SNF discharges: how structured review can eliminate unnecessary services

IN MARCH 2020, as covid outbreaks flared throughout the U.S., news articles began detailing the horrendous outcomes befalling patients in some nursing homes and other congregate living settings. That’s when clinicians at NorthShore University HealthSystem, a multi-hospital integrated system in Northern Illinois, mobilized to try to reduce the number of patients being discharged to skilled nursing facilities (SNFs). That, the thinking went, would lower those patients’ risk of becoming infected.

Here’s the fix they put in place: referring every patient being considered for a SNF discharge to a newly formed congregate living review committee. The multidisciplinary committee, which began meeting one hour each morning six days a week, reviews every potential discharge to a SNF, either signing off on that plan or revising it to recommend discharge to another setting instead.

As committee chair Christopher Boyle, MD, explains, the team then measured the number of SNF discharges that occurred between mid-March 2019 and mid-July 2020, matching populations both before and after the review committee went live. A study in the Journal of Hospital Medicine in September 2021 found that the committee was able to reduce the number of total discharges to SNFs by nearly half. Further, it reduced new discharges to SNFs by two-thirds.

“The cost savings are very large.”

~ Christopher Boyle, MD
NorthShore University HealthSystem

“We knew we were likely to direct more patients home, but we didn’t anticipate such a large effect,” says Dr. Boyle, a hospitalist and associate chief quality officer. He and his colleagues also looked at covid incidence among discharged patients. They estimate that reducing the number of SNF discharges prevented one covid infection every 5.6 days the intervention was in place— and one death from covid every 2.6 weeks.

“We’ve seen a lot of benefit,” says Dr. Boyle. The review committee is still active, and it continues to deliver results that are critical to the health system’s role in achieving high-value discharges and successful population health programs. “We realized as we put this process in place that there is a huge amount of benefit outside covid.”

No increase in LOS or readmissions
Dr. Boyle and his fellow committee members found another surprise in their data.

They expected these patients’ length of stay to increase, thinking that the new process would result in an alternative discharge plan for many of them. “We were OK with longer length of stay if we could lower patients’ risk of covid,” he says. But that increase didn’t materialize, nor was there any jump in the number of 30-day readmissions.

As Dr. Boyle points out, the CMS during the pandemic waived its three-day-stay rule for SNF coverage, making it much easier for hospitals to discharge patients to SNFs and have those stays covered. But with covid such a known high risk in congregate settings, both patients and providers may have been trying to steer clear of SNF stays. “That was something we did try to control for in the study,” he notes. The authors looked at Medicare claims data over the study period to see if the number of discharges to SNFs nationwide likewise took a dive.

But he and his research team didn’t see large reductions in those national data. “As a percentage of patients going to a SNF after a hospitalization,” Dr. Boyle says, “it didn’t look like there was any change.”

Alternative recommendations
The review committee was modeled on transplant committees or tumor board structures, where multidisciplinary teams review many cases through structured discussions. Committee members include physicians—half are hospitalists, the rest are outpatient doctors—as well as case managers, social workers, physical and occupational therapists, and the director of the health system’s home health agency. One of the committee’s physicians chairs each meeting.

When patients meet the criteria for a committee consult, their case manager or social worker sends a referral through the EMR by 5 p.m. for a next-day review. The committee coordinator—who is dedicated to that role— prepares all case summaries for appropriate consults by 10:30 a.m. the next day, when the committee meets.

During the meeting, the coordinator presents each case with a clinical summary as well as the patient’s covid status and testing history, functional and home-support levels, psychosocial needs, and barriers to discharge home, if any. Committee members then weigh in through a structured format. If they unanimously agree that a patient should be discharged to a SNF, the patient’s case manager or social worker receives a message to that effect and the physician chair of that meeting places a note in that patient’s chart.

If, however, members don’t think a SNF stay is warranted, the case manager or social worker will receive that message—and the physician meeting chair documents “Not recommend” in the EMR, along with the committee’s rationale and its recommended alternative discharge plan. Patients can be resubmitted to the committee as needed.

“We typically review between 15 and 20 patients a day over the course of an hour,” says Dr. Boyle. “We’ve become very efficient while retaining very high standards for case review.” Also, after meeting for close to two years, “we’ve seen a larger percentage of cases where we support the discharge plan that’s being proposed.” He chalks that up to cultural changes among the health system’s providers, who now have a better understanding of how to support more patients being discharged home and recognize the risks of inappropriate discharges.

A solution for any complex hospital problem
Committee members initially filled the role of coordinator by redeploying existing staff. Ultimately, however, the job went permanently to a former SNF care manager who had, Dr. Boyle says, “a lot of familiarity with SNF requirements and patient selection.” As for getting the administration to green-light funds for a dedicated position, “once the benefits were seen, there wasn’t much resistance to the resource needs.” According to published studies, a post-acute stay at home vs. one in a SNF costs between $10,000 and $15,000 less.

“The cost savings are very large,” he notes. “We’ve been able to justify this as an ongoing program.”

The committee now meets five, not six, days a week, moving its Saturday meeting to between 4 p.m. and 5 p.m. on Friday afternoon. Another change: Providers now make referrals for committee review earlier in patients’ stay “so we can provide input and direction sooner.”

Dr. Boyle believes that a review committee is “generalizable” to just about any complex problem in the hospital that requires the expertise of multiple stakeholders. Such a committee structure could be used to tackle issues related to length of stay, for instance, or to decisions on inpatient vs. observation stays.

He and his colleagues have likewise thought of dedicating some committee time to readmissions. “But we didn’t want that scope creep,” he notes. They’ve also thought about bringing frontline staff into committee meetings to make the case for certain discharge plans for specific patients.

“The providers are referring the cases, but they’re not actually hearing our conversations,” says Dr. Boyle. “That may be an opportunity for us in the future.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the January/February 2022 issue of Today’s Hospitalist