Postacute Care Transitions: Developing a Skilled Nursing Facility Collaborative within an Academic Health System

Abstract

Hospitals and health systems are under mounting financial pressure to shorten hospitalizations and reduce readmissions. These priorities have led to an ever-increasing focus on postacute care (PAC), and more specifically on improving transitions from the hospital.1,2 According to a 2013 Institute of Medicine report, PAC is the source of 73% of the variation in Medicare spending3 and readmissions during the postacute episode nearly double the average Medicare payment.4 Within the PAC landscape, discharges to skilled nursing facilities (SNFs) have received particular focus due to the high rates of readmission and associated care costs.5 Hospitals, hospital physicians, PAC providers, and payers need to improve SNF transitions in care. Hospitals are increasingly responsible for patient care beyond their walls through several mechanisms including rehospitalization penalties, value-based reimbursement strategies (eg, bundled payments), and risk-based contracting on the total cost of care through relationships with accountable care organizations (ACOs) and Medicare Advantage plans. Similarly, hospital-employed physicians and PAC providers are more engaged in achieving value-based goals through increased alignment of provider compensation models6,7 with risk-based contracting. Current evidence suggests that rehospitalizations could be reduced by focusing on a concentrated referral network of preferred high-quality SNFs;8,9 however, less is known about how to develop and operate such linkages at the administrative or clinical levels.8 In this article, we propose a collaborative framework for the establishment of a preferred PAC network.