Hospital, SNFs agree on post-acute indigent care
Some providers share cost of post-acute care
As part of its efforts to facilitate post-acute care for unfunded patients who no longer meet inpatient criteria, Sentara Healthcare has developed an Indigent Care Agreement for Post Acute Services that sets out four levels of bundled payments to the health system's seven skilled nursing facilities when patients who can't pay are transferred.
"In the past, we had to negotiate and complete individual patient care agreements with the skilled nursing facilities saying that our hospital will pay for patient needs when they no longer meet the acute level of care. But we decided to go with bundled payments because costs kept escalating as the stay progressed. This agreement specifies four tiers of payments, based on patient need and in accordance with managed care benchmarks," says Teresa Gonzalvo, RN, BSN, MPH, CPHQ, ACM, vice president for care coordination for Sentara Healthcare with headquarters in Norfolk, VA.
The agreement spells out a flat rate the hospital will pay for each tier—basic custodial care, skilled care, skilled care with additional rehabilitation, and care for patients with ventilators and tracheotomies. The rates are all-inclusive. Participating skilled nursing facilities have agreed to accept the rate when patients are ineligible for state or federal funding for post-acute care.
"We wanted to streamline the process and make it more effective and efficient while decreasing the administrative processes of tracking and reporting. Before we set the amounts, we researched what managed care payers had in their contracts with Sentara's skilled nursing facilities and created reasonable bundled payments," she says.
The post-acute providers agree to provide the hospital care coordination department with a monthly spreadsheet of patients including clinical progress and goals for transitioning the patient to a lower level of care.
"We also have asked our providers who receive a large volume of referrals from Sentara to partner with us in sharing the cost of care for unfunded patients, and three companies have agreed to help. The skilled nursing facilities have also agreed to take patients if Medicaid is pending, helping us transfer them to the appropriate level of care sooner," she says.
Sentara has created the Hampton Roads Long Term Care Council, made up of the Sentara Hampton Roads Hospital care coordination department members and representatives from skilled nursing facilities and long-term acute care hospitals in the area, including those that are not affiliated with Sentara. The council meets every other month with about 30 to 40 people attending.
The purpose of the council is to facilitate the transition of patients from Sentara acute care to long-term care facilities and back to acute care when appropriate and to effectively share information as patients transition. Council members have collaborated on initiatives that improve communication between levels of care. For instance, all providers have agreed to use a universal transfer form that provides consistent information when patients go from one level of care to another. "Our goal is to work collaboratively with the provider community and to help them understand that providing care for self-pay patients is a communitywide concern," Gonzalvo says.
The fund that is used to pay for post-acute care is part of the care coordination department's budget and isn't tapped unless all other potential sources of payment have been ruled out. "We have a budgeted amount to pay for indigent care. We look at it on a case-by-case basis," she says.
When patients no longer meet inpatient criteria but are self-pay, the care coordination department performs due diligence to make sure that patients truly have no assets and that no family member can help pay for the care. If patients or family members can pay a portion of the cost for post-acute care, the hospital works out a payment plan.
"Our social workers exhaust every possible option for a safe transition, even if families are unable to participate with the care of the patient. At the end of the day, we take the patient's choices into consideration and see that their needs are met," she says.
When patients can't pay and are eligible for Medicaid, they are asked to sign a Patient Responsibility Agreement, which requires patients or family members to agree to follow through with an application for Medicaid benefits. "Sometimes they have other priorities. This holds them accountable for applying for Medicaid so the patient's care will be covered," she says.
The agreement states that if the patient doesn't complete the Medicaid application in a timely fashion or the coverage is not approved, Sentara may bill the patient for any patient care services.
"In the past we simply asked patients and families to follow up with the paperwork. Now we are putting our request in writing and asking them to sign in hopes that it will help them understand the importance of completing the application," Gonzalvo says.