Skilled Nursing Facility Pre-Admission Best Practices │ Clinical Consulting Services │ Richter

When it comes to enhancing outcomes for individuals who are being admitted, cared for and ultimately discharged from skilled nursing facilities (SNFs), continuity of care is paramount for everyone involved.

First and foremost, 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. And from the standpoint of your SNF, 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 highlight five best practices for SNFs in relation to pre-admission functions.

 Best practice #1: Establish a framework to help you and your team effectively understand and quantify how patient outcomes and cost of care relate to one another for each potential resident.

As we said, continuity of care is essential—and with PDPM, it’s even more so. Why? Because reimbursement under PDPM is intended to more accurately reflect the utilization of SNF resources over the course of the resident stay.

In the past, facilities were compensated based on the number of minutes of therapy that were used, as well as the types of therapy administered. With PDPM, facilities are no longer paid according to the amount of therapy services provided. Instead, they must assess a multitude of patient characteristics in order to understand how much they will be paid. This means basing payments on specific resident diagnoses and asking questions such as:

• What will this resident really need in our facility?
• What are the comorbidities we will have to face?
• How much will it cost us?
• Is it cost-effective to bring this person into our facility? Can we meet the resident’s needs?

When SNFs are contacted about potentially admitting a patient, policies and processes must govern how decisions are made. These are big decisions for a SNF—and usually, they must be made in very short order…sometimes as quickly as 15 minutes from the initial referral. Therefore, prior to admitting any resident into your facility, you and your team should call upon written policies and procedures to help answer these and other questions and make pre-admission decisions that serve your facility and its residents well. Equally important, those policies and procedures should delineate specific responsibilities for each team member in the pre-admission process.

Whether circumstances are relatively normal or unusually complex, lots of important issues must be addressed:

• Who is responsible for evaluating the merits of the potential resident’s admission?
• What will that evaluation be based on?
• When and where will it occur?
• How will that potential resident’s information be obtained from an acute-care hospital or other health care provider? Electronically? Via paper records?
• How will you respond if potential residents or their loved ones choose your SNF, and through your process, it’s determined that the fit isn’t sufficient for either party? Certainly, a primary goal of any SNF is to fill beds; but sometimes, it’s actually more cost-effective for an SNF to maintain an empty bed than to serve a resident whose needs can’t be met sufficiently or profitably.

Woven into all of this is technology. When properly leveraged, technology can help optimize your pre-admission processes at every turn. Yet, when it’s misunderstood, underutilized or not utilized at all, your facility will face an uphill climb in streamlining pre-admission processes in the age of PDPM.

At Richter, we highly recommend conducting a thorough and honest assessment of your current technology, as well as your facility’s use of it. Do you have referral management software, and do you use it effectively? Does your software integrate with eReferral platforms? What are your paper processes, or do you use an electronic health record (EHR) solution exclusively? Are you analyzing all of the available information, or do you have other software that can enable you to flow pre-admission analyses of a potential patient through to the individual’s actual admission?

As you can see, there are many questions and issues to be addressed at the outset of establishing a sound pre-admission process. Once you begin to get answers, you’ll be better equipped to undertake our second pre-admission best practice…

Best practice #2: Establish comprehensive referral information requirements.

In order to admit an acute-care hospital or emergency room patient, a SNF must receive certain information from that provider. Yet all too often, that information transfer does not occur. Sometimes, SNFs receive hospital patients at their doorstep with no paperwork, or paperwork that is signed and dated but contains little or no medical information.

As a result, the SNF must now care for a resident with no background, diagnosis or qualitative information to guide that care. Even so, sending the patient back to the hospital can negatively impact Quality Measures, so the SNF faces a lose-lose proposition.

With PDPM, getting detailed patient information is a must for SNFs—and communication and collaboration among providers is the best strategy to make it happen. At a minimum, it’s critical to obtain primary diagnosis and surgical information for the last 30 days. To obtain these and all other pertinent information from outside providers, it’s important for pre-admission personnel to clarify and communicate specific criteria with your admission and acute staff members, including:

• Any additional information that will be needed from acute care to complete the minimum data set (MDS)
• Strategies to utilize EHR information to maximize reimbursement under the PDPM model
• A determination of whether the acute-care facility has packaged the appropriate clinical information in their referrals to conform with a SNF’s pre-admission process/procedural criteria

Certainly, this best practice is in the best interests of your SNF. But hospitals now face fines for failing to provide required documentation to SNFs – upwards of $1 million per incident – so communicating and collaborating on this important area benefits them as well—not to mention residents who rely on your facility for proper care.

SNFs simply cannot undertake all this in a vacuum. They must build and nurture relationships with case managers and discharge planners at acute-care hospitals and other health care provider institutions.

RELATED RESOURCE: Learn how to optimize continuity of care in all of your facility’s transitional policies and processes – download our free e-book, “Pre-Admission, Admission and Discharge Clinical Best Practices for Skilled Nursing Facilities.”

Best practice #3: Communicate in a time-sensitive and meaningful way with real people at referring institutions.

Whoever is charged with accepting a patient from another facility – ideally a nurse or case manager – should bear the responsibility of picking up the telephone and calling a designated peer (e.g., hospital charge nurse) at the referring facility for a brief nurse-to-nurse update on the client. This doesn’t need to be a lengthy call, or rely heavily on details and jargon. It could be as straightforward as confirming the name of the patient, the diagnosis, other medical conditions of note, medication allergies and any personal or family-related information that could be helpful in making pre-admission, admission and/or discharge decisions.

To make this best practice a reality, your SNF should establish defined procedures for hand-off communications at the point of transition. These should include how communications occur; who participates; timing; and specific client information.

Even with great communication and collaboration, your SNF must sometimes make difficult decisions with regard to non-network provider referrals. What to do? Our next pre-admission best practice has the answer…

Best practice #4: Spell out your facility’s pre-admission requirements in writing.

Do you know what portion of service to a given resident you’ll be able to carve out for additional reimbursement? Are you certain of what services you will be paid for—and does that make it feasible for you to accept the resident? Would an insurance company be willing to provide a single case management agreement if your facility is out of network? These and other issues should be clearly articulated in your pre-admission policies.

If you’ve followed our best practice recommendations so far, you’ll be well-positioned to make good pre-admission choices for your facility and potential residents. Once you make the decision to admit a resident, you’ll want to follow our fifth and final pre-admission best practice…

Best practice #5: Strive for 100 percent continuity of care in each transition of care you touch.

In this regard, there are five key steps that help to make this possible:

1. Encouraging communication with key stakeholders in your facility
2. Taking ownership of the transfer/discharge process
3. Obtaining all the necessary information regarding care essentials and PDPM requirements
4. Managing care effectively during the resident’s stay (including obtaining additional authorizations for their continued stay, if appropriate)
5. Faithfully executing a discharge plan that includes responsibly handing off information for the next level of care—be it a hospital, emergency room, another LTPAC facility, home health or hospice. Again, continuity of care is the goal.

KEY TAKEAWAYS AND ADDITIONAL POINTS:

• Clear written policies and procedures help to ensure an efficient pre-admission process. PDPM compels SNFs to carefully evaluate each potential admission with regard to payment and ability to provide effective service. Oversights and errors can negatively impact your facility’s Quality Measures and profitability.
• Evaluate your facility’s technology capabilities thoroughly and honestly. Do you have the right tools in place? Is your staff properly trained to use them—and do they trust them? Are you using those tools in ways that optimize efficiency and help ensure continuity of care during care transitions? The depth and breadth of today’s LTPAC technology can be intimidating; but when properly utilized, it can super-charge your facility’s efforts to streamline transitions and enhance patient outcomes.
• PDPM impacts pre-admission screening criteria. It’s imperative to obtain the resident’s primary diagnosis and any other active diagnosis information prior to admission. This includes identifying PDPM clinical categories and gathering data for the MDS Section GG functional items, as well as surgical history.
• Communication is key. Just as with admission and discharge, communication in the pre-admission stage is a crucial element in helping ensure continuity of care. Personal and meaningful communication between your staff and staff members at acute-care hospitals (or emergency rooms) is in the best interests of patients, your SNF and the referring institution.

Contact Richter’s Skilled Nursing Facility Consultants

Do you have questions about implementing pre-admission, admission and discharge best practices at your facility? Read our e-book, “Pre-Admission, Admission and Discharge Clinical Best Practices for Skilled Nursing Facilities” or call Richter’s skilled nursing facility consultants at 866-806-0799 to schedule a free consultation.

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