Continuity of care is paramount for everyone involved as far as enhancing outcomes for individuals who are being admitted, cared for and ultimately discharged from skilled nursing facilities (SNFs),

Continuity helps to ensure that residents receive the proper care in your facility as soon as they enter based on their unique circumstances. It also provides caregivers comprehensive and accurate information when it’s time to discharge the resident—either to their home, another SNF, an acute-care hospital or, in some cases, an emergency room. Additionally, it helps you maintain Quality Measures at desirable levels, avoid costly penalties, function at optimal efficiency and build a winning culture for employees and residents alike.

In this blog, we offer nine clinically focused best practices for SNFs in relation to admission functions.

Once your pre-admission team has done its due diligence on a potential resident and determined that admission is feasible and advisable, several admission-related best practices can help your SNF ensure a smooth process for residents and team members alike.

Best practice #1: Understand what your contract with insurance payers says.

You’d think this would be a no-brainer. But we’ve encountered lots of individuals in the SNF admissions realm who don’t even know what contracts they have—let alone what’s in them.

SNF clients have choices when it comes to which facility they seek admittance. Yet, insurance companies utilize preferred providers, and if your SNF isn’t in their preferred provider network (PPN), residents may be liable for self-payment. It’s up to specified individuals on your admissions team to understand the details of your contracts and be prepared to discuss implications with residents and/or their loved ones. Additionally, financial discussions with the resident and/or responsible party should be fully documented and signed off on.

We also recommend that the organization prepare a matrix of contracts and payer requirements for staff reference. Staff should have a clear understanding of what products are included in the contract and what services are covered. Documentation requirements should be discussed prior to admission to ensure that clinical documentation fully supports the claims. Payers may require multiple authorizations for specific services or carveouts and staff must be knowledgeable about these requirements to avoid payment denials or recoupment.

Best practice #2: Empower designated clinical staff to make decisions.

Patient acuity and clinical screening are vitally important elements that help to determine payment under PDPM. Accordingly, we at Richter believe strongly in giving experienced clinical personnel – oftentimes a nurse liaison – the authority to manage the admissions process. This includes autonomy to make clinical decisions based on the appropriateness for admission—knowing what cases should and should not be admissible under facility guidelines. Many experienced nurses have been “in the trenches” for years and understand these issues as well as anyone in a SNF. They should know the basic details of their contracts; be able to articulate the resident’s and facility’s needs to the insurer and/or hospital; understand the patient’s acuity; negotiate carveouts; and more. That’s not to say this isn’t a collaborative endeavor; but again, we believe clinical staff should have autonomy to make these key decisions.

Best practice #3: Get the correct diagnosis.

A diagnosis drives a patient’s potential admission, as well as payment. Without the correct diagnosis, your facility could face significantly adverse circumstances—from underpayment to non-payment.

Primary and admitting diagnoses are often the same—but not always. The admission diagnosis for a given resident should be the condition that required the resident’s admission to your facility, and the reason that individual needs care. The preceding hospital’s principal diagnosis may not be the reason long-term care is needed. SNFs should assign after-care codes or a condition code with a seventh digit indicating subsequent care.

RELATED E-BOOK: “Pre-Admission, Admission and Discharge Clinical Best Practices for Skilled Nursing Facilities.”

Best practice #4: Establish a clear division of labor.

Just as with pre-admission, each member of the admission team should have clear responsibilities for specific items and tasks. Take the example of a care plan…who is responsible for completing it? Who’s responsible for the assessment? Is it the admitting nurse, or the next shift? For every resident, there must be a specific understanding of who owns what. If it’s not currently included in your policies and procedures, we strongly encourage you to add it.

Best practice #5: Make sure your restorative nursing program and therapy department work collaboratively, and that restorative service begins on day one of the admission to keep the patient moving.

Prior to PDPM, it was customary for therapy personnel to spend time with a given resident for up to three hours per day. The resident likely would spend the day’s remaining 21 hours in a wheelchair, or in bed. Joint and muscle stiffness naturally sets in under this scenario, so when therapy returns the next day, there’s little progress being made. To rectify this, restorative personnel should work with residents during evenings and weekends. This can actually help to decrease the length of stay and enhance patient outcomes.

Best practice #6: Embrace the use of case management.

Today, case managers aren’t as readily used in skilled nursing environments as we at Richter believe they should be. Most minimum data set (MDS) nurses currently are charged with completing a large number of assessments—upwards of nine in some cases. With PDPM now in place, that number has decreased to two (one of which is a discharge assessment). As that administrative burden has decreased, MDS coordinators generally have taken on more of a case management role—monitoring length of stay, barriers to discharge and assisting with discharge planning. This may be a somewhat different role than they’re used to, but we believe it’s a necessary evolution, and we encourage your SNF to facilitate it.

Best practice #7: Understand interrupted stay vs. readmission.

Interrupted stay is a new policy that was implemented at the same time as PDPM. It basically determines if your facility is required to undertake a new assessment for a given resident. If that resident’s stay in your facility is interrupted for more than three consecutive midnights, you’re required to perform a new assessment. If the patient is only gone for 24-48 hours, no new assessment is needed.

With regard to readmission, SNFs receive penalties every time they send a resident to a hospital or an emergency room. Hospitals also are penalized when patients are readmitted from their homes or a SNF. Therefore, we encourage your SNF to be proactive and establish routine check-ins with discharged residents. There may be an opportunity to avoid a rehospitalization if you are able to identify a decline or other post-discharge issue. For example, if you send someone home for 15 days, and they’re not doing well, you could suggest to them or their loved ones that they return to your facility. You’ll still have points deducted, but the penalty won’t be as acute as it would be if they returned to the hospital or emergency room.

Best practice #8: Conduct SBAR assessments to minimize emergency room returns.

SBARs are thorough patient assessments conducted at SNFs in cases where there is a change in condition. They are conducted before contacting the resident’s primary physician. Assuming there is adequate time to conduct it (i.e., no imminent medical condition such as a heart attack, stroke or severe bleeding), a typical SBAR includes a description of the patient’s situation and background, as well as the treatment approach and physician response. Owing to their inclusive nature, SBARs compel nurses to compile all available data. This, in turn, provides physicians with information they need to determine whether treatment can be administered on-site at a SNF. In the absence of such data, many physicians simply send patients to an emergency room, which is an undesirable outcome for any SNF.

Best practice #9: Use root-cause analysis to analyze high rates of readmission.

Just as many young children pose the question why to appease curiosities far and wide, we encourage SNFs to take a similar approach to readmissions. Perhaps you’re sending patients to the hospital. Why is that? Are some physicians making more hospital referrals than others? If so, why? Keep digging and asking why until patterns appear, or answers reveal themselves.

KEY TAKEAWAYS AND ADDITIONAL POINTS:

• Capable and qualified clinical personnel should manage the admission process. They should be given proper autonomy to make clinical decisions regarding appropriateness of admission.
• Resident acuity and clinical screening are among the most important factors to consider in the admission process.
• Get the correct diagnosis. The diagnosis drives a patient’s potential admission, as well as payment. As we said in Best practice #3, primary and admitting diagnoses are often the same—but not always.
• Hospital documentation should arrive with the resident. If it doesn’t, that could mean penalties for the referring hospital. Regardless, your staff should work to build relationships with key personnel at referring hospitals so that when documentation is missing, diagnosis codes are needed or other questions arise, answers are a phone call away.
• Obtain the referring physician’s certification within 72 hours of admission.
• Communication is key. This applies to communication channels and processes within your facility, as well as communication with referring hospitals and emergency rooms. (By this time, it should be obvious that good communication underlies all care transition phases and enhances continuity of care.)

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