Nursing homes and hospitals are forging closer relationships and improving communication, and this trend is expected to lead to an increase in nursing home admissions, while readmissions and excess hospitalizations also decrease.
Increased urgency and staffing shortages in recent years have meant that nursing homes have been forced to seek help from nearby hospitals when staff are unable to handle medically complex needs, from behavioral health issues to those that require more coordination. They are often reluctant to accept difficult cases that are referred to them. Sharing resources.
But experts say the situation appears to be changing.
Matt Niekerk, OSF Healthcare's skilled nursing facility practice director, and DeAndra Sandgren, chief nursing officer at the Evangelical Good Samaritan Society, discuss how the nursing home-hospital relationship continues to evolve. We discussed what factors might be influencing this. They recently spoke at Skilled Nursing News' RETHINK conference in Chicago.
Overall, we need more communication and collaboration to manage patient flow between hospitals and nursing homes and ensure quality patient care, especially for patients with complex cases and behavioral health needs. They said it could be refined.
Although OSF does not currently own any nursing homes, the 17 hospital system has developed partnerships with 67 skilled nursing facilities and emphasizes the importance of quality and safety standards as a benchmark for its network.
OSF, which has medical facilities in Illinois and Michigan, partnered with physical therapy and care coordination group Puzzle Healthcare to deliver care transition programs to more than 50 SNF partners. OSF's skilled nursing partners were able to reduce readmission rates from 29% to 9% when facilities had Puzzle Physical Therapists.
As for Good Samaritan, Sandgren said the relationship between the SNF and the hospital changed significantly when it merged with Sanford Health in 2019. Five years later, that relationship has become a “blooming relationship” that has helped clinical teams move people out of the hospital and coordinate care through access to more than 1,000 physicians.
Higher acuity and the evolving SNF-hospital relationship
There are many benefits to working closely with hospitals, which makes nursing homes more reluctant to accept more acute cases. That's because nursing home staff can now easily have experts review specific patient issues that they previously didn't have access to.
In certain complex cases, nursing home staff may be sent to the hospital for training or even receive training and support using virtual care systems.
“It helps us, especially when we need wound care and behavioral health services, which can be very difficult,” she said. In areas where there is no nearby Sanford Hospital, Good Sam works with other hospital partners to ensure access to more difficult referrals.
For each hospital, OSF considers three to six nursing home affiliates in nearby areas. Sandgren points out that most operators in OSF's preferred network already have liaisons within their hospitals to assist with complex cases.
“We are committed to improving readmission rates and seeking to build better relationships with these facilities. We partner with organizations that have allowed us to leave our mark on nursing homes. I did it,” Newkirk said of the puzzle.
Puzzle physical therapists may see patients five days a week, depending on case complexity and patient volume, he noted.
Rather than relying on a five-star rating system, OSF looks for nursing homes that residents want to go to, Newkirk said. OSF, like other hospital systems across the country, understands that five stars are hard to come by and have become even harder to earn after the pandemic.
Given the severity of illness in most nursing home residents being discharged, hospital systems need to have nursing home partners and resources ready to support them, Niekirk said.
Accountability and results
Niekirk said accountability for readmission metrics from both organizations will also help develop that relationship. OSFs, hospitals, puzzles within priority networks and SNFs meet regularly to review readmission numbers.
“A big focus for us was to be accountable to our skilled facilities, who are reporting to us and reporting to us with metrics,” said Puzzle Physical Therapist. Newkirk said of priority network nursing homes. “They have a care management team that follows patients discharged from skilled facilities for 90 days.”
Physical therapists may also call patients daily after they are discharged from the hospital to make sure they have everything they need to live at home.
“We do readmission calls with a lot of (nursing home partners), and we actually use puzzles on those calls to give post-discharge metrics back to the facility so they can see how they are doing as well. So that you can see if you are in the situation.”
For Good Sam, we've put a lot of emphasis on integrated electronic health records to reduce hospital readmissions. Much information, including lab and other documentation, is easily passed to the right people.
“Our drug plan reviews are much more robust (thanks to integrated electronic medical records). We looked into some of the details and found that incorrect medications were the root cause of readmissions. So we're leaning toward that,” Sandgren said.
She said there is a lot of communication between Sanford nursing home staff and home health care workers focused on post-discharge metrics and readmission rates. At the other end of the continuum of care, as the patient prepares for discharge, the palliative care team may be brought in to discuss goals of care, depending on the patient.
One area that still needs improvement is prior authorization and denial of care. While these still appear to be major issues, the issue is more related to Medicare Advantage, Niekirk said. Nonprofit hospital systems work weekly with managed care organizations (MAOs) and nursing homes to improve prior authorizations, sometimes even initiating the authorization process themselves.
