SNF care for high-need patients who were denied care at other post-acute levels.

“This [partnership] has been very successful,” Leitch says. “We saved 2,382 hospital days over the fiscal year of July 2019 to June 2020 because we transitioned these patients to skilled nursing facilities sooner.”

Leitch recalls a case that involved a patient who was homeless and not ambulatory. The patient had no insurance when admitted to the hospital.

“We got the patient on Medicaid, but the patient was denied admission at every skilled nursing facility because of the person’s homelessness, possible substance use disorder, and behavioral issues,” Leitch explains.

The patient was transitioned to the special SNF program, received rehabilitation, and began to walk again — all within the 20-day stay. “We helped advocate for adult foster home funding and discharged the patient from the SNF to home health and physical therapy,” Leitch says.

The hospital-SNF collaboration can handle patients with complex needs and some social determinants of health issues, but not cases in which the patient poses a danger to staff, such as patients who are placed in restraints due to risk of violence, she adds.

Executive leaders meet weekly with SNF leadership. “We help support the local SNF in complex problem-solving and care coordination,” Leitch says.

Leadership teams developed criteria to identify patients who would benefit from the transition. “The first criterion is that patients have been denied to other skilled nursing facilities,” she says. “There typically are a lot of reasons why people were denied. When we worked with the SNF, we created a list of patients they could provide specialized clinical care pathways for. They put a lot of effort into education of their nursing staff to make sure they could care for complex wound patients, patients needing IV antibiotics, and patients needing trach care, and who had diabetes, strokes, traumatic brain injury, cognitive weakness, dialysis, and substance use disorder.” If needed, SNF staff could collaborate with the hospital’s addiction specialist.

The program begins with a structured escalation process at OHSU. Case managers escalate any patient with a barrier at discharge. The case goes to the leadership team to determine if the patient is eligible for the transition to the collaborating SNF. Once a patient is approved for the transition, a SNF liaison works with the case manager, who talks to the patient and explains transition options.

“The program discharges the patient from OHSU. We help the patient’s progression at the SNF, and then help the SNF discharge the patient from there,” Leitch says.

When patients transition to the SNF, case managers and other providers review patients’ progress and rehabilitation goals. “We go over how they’re doing with nursing and social services,” Leitch says. “We give advice and guidance on how to navigate social services and the community, and how to work with patients, families, and with community partners.”

After leaving the SNF, the patient may need services from adult foster home placement agencies, residential care placement agencies, or home health agencies.

“That’s why the program has been so successful,” Leitch says. “Skilled nursing facilities shy away from a lot of vulnerable and complex patients because they don’t have the staff education, support, and resources to manage complex discharge plans.”

But with the hospital case management and additional help throughout the patient’s stay, the SNF can provide quality care to these patients.

“The skilled nursing facility is managing the case, but our leadership team and post-acute care coordinator help,” she says. “We’re more like consultants who support them, and we build relationships, identifying barriers. The number of patients in the program fluctuates, depending on the need. We’ve had as many as 13 patients in the program, and these require highly complex care coordination with Medicaid, disability, and community agencies. We’ve had as few as five or six.”