In today’s rapidly evolving healthcare landscape, forward-thinking Skilled Nursing Facilities (SNFs) have an unprecedented opportunity to step out of the shadows of traditional post-acute care. Historically, SNFs have been viewed as providers that patients transition through on their way to recovery, but what if they could be something more? What if SNFs could become central players in an integrated, collaborative healthcare system—where the focus isn’t just on recovery but holistic, proactive care that transforms lives?
As the shift toward value-based care continues to reshape the industry, SNFs are well-positioned to expand their role. By leveraging technology, improving care transitions, and forging stronger relationships with home health services, health systems, and social care providers, SNFs can elevate their value, significantly impact patient outcomes, and reduce healthcare costs.
The introduction of Medicare programs like REACH, GUIDE, and PACE marks a pivotal shift toward proactive, holistic care. The aim is no longer to treat illnesses after they’ve occurred but to prevent them (or minimize impact) through teamwork, data-sharing, and patient-centered interventions. These programs emphasize collaboration across the continuum of care, bringing together SNFs, home health services, hospitals, and social care providers to create seamless, integrated care pathways.
For SNFs, this should be a wake-up call. The shift from reactive care to outcomes-based models is an opportunity to play a more vital role in managing complex patients and reducing costly hospital readmissions. Nearly 20% of Medicare beneficiaries discharged from hospitals to SNFs are readmitted within 30 days — a staggering statistic highlighting the need for change. Programs like Bundled Payments for Care Improvement (BPCI) Advanced and REACH incentivize SNFs to take control of these transitions to flag high-risk patients and ensure smoother handoffs to home health providers¹.
Let’s face it — one of the biggest challenges SNFs face today is poor communication during care transitions. Too often, patients are discharged from SNFs to home health services without adequate follow-up or communication between providers, leaving them vulnerable to complications or even rehospitalizations. Technology offers a solution, but are SNFs ready to embrace it?
Shared electronic health records (EHRs), data integrations, and secure messaging platforms can bridge this gap by allowing SNFs and home health agencies to exchange critical information. Studies have shown that poor transitions are a leading cause of hospital readmissions². What if it were straightforward for SNFs to integrate remote patient monitoring (RPM) and telehealth into their processes? In that case, they can track patients’ health post-discharge and catch issues before they become serious, reducing the likelihood of readmission³.
Consider the success story of an SNF in the Midwest that implemented RPM and saw a 30% reduction in rehospitalizations within six months⁴. When used right, technology isn’t just a tool; it can be a game-changer.
One of the most effective ways for SNFs to enhance care quality and improve outcomes is by actively involving patients and their families in the care process. Studies show that patients who feel more engaged in their care are more likely to follow treatment plans, leading to better health outcomes. Including families and informal caregivers promotes a sense of empowerment and ensures that essential information is communicated clearly during transitions between care settings. This approach can lead to reductions in hospital readmissions and adverse events post-discharge⁵.
A recent report found that patients actively involved in their care are 20% less likely to experience rehospitalization within 30 days of discharge⁶. By integrating family involvement, SNFs can help ensure that discharge plans are clearly understood and followed, which is particularly crucial during transitions from SNFs to home health.
By leveraging technology, SNFs can better engage patients and families throughout the care journey. Shared electronic health records, data integrations, secure messaging platforms, and telehealth services enable families to stay updated on care plans, ask questions, and monitor progress. This proactive involvement helps to identify potential issues before they escalate into more serious problems, allowing for early interventions that can prevent hospital readmissions and improve overall patient satisfaction⁷.
Including patients and families in decision-making is a key component of patient-centered care and aligns with broader value-based care initiatives, emphasizing outcomes, satisfaction, and cost control. SNFs can leverage this engagement to foster trust and build a stronger continuum of care that prioritizes the well-being of patients even after they leave the facility.
If SNFs want to remain competitive in this new healthcare landscape, they must look beyond their walls. The future of healthcare depends on collaboration — not just between SNFs and home health services but also with health systems and social care providers. By strengthening these relationships, SNFs can ensure patients experience a seamless continuum of care that follows them from the hospital to their home.
Imagine this: A patient recovering from surgery is discharged from the hospital to a SNF, receiving the needed rehabilitation. From there, they transition to home health care, and their health data is continuously shared between the SNF, home health provider, and hospital. Any complications are flagged early through RPM, and their care is adjusted in a timely manner.
Technology can revolutionize how SNFs operate — not just within their facilities but also in coordinating care post-discharge. SNFs that adopt care management platforms shared EHRs, RPM, and telehealth are not just keeping up — they’re leading. These tools allow SNFs to communicate with patients and their care teams long after the patient has transitioned to home health, reducing the need for in-person visits and ensuring complications are caught early⁸.
For instance, a large SNF in California began using a telehealth platform to provide follow-up consultations after patients transitioned to home health. This reduced in-person visits by 40% and cut readmissions by 25%⁹. The ROI on these investments is clear: fewer rehospitalizations, better patient outcomes, and a more efficient use of staff time.
But the question is: Are SNFs ready to reevaluate their role, and are they willing (and able) to invest in the people, technology, and training needed to bring about this transformation?
It’s not just about SNFs and home health services anymore. Health systems and social care providers play critical roles in this continuum of care. Hospitals provide the data needed to prevent rehospitalizations, while social care providers address the social determinants of health (SDOH) that are increasingly recognized as essential to improving patient outcomes.
Programs like Accountable Health Communities (AHC), launched by the Centers for Medicare & Medicaid Services (CMS), emphasize the need to address these broader determinants. By collaborating with social service organizations that provide housing, food security, and social support, SNFs can ensure patients receive comprehensive, holistic care that addresses their medical and non-medical needs¹⁰.
The future of healthcare is integrated, patient-centered, and outcomes-driven. SNFs have the opportunity — no, the responsibility — to redefine their role in this new system. By investing in technology, addressing communication gaps, and collaborating with home health, hospitals, and social services, SNFs can play a vital role in delivering holistic, value-based care.
It’s time for SNFs to redefine their place not just as care stops, but as leaders in the continuum, driving healthcare’s transformation into a patient-first, outcomes-driven system. And it’s time to explore how we should invest to make this happen.
1. Centers for Medicare & Medicaid Services (CMS), “Bundled Payments for Care Improvement (BPCI) Advanced Model Year 5 Evaluation,” accessed September 8, 2024.
2. The Commonwealth Fund, “Transitions of Care: Reducing Readmissions by Addressing the Gaps in Care,” accessed September 8, 2024.
3. Medicare Payment Advisory Commission (MedPAC), “Data Book: Health Care Spending and the Medicare Program,” July 2023.
4. Journal of Post-Acute and Long-Term Care Medicine (JAMDA), “Remote Patient Monitoring in Skilled Nursing Facilities: Case Studies and Benefits,” accessed September 6, 2024.
5. Robert Wood Johnson Foundation, “The Role of Social Determinants in Shaping Health and Health Care,” accessed September 8, 2024.
6. National PACE Association, “Outcomes of the PACE Model of Care,” accessed September 9, 2024.
7. Centers for Medicare & Medicaid Services (CMS), “Predictive Analytics and Health Outcomes: Optimizing Care for At-Risk Populations,” 2024.
8. Centers for Medicare & Medicaid Services (CMS), “Medicare Telehealth Snapshot,” March 2024.
9. Robert Wood Johnson Foundation, “The Role of Social Determinants in Shaping Health and Health Care,” accessed September 8, 2024.
10. The Commonwealth Fund, “Transitions of Care: Reducing Readmissions by Addressing the Gaps in Care,” accessed September 8, 2024.
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