With post-acute care functioning as a major driver of healthcare costs, accountable care organization (ACO) collaboration with skilled nursing facilities (SNFs) has never been more important.
In fact, Medicare patients discharged to a SNF have a 25% likelihood of readmission within 30 days.
And while there are many reasons for readmissions, poor transitions of care often play a leading role.
As patients move among care providers, information can be lost. CMS states that 1/3 (33%) of all SNF readmissions occur in the first 72 hours, with a whopping 50% of those due to medication errors.
Read on to learn more about how your organization can take preventative action to reduce readmissions and strengthen partnerships lines with providers.
Create a SNF Network
Creating networks of high-performing SNFs enables ACOs to engage with facilities that have demonstrated an ability to provide quality care.
Additionally, having preferred SNFs helps clinicians discuss care transitions with beneficiaries and caregivers.
To identify ideal SNF partners, ACOs should:
- Conduct data analysis to understand the highest volume facilities in terms of admissions for ACO beneficiaries
- Review quality and efficiency metrics, including readmission rate and average length of stay
- Assess CMS star ratings and clinical quality indicators, especially for ACOs that have, or are planning to apply for, the SNF 3-day Rule Waiver
- Engage potential SNF partners to collect other information, such as clinical capabilities, staffing ratios, technology platforms used, and more
Interview facility leadership to gauge the SNF’s willingness to collaborate with the ACO and other partners on use of shared technology and initiatives to support goals, such as reducing readmissions
Dedicate Care Coordination Staff
When possible, it’s beneficial for ACOs to dedicate one or more staff members to coordinate care for beneficiaries requiring care in a SNF.
These staff members can collaborate with the SNF staff on the care plan, coordinate with the outpatient care team, and assist with discharge planning.
This additional layer of ACO support may help improve patient experience and reduce risk for inpatient readmissions through enhanced care coordination.
Leverage Real-Time Data
ACO care managers often have visibility into inpatient and ED visits for their members but lack visibility into SNF admissions and discharges.
Ideally, ACO care managers can be alerted in real time when an ACO member is admitted to a SNF setting, enabling the care manager to reach out and collaborate with the SNF on setting length of stay expectations, developing a care plan, and providing coordination support.
SNF discharge notifications are also critical, given the high risk of readmission when a patient goes home after a SNF stay.
Unfortunately, some ACOs are not aware that a patient has left the SNF until the patient is in the emergency room and it’s too late.
With real-time data, an ACO care manager can promptly follow up post-SNF discharge to ensure that follow up care occurs and help address care barriers.
By laying the foundation for a transparent, collaborative partnership, both parties and patients benefit.
To learn more about how Collective Medical, a PointClickCare company, can help you foster a connected partnership powered by real-time data, click here.