This post explores how we can help our Skilled Nursing Facility (SNF) colleagues as they try to address their re-admission challenge and become part of a quality post-acute care continuum and ACO.

Skilled nursing facilities have spent the last few years learning a great deal about the hospitals they work with. For obvious reasons!! Unfortunately our SNF colleagues don’t know a great deal about the hospice and home care companies in their building. One of the reasons is because we haven’t done a good job of working with them.

Here is a mini case study on how a SNF executive I work with who runs a “Super SNF” went about strengthening his building use of hospice, home care and personal care services.

Too Many Cooks In The Kitchen. This building had 8 hospices, 10 home care companies and 6 personal care home health companies all working in this SNF. WAY too many!! The variance in the services delivered were all over the map as well as the ability to get and manage reliable data. The first thing he did was to make all these companies aware he was going to select three providers in each category. A bold move, but it worked. He went through a “mini” RFP process to select his “team.” He still allowed other providers to work in his building if the patient that came into his facility was already working with them. Otherwise, referrals from within the building went to one the “team”! This process set a stage for better team work, data sharing, use of EMR and better outcomes!

Working Together To Avoid Visits To The Emergency Department. When the team could, they looked for opportunities to avoid the ED and sent appropriate patients directly to one of the team members. Hospice, Home Care and Personal Care Companies work creatively to keep patients safe and secure in the home setting.

If a patients did go to the ER, the team worked to send them right back; the team could manage the care.

There are continuous process improvement initiatives around ED transfer processes inside the post-acute setting (the team). Using this approach, this SNF learned to master CHF, pneumonia, and myocardial infarction. Now this SNF is better prepared for the next set of penalized diagnosis-related groups.

Developed a General Inpatient (GIP) Hospice Program. One of the three hospice team members worked with the SNF to develop a GIP Cluster Bed Program. This was an excellent development of a program element that greatly improved the SNFs ability to reduce readmissions. Here is why and how.

Two beds at the end of a wing were turned into Palliative Care suites. For patients in the SNF that met GIP criteria were cared for in one of these suite to get their break-through pain or out of control symptoms under control. This helped make a discharge home more manageable.

For those patients at home having GIP related issues instead of going to the hospital, they could be admitted to the Palliative Care suite for care. All appropriate care was handled by the team.

Data Tracking. The SNF monitored both team member as well as physicians’ compliance through benchmarking.

The SNF started to share the data with hospitals. This resulted in the SNF becoming part of a hospital’s post-acute provider networks. This benefited all the members of the team. This SNF customized their data and actually provided more information than is often requested to help you get a clear picture of our efforts and results.

So what is the takeaway from this case study that you can use??

If you have a good working relationship with the executives in the SNFs you work with, sit down and talk with them and use this example to simulate a dialogue. If you are able to the help a SNF get better organized around readmissions, you will have a friend for life!!

The Best!!