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As hospital discharge planners and case managers struggle to place patients with complex care needs in skilled nursing facility (SNF) beds amidst the challenges of the prospective payment system (PPS), many are keeping their heads above water with a mix of timely planning, community collaboration, and creative thinking.
That’s the combination recommended by Pat Orchard, CCM, CHE, RN, MSHA, MEd, market development executive for a Philadelphia-based consulting company called Care Science. "When hospitals call, I tend to be the person who does the assessment of what’s going on in terms of discharge planning and case management."
As a former nursing home administrator, she sees both sides of the problem: Hospitals must find places for increasing numbers of stable but medically complex patients. Nursing homes can’t afford to keep their doors open if their patient mix is too heavily weighted toward these high-cost patients.
A big part of the dilemma is that nursing homes can say no, Orchard notes. "They can say, Sorry, I can’t take that patient.’ It’s not like a hospital, where they have to take them."
New pharmaceuticals and advanced technology are adding to the logjam created by the PPS, Orchard points out. "There are expensive drugs the nursing homes can’t possibly maintain with their reimbursement and equipment needs that are more expensive than they used to be."
If care requires an advanced bed system - for a burn victim, for a frail, elderly person, or for an obese patient - "most nursing homes don’t keep those, and they have to be bought or rented," she says. "You can [afford to] put those in an acute setting; but in a nursing home setting, it may be cost-prohibitive."
Community collaboration is crucial in such instances, Orchard notes, and often includes a healthy measure of negotiation and relationship-building. Ideally, she says, nursing homes will agree to take higher-cost patients if they get a fair share of the less complex variety.
Sometimes, she adds, hospitals - and payers - find ways to make it easier for the nursing home to cover the cost of a complex patient. "There are patients who need IV antibiotics long term, and they are expensive. Many payers offer to work with the nursing home to continue to provide those through additional reimbursement above the daily rate."
In the Medicare realm, "the leeway is limited. It frequently depends on what the antibiotic is, but a physician who is more in tune [with financial concerns] may transition more quickly to another [less expensive] kind of antibiotic," notes Orchard.
In some cases, she adds, hospitals may send the necessary equipment to the nursing home along with the patient. Those kinds of solutions require that a discharge plan be created as early as possible, Orchard emphasizes.
"The sooner the plan is put together and you can discuss it, the quicker you can start resolving some of the issues," she says. "You may want to do some joint responsibilities. The providing facility may work with the sending facility to cover some of the expenses.
"For example," she adds, "the hospital may rent some equipment and keep sending it over [to the SNF] until the patient doesn’t need it anymore." Or, Orchard says, as mentioned above, the hospital can collaborate with the physician and the nursing facility on covering the cost of antibiotics and other expensive medications.
"Many of the commercial payers work with the nursing home and providers to add more dollars," she says. A win-win situation can be created, notes Orchard, because the patient’s benefits are not used up as quickly.
"The physician makes sure the patient gets the services needed while moving the patient to a lower level of care, which is beneficial for everybody, she says. "There is some flexibility, but it needs to be well-planned out and orchestrated with all parties. You can’t do it on the day the patient is discharged."
That’s the kind of cooperative approach taken at OSF Saint Anthony Medical Center in Rockford, IL, explains Joyce Nicklas, RN, MBA, director of quality/care management. She notes the problem in finding enough SNF beds is not the number of beds but the payer mix required by the nursing facility. "They’re looking at how many more Medicare and Medicaid patients they can take. There might be beds out there, but because of their financial situation, they’re not able to take all comers. So they stratify to get some kind of balance."
To facilitate patient placement, Nicklas says, she meets every other month with SNF administrators, as well as with representatives from hospices and other nursing homes. "We’re just trying to work on some kind of collaboration," she adds, "[letting them know] we’re not trying to get rid of patients, or you’re being dumped on, but that there are a lot of common performance indicators, and how do we manage those collectively?"
To ensure care consistency, for example, the hospital and nursing home share forms containing information on patient treatment, Nicklas says. "If the patient is on a skin protocol [at the SNF], we bring that here with us. If they’re doing a good job, we want to be able to keep that up. Then, we give [SNF personnel] a contact person here, so they understand what we teach our patients at discharge," she adds. "If the patient starts to deteriorate [back at the SNF], they have someone to call, to do some troubleshooting, so the patient is not sent directly back to the hospital."
Thanks to case management initiatives in the emergency department (ED), Nicklas says, SNF patients who are brought to the ED because their blood pressure dropped or their condition began to deteriorate - and in the past would have been admitted to the hospital - often can be treated and sent right back to the nursing facility.
"They might just need an IV dose of antibiotics and to get started on therapies," she notes. "Some are identified as needing palliative care, and there’s nothing we can do for them here. We have Social Services go down and talk to the family, and they are sent back."