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Variability in skilled nursing facility screening and admission processes

Implications for value-based purchasing

Lawrence, Emily; Casler, Jessica-Jean; Jones, Jacqueline; Leonard, Chelsea; Ladebue, Amy; Ayele, Roman; Cumbler, Ethan; Allyn, Rebecca; Burke, Robert E.

doi: 10.1097/HMR.0000000000000225
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Background: Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care.

Purpose: The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms.

Methods: We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs—including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach.

Results: We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients.

Conclusions: We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing.

Practice Implications: SNFs can most effectively respond to these pressures by increasing their agency within hospital–SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.

Emily Lawrence, MPH, is Research Analyst, Denver-Seattle Center of Innovation, Denver VA Medical Center, Colorado.

Jessica-Jean Casler, PhD, is Post-Doctoral Fellow, Denver-Seattle Center of Innovation, Denver VA Medical Center, Colorado.

Jacqueline Jones, RN, PhD, FAAN, is Professor of Nursing, University of Colorado College of Nursing, Aurora.

Chelsea Leonard, PhD, is Research Analyst, Denver-Seattle Center of Innovation, Denver VA Medical Center, Colorado.

Amy Ladebue, BA, is Research Analyst, Denver-Seattle Center of Innovation, Denver VA Medical Center, Colorado.

Roman Ayele, PhD, MPH, is Research Analyst, Denver-Seattle Center of Innovation, Denver VA Medical Center, Colorado.

Ethan Cumbler, MD, is Professor of Medicine, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora.

Rebecca Allyn, MD, is Associate Professor of Medicine, Department of Medicine, Denver Health and Hospital Authority, Colorado.

Robert E. Burke MD, MS, is Associate Professor of Medicine, Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, and Hospital Medicine Section, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia. E-mail: Robert.Burke2@uphs.upenn.edu.

This work was supported by the National Institute of Aging, R03AG050885 (Dr. Burke, PI). Dr. Burke was also supported by a VA HSR&D Career Development Award (1IK2 HX001796). An abstract of these findings was presented at the Society for General Internal Medicine (SGIM) 2018 national meeting.

The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this study.

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