Treating Patients in Postacute Care: SNF vs. Home

By Matt Phillion

A recent survey published by Brigham and Women’s Hospital revealed a shift in postacute care, with a move from skilled nursing facility (SNF) environments to home-based services. The survey followed 10 participants, randomly assigned to either rehabilitation at home or traditional SNF care. The results: Those recovering at home saw both a decrease in the cost of care and an increase in their activities of daily living, such as personal hygiene and feeding themselves.

CarePort, powered by WellSky, had noticed this trend in their own data.

“We’ve been thinking about this the last couple of years,” says Lissy Hu, MD, CEO and founder of CarePort, which works with organizations and patients in transitions from the hospital to postacute care settings—such as SNFs and home health—to ensure patients’ needs are met wherever they need to go next. “About one-third of patients in U.S. hospitals will flow through the CarePort platform, so we’re looking at millions and millions of transactions. We’ve seen this data holistically, as more and more referrals go to home health versus SNF.”

Some of the move to home health, Hu notes, was accelerated by the pandemic, as SNFs faced labor shortages or closed the door on new admissions while trying to get a handle on the coronavirus. But the trend was apparent even earlier.

“There was a precipitous drop in SNF referrals in March and April of 2020, and since then it has rebounded, but not to the level or extent of home health,” says Hu. “It’s above the 2020 baseline, and even with a 10% bump, we’re still talking about millions of referrals to home health.”

Increasingly, patients want to recover at home, Hu says. Payers, meanwhile, have seen that providing services at home is more cost effective than in SNFs.

In many ways, the Brigham and Women’s survey validated on a smaller scale what CarePort was seeing on the national level. “As more patients want to go home, and if it is truly a cost-effective option, then how do we make it happen?” says Hu. “What services need to be in place?”

Roadblocks to transitioning

One challenge in shifting from SNF to home health is staffing—not just the headcount issues all healthcare settings face right now, but getting the right staff for the patient’s needs.

“It’s getting the staff you need when you need it—these patients coming out of the hospital can’t wait a week for someone to come visit them in the home,” adds Hu. “They need them the day of or 48 hours later.”

There’s also how SNFs are staffed versus how care is supplied at home. Patients going home need more referrals than patients going to a SNF, says Hu.

“If you’re transferring to a SNF, your physical therapist, your nursing services, your physician, and other members of your care team are all in one place. It’s a one-stop shop for necessary care and services,” says Hu. “Now if you’re trying to place all those patients at home, they need to basically order all of those services a la carte, and lay out when and the right sequence they need to come in—there’s a greater need for care coordination.”

The Brigham and Women’s study, while impactful, was somewhat artificial in that the patients involved had someone coordinating their care and services.

“One of the barriers to implementation at scale is who is doing the coordination, what technology are they using, whose responsibility is it to make sure the services come into the home and when,” says Hu. “And how much of this falls on the family.”

Another barrier is selecting the right postacute care setting. While the study looked at a randomized group of patients, there is more gray area when taking things a step further and looking at the entire field of patients.

“Many patients could go to a SNF or go home,” says Hu. “It’s not that they need everything from the SNF at home—maybe they don’t need 24-hour care, but they need 12-hour care. Traditionally that hasn’t been provided at home.” Patients who could probably manage at home but have more need for services have traditionally gone to a SNF.

“A lot of our health systems are thinking about how to select the appropriate postacute setting for these patients who could go either way,” says Hu. “These are some of the areas where we’re seeing a lot of healthcare innovation in analytics around which patients do well in the home, and who would have been sent to SNF, and the technology used to track these patients. If you’re trying to scale one of these programs, you can’t call every home health agency.”

Determining the right care

Traditionally, the hospital care team (whether that’s a case manager or physician) uses various assessments to examine the patient’s functional status and determine whether they are ready for home care or need a SNF.

“What we’ve seen over time is there is obviously no substitute for clinical judgment, but what clinicians find helpful is to look at data and, based on other similar patients, determine the probability of success in the home,” says Hu. “Readmission rates help make that determination. Because of the significant volume of data that we can share with our clients, providers can make more informed decisions based on what other patients have gone through.” They’re able to see which patients with similar conditions have higher readmission rates, or which patients go home but don’t have a commensurate uptick in readmissions.

“The home is an important and growing setting, but we need to make sure it’s appropriate for the patient,” says Hu. “The other thing we’ve learned is that SNFs will always be really important. There are still millions of patients who need to go into a SNF.”

The study touched on the variability of SNFs, and the range of readmissions within 30 days or with adverse events. “I don’t think the answer going forward is getting as many patients home as we can,” she says. “Get them home successfully for those who are appropriate candidates, but also think about personalizing which patients can do best with which SNFs.”

There are meaningful differences in what SNFs provide, Hu notes. Some have more custodial care, others more rehabilitative care. A patient who had their hip replaced, for example, will want the latter so they can improve rapidly and go home.

“One of the things we’ve been working on is using data to better assess patients at home but also employing data from SNFs to try to understand which patients do best with which types of SNFs,” says Hu. “There’s a lack of personalization and lack of data as a lot of publicly available data is a blended score of long-term care and short-term care without a way to drill down into that. We need more personalization and more consumerization so you can present this data back to the patient.”

This will enable patients, families, and providers to make informed decisions and weigh trade-offs: Are they willing to travel 25 or 50 miles for a facility that offers the best type of care for the patient, or would they prefer a compromise that keeps them closer to home?

Meanwhile, payers are looking more closely at home health as well. “There’s real savings there, and not just from reducing the amount of care. The study shows that there’s more patient satisfaction around the home, and these things are really important,” says Hu. “They’re seeing ROI not just getting the patient out of the hospital efficiently but adding quality to the process.”

Hu sees this change and innovation as a more intelligent process for transitioning patients from one setting of care to the next.

“In terms of guiding patients across the care continuum, rarely do they just need a hospital stay or SNF. They go from SNF to a nursing home, or to home health to personal care on an ongoing basis,” says Hu. “Patients have so many touch points within the healthcare system. Over the past 10 years, everyone was very focused on the efficiency aspect: ‘I’ve done what I needed to do with this patient within my own four walls, so let me get them to the next four walls.’ ”

Hu says she thinks the Brigham and Women’s study is a great starting point for discussions around taking patients from the hospital to a SNF vs. home health, scaling that process, and using analytics to identify which patients are appropriate for each option.

“One of the things I’m excited about is not just care coordination and more efficient transitions, but how the industry can make those transitions more intelligent and add that to the process so it’s more than just getting the patient from point A to point B,” says Hu.

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.