By Melinda Young
EXECUTIVE SUMMARY
Transitioning patients from the hospital to skilled nursing facilities has become more difficult for case managers since the COVID-19 pandemic began. Case management leaders from several different hospitals have developed solutions.
- One South Dakota hospital reduced readmissions and excess hospital days through a program focused on improving efficiency and eliminating barriers.
- A health system in Oregon created a bed reservation program that helped case managers transition the most challenging patients.
- A discharge navigator program in North Carolina helped a hospital reduce the time to obtain authorization for transitions to skilled nursing facilities.
Hospital case managers have struggled over the past few years with transitioning patients to skilled nursing facilities (SNFs) and other post-acute settings. The COVID-19 pandemic wreaked havoc on staffing and bed availability. This has continued in 2023.
But some case management leaders say their health systems found solutions that work well. These programs produce additional benefits of reducing hospital readmission rates and improving bed turnover.
Each SNF uses its own policies, procedures, and admission processes. It can be hard for case managers to keep track of these processes to ensure patients are transitioned to the right place at the right time.
“They may use different pharmacies, have a different admission process, and have different expectations about transportation and what they want from [medical] orders,” says Anita Dunham, MS, BSN, CMAC, a senior director of case management at Monument Health in Rapid City, SD. “We struggled to find community physicians willing to follow patients into nursing homes.”
Using Lean methodology, the health system developed a process for smoother and more efficient hospital-to-SNF transitions. (For more information, see story in this issue on the health system’s transition solution.)
First, they tackled the issue of over-regulation. Sometimes, nursing homes referred to regulations when their requirements made it harder to handle patients’ medication or other aspects of the transition. But the actual regulations did not require all the bureaucratic steps the facility wanted.
“There are some assumptions that are being made, and we needed to tease out what was an assumption vs. what was a regulation,” Dunham explains.
Dunham and colleagues held meetings with pharmacy directors, along with hospital and nurse home leaders, to reach a consensus on how a more efficient process would look.
“There was a lot of ‘A-ha’ moments, and ‘If you don’t need it, and I don’t need it, what do we need?’” Dunham says.
Since changing the transition process, the hospital has reduced its excess days from 1,585 days in the fourth quarter of 2022 to 1,303 days in early 2023.
The goal is to reduce the number of excess days to 1,000 days, which is where the hospital was before the pandemic, Dunham notes. “We’re not back to pre-pandemic levels yet, but we’re moving in that direction,” she adds.
Also, the hospital’s readmission rate for nursing home discharges decreased from around 20% to below 15%. “We saw a nice downward trend in readmission rates while also reducing hospital days,” Dunham notes.
An Oregon health system’s bed reservation program has saved 11,217 patient days from July 2019 to March 2022. This increased the hospital’s capacity for 1,253 new critically ill patient admissions, according to internal quality improvement data presented at the American Case Management Association’s conference in April.
“Reflecting on the success of the [bed reservation] program, the biggest win for us is the ability to place patients who wouldn’t be able to be placed,” says Molly Ghassemi, BSN, a nurse manager in care management at Oregon Health & Science University (OHSU) Hospital in Portland. “These are patients who are more medically complex. Before this program, they would be discharged to a less-than-ideal setting. With this program, we can send them to a skilled nursing facility, where they’ll receive good care.”
Often, patients lack the insurance and funds to receive SNF care, so they may end up staying in the hospital longer than optimal, or they may be discharged to the community when they still need post-acute care. With the SNF bed reservation program, the hospital can transition more patients to the ideal level of care. (For more information, see the story in this issue on the bed reservation program.)
“We partner with one company, and it’s designed to be a virtual process,” says Jenn Leitch, MN, RN, CCM, CGS, administrative director in the division of care management at Oregon Health & Science University. “This allows us the opportunity to place patients where [staff] have the best skills and skilled care.” For example, some SNFs are more experienced in wound care, so patients requiring that care would be placed in those facilities.
The partnership entails hospital staff training a nurse from the SNF to learn new skills that can be used for these complex care patients. That nurse then trains staff at the SNF. Before the pandemic, more SNF nurses may have been invited to the hospital for training. But now it works well just to train the trainer, Leitch says.
“One of the most important things is we formed a relationship with facilities that could accommodate our patients’ needs,” Ghassemi says. “The types of patients we serve are more medically and socially complex.”
As patient care has trended toward more complex cases, SNFs also are seeing patients who are much more medically complex and struggling with social determinants of health.
“Skilled nursing facilities have changed,” Leitch says. “I’m interested in seeing the post-pandemic research that comes out. It could be people who didn’t access care during the pandemic need more care now.”
Another health system found a solution to improving throughput and shortening hospital length of stay.
The health system created a discharge navigator program, which includes three bachelor’s-level social workers in the role, says Amanda Hargrove, DNP, NE-BC, CMAC, ACM-RN, senior director of case management and utilization review at ECU Health in Greenville, NC.
The new program takes ownership of obtaining authorization for SNF placements within managed Medicare plans and commercial payors. (For more information, see the story in this issue on discharge navigators.)
“Hospital throughput is a hot topic today for all hospitals across North Carolina,” Hargrove says.
Before the program launched, hospital providers made referrals to SNFs, gave them insurance information, and waited for them to obtain authorization for transfer.
“If they needed a patient right away or had a bed to fill, they’d get the authorization very quickly,” Hargrove explains. “If they didn’t, they’d wait.”
This resulted in turnaround times of three to four days to obtain authorization for the transition. “We started partnering with a third-party vendor for managed Medicare and worked directly with them,” Hargrove says. “We did requests for approval, and our turnaround time decreased to hours. We were getting authorization on the same day — and sometimes within hours.”
If the payor does not authorize the patient’s transition to a SNF, the patient may be transferred to a rehabilitation facility, a nursing facility, a long-term acute care facility, or to home health.
“We partner with our therapist and providers in assessing what level of care is necessary for that patient,” Hargrove explains. “We’re always thinking ahead about ‘What if that insurance company doesn’t agree? What then? What’s the next safest option for discharge?’”
Their tactic is to always go down two pathways — the path they would like, and the path they will take if the patient’s insurance company denies coverage for a transition to a SNF, Hargrove adds.
Transitioning patients from the hospital to skilled nursing facilities has become more difficult for case managers since the COVID-19 pandemic began. Case management leaders from several different hospitals have developed solutions.
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