Key takeaways:
- A Midwestern health system developed its own program to reduce readmissions from SNFs but didn’t have enough staff to cover all participating facilities.
- Contracting with an outside company brought the coverage and care coordination needed to prevent readmissions.
- The health system’s 30-day readmission rate from SNFs is now under 10%.
WITH PATIENT ACUITY levels rising in hospitals, it makes sense that the patients being discharged to SNFs are likewise increasingly complex. It’s also a big reason why bouncebacks from SNFs are so common. By some estimates, one in four patients discharged to a SNF are readmitted.
Like many health care systems, OSF HealthCare—now with 17 hospitals throughout Illinois and Michigan—has found that bouncebacks from SNFs are the single biggest slice of that system’s preventable readmissions. For years, the health system tried to tackle that problem with its own homegrown SNF program.
But, says Matt Nieukirk, director of OSF’s SNF program, “we found that there were too many moving parts and not enough staff” to really make that iteration of the program work. That’s when the health system turned to a company that provides a turnkey SNF-care program.
“We went from working with about 25 nursing homes to now being in between 75 to 80 nursing homes.”
Matt Nieukirk
OSF HealthCare
Because of that partnership, the health system now has much more comprehensive coverage for the patients discharged to SNFs. It also has a 30-day readmission rate that’s dramatically below what it used to be.
A struggle for enough staffing
When the federal government launched the readmission penalty program in 2013, staff with OSF HealthCare knew their readmission rates fueled by bouncebacks from SNFs were running between 18% and 25%.
“We developed our own program to follow patients into SNFs,” Mr. Nieukirk explains, although he didn’t come on board as the director of that program until 2017. “We had our own APRNs, our own physicians and our own back-office staff following those patients.”
The problem: The program just couldn’t hire enough APRNs to effectively cover all the patients in all the SNFs they were being discharged to.
“Not surprisingly, we had checkered results,” he reports. “In the nursing homes where we actually had our own APRNs visit, our readmission rates were under 10% and probably more around 5% to 7%.” Yet from those SNFs the OSF program couldn’t cover, “readmission rates ran between 25% and 35%. We didn’t really have enough staff to make an impact with the number of facilities we needed to work with.”
Fast forward to 2022 when those spotty results led OSF HealthCare to scrap its homegrown SNF-coverage program and contract with Puzzle Healthcare. That company, which is based in Detroit, focuses on providing post-acute care, complete with physiatrists and APRNs, as well as care managers and coordinators.
That decision, says Mr. Nieukirk, solved the problems that OSF HealthCare was having with SNF bouncebacks, including the problem of scale.
“We went from working with about 25 nursing homes throughout our entire footprint to now being in between 75 to 80 nursing homes,” he says. “We can focus in on a lot more patients, and those patients now get many more ‘touches.’ ”
Follow-up after SNF discharge
As Mr. Nieukirk explains, Puzzle Healthcare follows every single patient who is discharged from an OSF hospital to a SNF. The company fills out a tracker form for each, giving each a score based on their readmission probability.
“But the company really focuses in on patients going to SNFs with COPD, CHF, diabetes—these are the high-acuity diagnoses that you need to pay close attention to,” he points out. “While APRNs from Puzzle may visit low-acuity patients in SNFs only once or twice a week, those with high acuity are seen every week three to five times.”
Physiatrist coverage is also key to the program’s success, given how spotty the presence of physicians in SNFs can be.
“Twenty years ago, we never had nurse practitioners coming into SNFs, and we were lucky to get a physician in once or twice a month,” says Mr. Nieukirk, who joined OSF HealthCare after many years as a nursing home administrator. “Now, Puzzle physiatrists can be in every SNF where we have a discharged patient every single day.”
And Puzzle follows high-acuity patients home after their SNF discharge for 90 days. Why track patients so far out when the readmission penalty program looks at only 30 days post-hospital discharge?
“Puzzle is tracking these patients, making sure they’re stable, and getting patients’ data to us,” says Mr. Nieukirk, who adds that eventually patients post-SNF discharge will be followed for only 60 days.
While Puzzle case managers and care coordinators stay in touch with high-acuity patients by phone, those at the highest risk of being readmitted are outfitted at home with wearable devices that send data on their vitals and mobility to Puzzle. Those data can provide clues that patients may be starting to struggle at home.
Their results: “With SNF patients, we now see 30-day readmission rates under 7%,” Mr. Nieukirk notes. “The rate at 60 days is under 10%, and even at 90 days, we’re under 18%. We’ve seen our readmission rates drop drastically.”
The new status quo
Another plus of partnering with Puzzle: Participating SNFs don’t need to provide any additional staff or resources or undergo additional training. And Puzzle provides all program personnel, including those who follow patients once they are discharged home.
The program has been so successful, says Mr. Nieukirk, that OSF HealthCare hasn’t had to make any changes to it since it began several years ago. Instead, he and his staff have become very strong boosters.
“We have been absolutely ecstatic with the results,” he says. “The number of patients we are now able to follow on a monthly basis has been fantastic.”
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
