Washington Update: Monday, April 3, 2023

Select Medical joins the National Association of Rural Health.

We’re pleased to join the NRHA, a national non-profit association of healthcare clinicians and facilities who provide care in rural and under-served areas of the nation. NRHA's three main advocacy priority areas include: (1) Addressing rural declining life expectancy and rural equity, (2) Reducing rural health care workforce shortages and (3) Investing in a strong rural safety net. Rural health is a priority for new Ways & Means Chairman Jason Smith (R-MO).

Modern Healthcare reports on patients’ limited access to post-acute care.

Modern Healthcare recently published a cover story on the difficulties facing patients and general hospitals as they try to discharge patients to post-acute facilities. It’s not just payor practices slowing down discharges. Post-acute providers face a nationwide staffing shortage as well as new regulatory issues. While the article primarily focuses on SNFs, many of the same challenges face our IRFs and LTCHs. The article is appended.

New report on national hospital margins shows the “new normal.”

Kaufman Hall, a Chicago-based consultancy, released its annual look at hospital margins. The report says general hospitals continue to shift patients to ambulatory settings. The onset of the COVID-19 pandemic kickstarted a shift in patient behavior that continues today. Hospitals continue to face labor shortages, but labor expenses appear to be holding steady indicating less dependence on contract clinicians. Find the complete report at this link.

https://www.kaufmanhall.com/sites/default/files/2023-03/KH-NHFR_2023-03-V2.pdf

Wisconsin goes to polls to elect swing-vote judge on state supreme court.

Tomorrow, Badger state citizens go to the polls to decide whether Republican Daniel Kelly or Democrat Janet Protasiewicz will sit on the state’s highest court. The race will decide the ideological balance of the court with implications for abortion rights, gerrymandered legislative districts and possibly the 2024 presidential election. The race is the most expensive judicial election in the country – with at least $30 million spent on television ads.

Senate Republicans hoping to recruit Jim Justice to take on Joe Manchin.

Sen. Joe Manchin (D-WV) is up for reelection in 2024 and is likely a vulnerable Democrat in a state won by Donald Trump by 40%. Jim Justice is the popular Republican governor of West Virginia who, if he won a Senate seat, could help tip the balance in today’s closely-divided Senate (51-49). A Jim Justice candidacy would break Republicans’ losing streak in recruiting popular governors. Still, Justice may have to deal with a messy Republican primary challenge.

Amazon closes deal to acquire One Medical primary-care.

Amazon closed on its $3.9 billion acquisition of One Medical. With the deal, Amazon makes an additional foray into healthcare delivery, after acquiring a mail-order pharmacy in 2018. With One Medical, Amazon gains over 200 medical office sites, treating 815,000 patients in 26 different markets. Analysts are already speculating that Amazon may seek to build on this footprint by expanding One Medical’s offerings through Amazon’s Whole Food stores or other company sites.

Walmart to open more primary care centers.

Walmart plans to open at least 28 new health care centers in four states by the end of next year, bringing the retail giant's total Walmart Health sites to 75. The centers will be in Walmart Supercenters and offer primary care, mental and dental health, audiology, X-ray, laboratory and telehealth services. Walmart says 90% of Americans live within 10 miles of one of its stores and it is well-positioned to offer additional healthcare services.

MODERN HEALTHCARE

February 20, 2023

Transitions to post-acute care are getting even more challenging

BY ALEX KACIK

About 25 patients were ready to be discharged in mid-January from Bryan Health’s two hospitals, but the nonprofit system in Lincoln, Nebraska, couldn't find any post-acute providers to admit them. Several patients had been in limbo for more than 200 days. With medical-surgical units at capacity, the resulting backlog forced Bryan Health to treat would-be discharged patients in the emergency department.

Halfway across the country, Erin Doss, regional administrator at skilled-nursing and rehabilitation provider Queen Anne Healthcare in Seattle, described a similar situation. “Hospitals board patients on a gurney in a hallway, where they can wait for days,” she said. “It’s happening nationwide.”

The transition to post-acute care has historically been difficult to manage. Hospitals must find a facility able to take patients, obtain pre-authorization from insurers and relay discharge plans despite frequently incompatible technology. The latest round of staffing shortages has exacerbated the chronic challenges, raising safety and quality concerns.

“It is rather shocking what we are willing to put up with in this industry regarding transitions of care,” said Dr. Kathleen Unroe, a geriatrician and associate professor of medicine at Indianapolis-based IU School of Medicine who helps nursing homes and hospitals improve care transitions.

Around 400 nursing homes have closed since 2020, according to Centers for Medicare and Medicaid Services data through January 2023. Nursing and residential care facilities shed more than 210,000 jobs over that span, Bureau of Labor Statistics data show.

“A lot of facilities do not have the personnel needed to take care of residents,” said Deb Burdsall, an infection prevention specialist and board member of the Association for Professionals in Infection Control and Epidemiology who worked in long-term care for more than 40 years.

Employment is slowly starting to rebound: Nursing homes filled an average of 3,700 jobs per month from May 2022 through January. But at that pace, it would take until 2027 for staffing at nursing homes to reach pre-pandemic levels, according to a recent report from the American Health Care Association and National Center for Assisted Living, which represents long-term care and post-acute providers.

“When I speak with my peers, all are suffering extreme staffing shortages, especially in nursing and nursing assistants,” said Tonja Myers, administrator of Christian Health Care Center, a nonprofit skilled-nursing and rehabilitation facility in Lynden, Washington. “Without those professionals in place, we cannot afford to take as many admissions as in the past.”

Christian Health Care Center only accepted 4% of referred patients in 2022 due to a lack of staffing, compared with 5% in 2021, 9% in 2020 and 17% in 2019.

“Without having [a patient] census at previous levels, we don’t have the revenue needed to stay in business,” Myers said. “Most of us long-term care facilities are using our savings to stay afloat, and many will close within the next year or two.”

The lack of workers has disrupted the care transition process, presenting potential dangers. Protracted waits can mean patients don’t get referred to the post-acute facilities best suited to treat their needs, said Jean Harpel, operations manager for aging services at ECRI, a patient safety organization.

A 2022 study published in the Journal of Patient Safety found that the longer patients were held in the emergency department after they were ready to be discharged, the more likely they were to experience a fall, medication error or other safety event.

COVID-19 outbreaks and prior authorization hurdles have also stalled hospital discharges, said Glen Roebuck, executive director of home, outpatient and senior services at Genesis Health System, which operates six hospitals and a network of home health, hospice, rehabilitation and long-term care facilities headquartered in the Quad Cities area of Iowa and Illinois. Pre-authorization processes cannot begin until a patient’s discharge is imminent, and insurers typically take between two to five business days to respond to authorization, prolonging hospital stays, Roebuck said.

The slowdowns can mean transitions take place after normal business hours, when skilled-nursing facilities don’t usually have physicians or pharmacists on site. Any potential gaps in care plans or pharmaceutical needs then become extraordinarily difficult to fill, he said. “Those types of discharges come with great risk to the patient, as well as regulatory risk for the facility,” Roebuck said.

A looming regulation from CMS may further constrain nursing homes, operators warned. The agency announced plans in February 2022 to implement minimum staffing requirements by this spring in an attempt to improve safety across skilled-nursing facilities.

The move would disproportionately impact access to providers in rural settings, which already have trouble filling employment rosters, said Nathan Schema, president and CEO of Evangelical Lutheran Good Samaritan Society, a post-acute and home health provider that merged with Sanford Health in 2019.

Wide gaps in reimbursement rates can also delay discharges. The national median for base Medicaid reimbursement rates, which doesn’t include skilled-nursing facilities’ supplemental payments, was 86% of reported facility costs, according to a Medicaid and CHIP Payment and Access Commission analysis released in January of 2019 wage- and acuity-adjusted data, the latest available. About one-fifth of skilled-nursing facilities received base payment amounts greater than 100% of costs, and 15% of facilities received payments that were less than 70% of costs.

Medicare, on the other hand, paid more than most facilities’ costs, according to the Medicare Payment Advisory Commission. Skilled-nursing facilities reported receiving 11.3% more in reimbursement for Medicare-covered patients than they spent.

The payment differential incentivizes nursing homes to seek Medicare beneficiaries who require a short visit after they are discharged from a hospital, said David Grabowski, a professor of healthcare policy at Harvard Medical School. “We need more of a unified approach to Medicare and Medicaid reimbursement,” he said.

Providers say the disconnect’s effect is evident in Nebraska, where nursing homes receive the second-lowest base Medicaid reimbursement rates relative to costs in the country, behind Nevada. In December, roughly 200 patients in the state—a quarter of whom were on Medicaid—had been waiting more than a week to be discharged to a post-acute facility, according to data from the Nebraska Hospital Association. “We really need more Medicaid beds,” said Abby Baldwin, lead social worker at Bryan Medical Center.

Many nursing home operators are calling for a payment boost to mitigate the staffing crunch and narrow the reimbursement gap. “Medicaid reimbursement for long-term care facilities rarely covers the cost of care,” Genesis’ Roebuck said, noting that Medicaid typically makes up over half of skilled-nursing facilities’ payer mix. “The long-term care providers I speak with report consistent financial losses month-over-month" he said. "The current economic position of long-term care is not sustainable and will lead to more closures and consolidations.”

But not all industry observers are convinced an across-the-board reimbursement increase will remedy the issue. To improve skilled-nursing facilities’ financial viability, the Medicaid and CHIP Payment and Access Commission recommended states should analyze Medicaid payments relative to care costs, quality outcomes and health disparities. Providers could use that data to potentially apply for more funding, commissioners said at a January meeting. States should also publish facility-level payment, cost and quality data in a uniform, public format to increase transparency, commissioners said.

Though higher quality ratings were associated with higher Medicaid base payment rates, the commission did not find a clear relationship between reimbursement and staffing levels.

Most nursing home operators disagree, arguing that bigger Medicaid payments would enable them to offer higher wages, attracting more employees.

“Until we as a nation prioritize people and real healthcare, payment structures will continue to be far less than needed in the post-acute world,” Christian Health Care Center’s Myers said. “If our reimbursement was anywhere near that of the acute care facilities, we could compete for staffing.”

Once placement for a patient is found, some hospital and post-acute providers have developed thorough discharge planning processes. But insurance plans don’t typically reimburse those safety measures—and communication breakdowns between hospitals and post-acute providers remain prevalent.

“Many times, [discharge] plans aren’t being discussed with patients and all the forms aren’t completed or delivered to post-acute facilities,” ECRI’s Harpel said. “Electronic health records may not be compatible with the skilled-nursing facility, leading to medication errors and readmissions.”

Most post-acute facilities use the software platform PointClickCare for record management, which doesn’t typically mesh with hospitals’ platforms, said Alice Bonner, chair of the Moving Forward Coalition, a nursing home quality group, and the former head of CMS’ nursing home division.

As a result, some hospitals and nursing homes still rely on fax machines to relay discharge notes. When patients are transferred between hospitals and unaffiliated nursing homes, hospitals may fax discharge plans up to four inches thick, said Unroe, who is also CEO and chief medical officer of Probari, a software company that looks to improve the care transition process.

Treatment updates can get lost in the mix. In one recent case, a patient with an epidural abscess needed to be on eight additional weeks of intravenous antibiotics. But the discharge notes didn’t clarify dosage levels and follow-up tests, and Unroe said she had to find that information on behalf of the skilled-nursing facility.

“I have heard multiple nursing leaders and facilities talk about how stressful it is. They don’t have enough time to triple-check everything and things are falling through the cracks,” Unroe said. “We spend a lot of time tracking down information so we can safely take care of people, and there is a cost to that.”

Unroe said she once had to call a patient’s brother in California to ask about the setting of their continuous positive airway pressure machine. “There are consistent pieces of information we want to know every time someone is admitted. Why is that not served up on a platter?” she said. “Information handoffs are so inconsistent from facility to facility, provider to provider and shift to shift.”

Researchers, advocates and nursing home operators said the federal government should increase funding for designing interoperable electronic health records. “There are [government and academic-based] working groups tasked with co-designing these systems to ensure they work together. But in most cases, we don’t have interoperability between hospitals and skilled-nursing facilities,” Bonner said. “We need more dedicated funding that will support technology that allows data sharing.”

Affiliation can make the process more straightforward, although problems can still happen if specialists’ notes aren’t included in the electronic health record, for example.

After Sanford Health merged with Good Samaritan Society, the 47-hospital system designed a digital bridge to link the disparate health record software platforms and make it easier to alert post-acute providers of forthcoming patient needs.

Hospitals should also create transition teams to put together a comprehensive discharge summary, a contact list and follow-up care plans, Harpel said. Again, staffing shortages have limited the process’ efficacy: Post-acute workers may not have time to get to know residents after they are transferred or to document what they learned during those conversations.

To ensure smoother handoffs, Queen Anne Healthcare—part of Wilsonville, Oregon-based Avamere Living—developed a discharge and intake process with its sole referral partner Harborview Medical Center, a 368-bed hospital in Seattle managed by UW Medicine, Doss said.

Hospital physicians, nurse practitioners and social workers work with Queen Anne each day to discuss care transition plans, even though those visits aren’t directly reimbursed. Workers from the Washington State Department of Social and Health Services also help coordinate housing and Medicaid enrollment for some of the patients.

 Harborview has exclusive access to 85 of Queen Anne’s beds, which are predominantly occupied by Medicaid beneficiaries and uninsured people. Harborview pays for the room and board for those who don’t have insurance or documentation.

But the hospital still winds up holding patients in its emergency department. “We are all struggling with staffing, especially certified nursing assistants,” Doss said. “Seattle has the highest minimum wage in the nation, so it’s really competitive.”

https://www.modernhealthcare.com/post-acute-care/nursing-home-transfers-delays-staffing-payment-post-acute-care-technology-medicare-medicaid