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Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
9
home or SNF for long-term custodial care at the time of the decision to admit to a
SNF; and (2) the beneciary meets all other Centers for Medicare & Medicaid
Services (CMS) criteria for SNF admission:
• Is medically stable
• Has conrmed diagnoses (e.g., does not have conditions that require further test-
ing for proper diagnosis)
• Does not require inpatient hospital evaluation or treatment, and
• Has an identied skilled nursing or rehabilitation need that cannot be provided
on an outpatient basis or through home health services
In order to achieve this, SNFs may begin to accommodate direct admissions at
their facilities. In most cases, when it is determined that a patient needs to be admitted to an SNF, they are sent to the emergency department (ED) and then admitted to
the hospital. Only after they have been evaluated are they sent to an SNF. This process can be stressful, costly, and time consuming. Direct admission to the SNF can
remedy many of these issues and as such continues to be a growing area of focus. A
SNF is required to have and maintain an overall rating of 3 Stars or higher in the
CMS 5-Star Quality Rating System in order to participate in the SNF 3-day rule
Waiver. A focus on initial and ongoing treatment—as well as assessment of those
treatments in a timely manner—requires careful planning.
There are both clinical and nancial benets to utilizing SNFs for direct admissions. Beyond the obvious nancial benets, there are also clinical reasons, as it is
commonplace for older adults to experience iatrogenic events when hospitalized. In
one paper on the subject, it was found that at least one-third of all patients had some
ill effect during hospitalization that was not related to the progression of any pathologic process, and 9% of patients had a major untoward event [2]. Thus, decreasing
hospital admissions has both signicant clinical and nancial benets that are critical in a value-based care system.
Perhaps the easiest direct admissions to SNFs are those coming from an ED,
since a rapid comprehensive assessment can be completed as well as the initial treatment. In fact, our facilities, Forest and Chestnut Hill Healthcare Center in Newark
and Passaic New Jersey, have developed programs where patients are sent for Rapid
Assessment + Initial Treatment, a process which we affectionately refer to as
RAbbIT.RAbbIT requires collaborating with the ED in advance to establish a process where patients can be rapidly assessed with initial treatment started for continuation within the SNF.Without a value-based collaborative process in pace, EDs
typically admit to the hospital patients who could be directly admitted to the
SNF.Besides the ED, this collaboration can be set up with ever-expanding urgent
care centers. Together, EDs and urgent care can be used as the starting point for
admission directly to the SNF.
For those not coming through these channels, the SNF must be prepared to have
a primary care provider (PCP) make an assessment and establish the treatment plan
upon admission. This availability of an admitting provider through either virtual
provider access or having a dedicated advanced practice nurse at the facility is critical to managing direct admission. Increased PCP availability in an SNF can come
10
R. G. Stefanacci and M. A. Kaminski
through the establishment of a PCP community ofce within the SNF.This PCP
community ofce not only allows for greater PCP time in the SNF but provides an
opportunity for a community’s older adults to become familiar with the SNF in a
positive light.
A potential barrier to efcient direct admissions is access to medications. Onsite
instant dispensing machines for medications often have mechanisms to help prevent
errors, for example, the machine can require that a patient identication number be
entered before a medication will be dispensed. Many dispensing machines can also
interface with hospital computer systems to integrate their data with information
from order entry systems and medication administration records. Dispensing
machines can also issue alerts and ask whether an adverse drug event has occurred
whenever the machine dispenses a common reversal agent or antidote.
Subacute/SNF-ST Reimbursement
On July 31, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a
nal rule [CMS-1696-F] outlining scal year (FY) 2019 Medicare payment updates
and quality program changes for skilled nursing facilities (SNFs) [10]. The nal
rule includes policies that continue a commitment to shift Medicare payments from
volume to value via three signicant changes to:
1. The case-mix classication system used under the SNF Prospective Payment
System (PPS),
2. The Quality Reporting Program (QRP), and
3. The Value-Based Purchasing Program (VBP)
The nal rule builds on the Improving Medicare Post-Acute Care Transformation
of 2014 (IMPACT) Act. Understanding these programs and the impact the nal rule
has on them is important for long-term care (LTC) and SNF providers as it will
affect how care is delivered and what outcomes facilities will be held accountable.
The process to modernize the SNF PPS case-mix classication system began as
CMS outlined a new case-mix model called the Resident Classication System,
Version I (RCS-I) that it was considering as a replacement for the existing Resource
Utilization Group, Version IV (RUG-IV) case-mix model, used to classify residents
in a covered Part A stay into payment groups under the SNF PPS. Through input
from LTC stakeholders, CMS made signicant changes to the RCS-I model, resulting in the new model called the SNF Patient-Driven Payment Model (PDPM).
Effective October 1, 2019, CMS began using PDPM, with a focus on the patient’s
condition and resulting care needs, rather than on the amount of care provided, in
order to determine Medicare payment. This new model increases the incentives to
treat the needs of the whole patient instead of focusing on volume of services, which
had required substantial paperwork to track over time [11]. PDPM is a case-mix
reimbursement model that will pay SNFs based on how they meet a patient’s needs
using ICD-10 diagnosis codes, patient characteristics, and other clinically relevant
Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
11
factors to classify patients [12]. CMS also signicantly reduced the overall complexity of the PDPM with the nal rule, as compared to the RUG reimbursement system.
Specically, PDPM adjusts Medicare payments based on each aspect of a resident’s care, most notably for non-therapy ancillary services (NTAS), which are
items and services not related to the provision of therapy such as drugs and medical
supplies, thereby more accurately addressing costs associated with medically complex patients. The rule also places a 25% limit on group and concurrent therapy, i.e.,
75% of care needs to be individual to that patient; this is meant to ensure that SNF
patients will continue to receive the highest caliber of therapy in line with their
individual needs and goals rather than completely within a group session [4].
Based on changes contained within this nal rule, CMS estimates that the FY
2019 aggregate impact will have been an increase of $820 million in Medicare payments to SNFs, resulting from the FY 2019 SNF market basket update required to
be 2.4% by the Bipartisan Budget Act of 2018 [1]. While this may seem like a large
number, it represents less than $50,000 per SNF.
Under the SNF QRP, SNFs that fail to submit the required quality data to CMS
will be subject to a 2% reduction in funding [5]. CMS states that they reviewed the
SNF QRP’s measure set in accordance with the Meaningful Measures Initiative to
identify how to move the SNF QRP forward in the least burdensome manner while
continuing to incentivize improvement in the quality of care provided to patients.
Specically, the goals of the SNF QRP and the measures used in the program cover
most of the Meaningful Measures Initiative priorities, including:
• Making care safer
• Strengthening person and family engagement
• Promoting coordination of care
• Promoting effective prevention and treatment
• Making care affordable
Currently, all measures adopted in the SNF QRP meet the requirements and are
in satisfaction of the Improving Medicare Post-Acute Care Transformation of 2014
(IMPACT) Act. There were no new measures proposed in the nal rule for the
SNF QRP.
However, in the nal rule, CMS did adopt an additional factor to consider when
evaluating measures for removal from the SNF QRP measure set. This factor considers costs that are associated with a measure, and then weighs them against the
benet of its continued use in the program. CMS will also publicly display the four
SNF QRP assessment-based quality measures and increase the number of years of
data used to display two claims-based SNF QRP measures, Discharge to the
Community and Medicare Spending per Beneciary, from 1year to 2years.
Beginning October 1, 2018, the SNF VBP Program applied either positive or
negative incentive payments to services furnished by SNFs based on their performance on the program’s readmissions measure. The single claims-based all-cause
30-day hospital readmissions measure in the SNF VBP aims to improve individual
outcomes through rewarding providers that take steps to limit the readmission of
12
R. G. Stefanacci and M. A. Kaminski
their patients to a hospital. This single measure does not require SNFs to report
information in addition to the information they already submit as part of their
claims because CMS uses existing Medicare claims information to calculate the
measure.
Again, these changes likely will result in a shift to caring for medically complex
patients as well as shift to value as a foundation for reimbursement. This means that
the “who” we care for in a SNF will shift from those needing therapy services such
as stroke and joint replacement to more medically complex patients such as those
with chronic obstructive pulmonary disease (COPD) or congestive heart failure
(CHF). The “how” of care delivery will also change as a result of these new types
of patients, as they will require less therapy and more nursing and other specialized
services like respiratory or cardiac therapy for end-stage management of COPD
and CHF.SNF providers will need to think more about how to deliver care to these
medically complex patients with these value-based accountability outcomes. The
result will be SNFs that are better integrated into the entire care continuum, better
equipped to care for medically complex patients, and better at linking patients from
the hospital to the community. But this will require unique skill sets and team
members that are able to keep SNF patients healthy in the community rather than
requiring avoidable hospitalizations, improving both clinical and nancial
outcomes.
Preferred SNF Network
As health systems increase their focus on population health through care coordination, they are looking to manage their post-acute care more aggressively, especially
through development of a Preferred SNF Network [13]. SNFs with higher quality
scores and greater efciency (lower 30-day readmission rate, for example) and who
collaborate more effectively with health systems are preferred. The value of health
system-preferred SNF networks was illustrated in a recent study in Health Affairs
[14]. In the article, researchers studied several hospitals that had developed formal
SNF networks as part of their care management efforts. These hospitals saw a relative reduction from 2009 to 2013 of 4.5% in readmission rates for patients discharged to SNFs compared to hospitals without formal networks. Overall,
researchers found that establishing preferred SNF provider networks is one approach
hospital administrators are using to reduce excess 30-day readmissions and avoid
Medicare penalties, and to reduce beneciaries’ costs as part of value-based payment models.
By appreciating this benet of preferred SNF networks, leaders at SNFs can better understand how to become a successful partner with health systems while
improving care for their residents.
Figure 2 contains an adaptation of a letter sent by a health system, Meadow Creek
Healthcare System, to an area SNF after they had evaluated the facility as a potential
member of their preferred network. This correspondence illustrates the basis of
selection for a preferred provider and specic areas of opportunity for improvement.
CMSStar Rangs
Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
Fig. 2 Preferred SNF evaluation report
While all health systems will have their own individual process, most will concentrate on these same critical elements when choosing a preferred network. SNF leaders can proactively ready their facility in the key areas discussed in the letter.
successful on the basis of a panel of measurable outcomes. These accountability
measures will likely be centered on the following:
cal and nancial outcomes. These accountability measures focus primarily on keeping patients safe in the SNF and community. The measures considered include those
in Table3.
care for patients in their facility, which includes transitioning them to their homes in
the community. These efforts depend on each SNF having the resources and skilled
staff to provide the level of care needed to recognize and treat issues rather than
allowing them to escalate to require a hospitalization. A central component of delivering this care is having a process in place to identify opportunities to prevent avoidable emergency department (ED)/hospital utilization—one such method is use of
the INTERACT tool [15].
tions undergo a thoughtful analysis to identify opportunities to prevent future occurrences. This activity typically reveals care improvement opportunities related to
end-of-life planning or access to medical evaluation. Once an area is identied, a
plan can then be put into place to address the perceived problem, such as maintaining physician orders for life-sustaining treatment forms for all residents, using virtual after-hour medical services, or having a dedicated advanced practical nurse
available to care for all facility residents.
direct result of health systems increasingly taking on nancial responsibility for
care outside of the hospital through bundled payments, accountable care organizations (ACOs), and other risk arrangements. Thus, managing total cost of care is
critical for success in these arrangements. As previously discussed, an SNF that has
13
Overall
Inspecon
Staffing
QualityMeasures
Re-Hospitalizaon Rate
DuringSNF Stay
Following SNF Stay
Overall
Surveys of Health System Discharge/TransiontoSNF Team (Rang:1negave –5posive)
PerceponofSupport or Challengesindealingwith facility
Perceponof Scope &Qualityof ServicesOffered
Desire forreferralof Self or LovedOne to this facility
AverageRang
Once established, each health system’s preferred SNF network will be deemed
The measure of success of many health system’s SNF network is based on clini-
Note that these measures rely heavily on each SNF being able to successfully
Health systems often strongly recommend that all unplanned ED/hospitaliza-
Also of note is the CMS Star Rating and total cost of care measures. These are a
14
Table 3 SNF measures of success
CMS star rating (must be >3)
• Overall
• Quality measures
HCQIS (QIO) Data
• Readmission rate to hospital during SNF stay
• Readmission rate to hospital after SNF stay
• Overall SNF readmission rate to hospital
CMS Star Rating
• Percentage of short-stay residents who were rehospitalized after a nursing home admission
• Percentage of short-stay residents who have had an outpatient emergency department visit
• Percentage of short-stay residents who were successfully discharged to the community
SNF total cost of care
• Average SNF stay cost
• Average SNF total cost of care
R. G. Stefanacci and M. A. Kaminski
and maintains an overall rating of 3 Stars or higher in the CMS 5-Star Quality
Rating System will be preferred in order to participate in the SNF 3-day rule Waiver
and provide for direct SNF admissions.
Special Needs Plans
While much has been talked about regarding ACOs and bundled payments, Special
Needs Plans (SNP) miss the attention of long-term care (LTC) stakeholders despite
the fact that these are the most signicant value-based offerings for LTC [16]. SNPs,
created by Congress in 2003, are Medicare coordinated care plans (CCP) specically designed to provide targeted care to a limited enrollment of special needs
individuals. SNPs are responsible for addressing the total cost of care. There are
three different types of SNPs:
1. Dual Eligible SNP (D-SNP) for dual eligible beneciaries (2,157,682 enrollees)
2. Chronic Condition SNP (C-SNP), serving an individual with a severe or dis-
abling chronic condition, as specied by the Centers for Medicare & Medicaid
Services (CMS) (345,951 enrollees)
3. Institutional SNP (I-SNP) for an institutionalized individual (71,474 enrollees)
Obviously the I-SNP has direct application to LTC stakeholders, as it is specic
to skilled nursing facilities (SNFs). But the other SNPs, C-SNP and D-SNP, also
have LTC application, as those individuals will be served in the SNF subacute setting as well as after transitioning. A detail even more signicant for LTC stakeholders is that, as LTC shifts from facility-based SNFs to the community, older
individuals in need of LTC can be better served through these SNPs.
Again, these models provide LTC providers opportunities to better coordinate
care and provide services beyond those covered by Medicare or Medicaid, such as
needs related to social determinants of health.
Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
15
I-SNPs are SNPs that restrict enrollment to MA eligible individuals who, for
90days or longer, have had or are expected to need the level of services provided in
an LTC/SNF, an LTC nursing facility (NF), a SNF/NF, an intermediate care facility
for individuals with intellectual disabilities, or an inpatient psychiatric facility. A
complete list of acceptable types of institutions can be found online.
An I-SNP may operate either single or as multiple facilities; CMS may allow
establishment of a county-based service area, as long as the I-SNP includes at
least one LTC facility that can accept enrollment and is accessible to county residents. “As with all MA plans, CMS will monitor the plan’s marketing/enrollment
practices and LTC facility contracts to conrm that there is no discriminatory
impact.”
The below conditions must be met for an I-SNP to enroll MA eligible individuals
living in the community but requiring an institutional level of care (LOC):
1. “A determination of institutional LOC that is based on the use of a state assess-
ment tool. The assessment tool used for persons living in the community must be
the same as that used for individuals residing in an institution. In states and territories without a specic tool, I-SNPs must use the same LOC determination
methodology used in the respective state or territory in which the I-SNP is authorized to enroll eligible individuals.”
2. “The I-SNP must arrange to have the LOC assessment administered by an inde-
pendent, impartial party (i.e., an entity other than the respective I-SNP) with the
requisite professional knowledge to identify accurately the institutional LOC
needs. Importantly, the I-SNP cannot own or control the entity.”
These “at-risk” models administered through an SNP, through investment in
clinical management in the nursing home setting, have the potential to allow individuals to receive care on-site and avoid costly inpatient transfers.
Given the high need for exibility beyond FFS, successful SNPs should focus
their attention on wellness, caregivers, coordination, prescription/medication management, end-of-life care, social determinants of health, and mental health. Of
these, one of the most critical is medication management. Medication management
is meant to assist individuals in taking their medications on time, at the proper time,
and consistently, while helping prevent incorrect medication administration and the
resulting potential harms.
Learnings fromCOVID-19
Almost 1 month prior to being declared a worldwide pandemic, a case of coronavirus disease (COVID-19) was identied in a resident of a long-term care skilled
facility in King Country, Washington. It was among the earliest reported in the
USA.As of June 2021, 4% of COVID-19 infections but 31% of deaths (at least
184,000) were reported in USA nursing homes. At one point, 43% of deaths were
attributed to LTC facilities. The rate has declined dramatically with the COVID-19
vaccine rollouts. The Pandemic underscored the vulnerability of the frail geriatric
16
R. G. Stefanacci and M. A. Kaminski
population residing in LTC facilities. The enclosed, congregate living settings that
nursing homes represent, the volume of outside visitors, and staff members, many
paid low-wages with multiple jobs at other LTCFs caring for the residents, augmented the risk of infection for the vulnerable elderly residents.
The response by nursing homes mitigated the risk of transmission of COVID-19,
but also highlighted key strategies to maximize residents’ and staff members’ safety.
These involve some key insights that lead to “best practices”:
• Reinforce basic infection transmission precautions such as consistent handwash-
ing, and mask wearing for residents or staff with respiratory symptoms. Staff,
resident, and visitor education is necessary.
• Promote successful immunization campaigns for residents and staff of facilities.
• Realize that National and Global infectious disease trends will ultimately invade
long-term care facilities. Keep abreast of public health information.
• Promote an organized team response for consistent, successful program manage-
ment. Nursing facilities are required, as part of the Pandemic response, to desig-
nate one or more individual(s) as the Infection Preventionist(s) (IPs) who are
responsible for the facility’s Infection Prevention Control Program (IPCP).
• Assure adequate Personal Protective Equipment (PPE) inventory for infection
breakouts. Funding and inventory processes need to be in place
• Screen and limit outside visitors during epidemics or pandemics.
• Avoid staff turnover and employment of outside temporary staff members as
much as is feasible.
• Reduce outside visitors through use of automated dispensing pharmacy services
instead of manual delivery of pharmaceuticals.
• Encourage physicians and other provider staff, who often visit other facilities, to
conduct rounds and patient visits virtually/remotely.
Providers who are in leadership positions can help promote nursing facility safety:
• Gain credibility and apply pressure for response with leadership, including com-
munication with Board members.
• Work for buy-in of your residents, families, and staff; communicate with them
regularly.
• Make PPE and the protection of your residents and staff the top priority. Control
the environment as much as possible.
• Rely on the basics of process development and management.
• Work with a lead for policy development, tracking, and education.
• Partner with your workforce to achieve the common goal of safety; make expec-
tations clear.
Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
17
COVID-19 demonstrated much about skilled nursing facilities from the vulnerability to the need to share information on the dangers and appropriate management
of an infectious disease. COVID-19 demonstrated much about skilled nursing facilities from the vulnerability to the need to share information on the dangers and
appropriate management of an infectious disease.
The Interdisciplinary Team
An interdisciplinary team of health care professionals who provide both a comprehensive and coordinated assessment and management of each resident’s medical,
psychological, social, and functional needs is essential for resident well-being in LTC
(Table4). This in fact is mandated in nursing facilities but is also a practical approach
to provide care for the elderly in the assisted living facility and home as well.
Summary
In this chapter, we have reviewed how evolving payment models are impacting providers of Post-Acute Care and Long-term Support Services. While previously based
on simple fee-for-service payment, new value-based payment strategies are increasingly holding providers accountable for the total cost of care. This requires the coordination of care across all care venues, including the patients’ homes. Higher value
SNFs and Home Care service providers will be rewarded through designations in
preferred networks. Success requires evolving to a model of care involving close
collaboration across teams of providers that continually deliver value care.
Table 4 The interdisciplinary care team in nursing facilities
Title Scope of practice Education
Certied
nurses aids
(CNA)
Licensed
practical nurse
(LPN)
Work under the supervision of a nurse and
provide assistance to patients with daily
living tasks
Provide the patient care on a very personal
level. They usually report directly to
physicians and RNs, and are usually
responsible for taking vitals and monitoring
in-and-out volumes, treating common
conditions like pressure sores, and preparing
or performing several procedures such as
dressing wounds, bathing and dressing, and
giving enemas. In some, but not all, states
LPNs and LVNs may administer prescribed
medicines or start IV uids
In addition to a high school
diploma or GED, completion of
a 6- to 12-week CNA certicate
program at a community college
or medical facility
Required to pass a licensing
examination, known as the
NCLEX-PN, after completing a
State-approved practical nursing
program. A high school diploma
or its equivalent usually is
required for entry
(continued)
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R. G. Stefanacci and M. A. Kaminski
Table 4 (continued)
Title Scope of practice Education
Registered
nurse (RN)
Registered
Nurse
Assessment
Coordinator
(RNAC)
Work directly with patients and their
families. They are the primary point of
contact between the patient and the world of
health care, both at the bedside and in
outpatient settings. RNs perform frequent
patient evaluations, including monitoring and
tracking vital signs, performing procedures
such as IV placement, phlebotomy, and
administering medications. Because the RN
has much more regular contact with patients
than physicians, the RN is usually rst to
notice problems or raise concerns about
patient progress
The Registered Nurse Assessment
Coordinator (RNAC) will assist the Director
of Nursing (DON) with ensuring that
documentation in the center meets Federal
State and Certication guidelines. The
The three major educational
paths to registered nursing are a
bachelor’s degree, an associate
degree, and a diploma from an
approved nursing program.
Nurses most commonly enter
the occupation by completing
an associate degree or
bachelor’s degree program.
Individuals then must complete
a national licensing examination
in order to obtain a nursing
license
RNAC will coordinate RAI process assuring
the accuracy timeliness and completeness of
the MDS RAPS and Interdisciplinary Care
Plan. The Registered Nurse Assessment
Coordinator (RNAC) conducts the nursing
process—Assessment Planning
Implementation and Evaluation—under the
state’s Nurse Practice Act for Registered
Nurse Licensure
Director of
Nursing
(DON)
The Director of Nursing has the
responsibility of overseeing the standards of
nursing practices for the organization’s
nursing services. The DON participates with
other members of Nursing Services and
Administration in the development of patient
care programs, policies, and procedures to
meet all requirements including ethical and
legal concerns
Social worker Assist people by helping them cope with
issues in their everyday lives, deal with their
relationships, and solve personal and family
problems
All States and the District of
Columbia have licensing,
certication, or registration
requirements regarding social
work practice and the use of
professional titles. Although
standards for licensing vary by
State, a growing number of
States are placing greater
emphasis on communications
skills, professional ethics, and
sensitivity to cultural diversity
issues. Most States require
2years (3000 h) of supervised
clinical experience for licensure
of clinical social workers
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