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Senior and Post-Acute Healthcare News and Topics

SNFs: A New Era in Post-Acute Care Begins

Over the years I have written about the changing landscape in post-acute care, principally due to the health policy ground swell resultant from the ACA (other reasons too but the ACA concretized them all, more or less). Boiled down, the fundamental driver of change is “pay for performance”; the notion that payment will migrate toward value based concepts, away from fee-for-service.  The ACA and ACOs, bundled payments, readmission penalties, etc. concretized this oft discussed concept into policy (good, bad, flawed in some regards, and other).  However, before the ACA, the notion that healthcare was just too darned expensive wasn’t new fangled.  The healthcare industry prior was moving toward pay-for-performance, incentive based models; privately and publicly.  Some reference posts on these concepts can be found on this site at and .

From an article this morning on the Modern Healthcare website, “Hospital Select Preferred SNFs to Improve Post Acute Outcomes”, the beginning of the new era for the post-acute industry has arrived.  Because of readmission penalties, bundled payments, ACOs and value-based purchasing/pay-for-performance, hospital systems have begun identifying and thus, partnering with only select SNFs.  Article link is here:

What is interesting to note isn’t what is in the story but what is behind the movement and thus, the implications for SNFs.  First, given all that we have seen (and for readers, read about) regarding SNFs and Medicare fraud, the Modern Healthcare story is the antithetical strategy of current environment survival.  Hospitals are seeking to partner with SNFs that are efficient, lower cost, higher quality.  Essentially the mantra is: There is no survival for those that can’t shorten length of stay and improve quality.  Nothing about this trend relies on maximizing RUGs, providing unnecessary care, or delivering sub-standard care (the DOJ suits against HCR/Manor Care, RehabCare and Extendicare representative examples).

Second, the trend is all about quality and competence.  The SNFs that are referenced invested in quality and core competence some time ago.  They planned, made the staff investments to deliver the care (RNs, Therapists, etc.) and implemented strong programs of QI/QA (ala QAPI).  They didn’t rely purely on maximizing rehab but on building overall case-mix and thus with it, case-mix competency.  They excel at advanced care planning, care coordination, and med reconciliation.  They also have strong committed leadership, boards, and competent facility based management (I know because I have consulted with many and still do).  Moreover, they seek to add new programs and innovations to be better, more efficient and high quality providers and understand the relationships between care outcomes and patient satisfaction.

As the title of this post references, this is a period of “new beginning”.  This means that for many SNFs in many markets, there is still time to reform and get into this new era.  Below are my six stepping-stones to get into this new era and quickly; to become a valued and wanted partner in the ACO, bundled payment, pay-for-performance world.

  • QAPI: If you don’t have a program, build one now.  This site has lots of reference material.  This is a backbone, fundamental requirement for membership in this new era.
  • Align Your Internal Resources: What does your staffing levels look like?  How many contracted services do you provide?  Where are your contractors at with regard to these concepts (quality, improved care outcomes, commitment to education and development)?  Do you have sufficient staff resources to increase your acuity?  If not, what investments do you need?
  • How Integrated is Your IT Infrastructure?: Are you capable of connecting with your partners?  Can you share data seamlessly?  Are your physicians capable of accessing patient information remotely? Can you provide patient/families with access?  Are your contract services connected (lab, radiology, etc.)?
  • What are Your Key Competencies?: Do you reconcile medications on admission? Do you begin advanced careplanning discussions prior to and concurrent with admission?  Do you have specific staff expertise in wounds, neuro, behavior management, respiratory, pain, etc? What are your current quality indicators for falls, infections, wounds, hospitalizations? What do your partners want and need and do you provide it?
  • Who are Your Partners?: The SNF environment isn’t the last stop for transitional patients.  Home care, hospice, outpatient services are all part of the continuum and the equation.  SNFs need to have their distinct partners in the same vain and alignment as hospitals with the SNF.  Vet your partners and get understandings made.  Share information, build infrastructure, develop common understanding, meetings, etc.  Get on the same page.  Being able to rapidly discharge when ready is all about having key partner relationships.
  • Become Service Centered: Giving good care is one element.  Being good at caring is of equal importance.  Outcomes are great but satisfaction in health care is rarely about just good care.  Frankly, most patients don’t understand what the outcomes are all about rather, how do they feel and how were they “cared for” during their stay.  Service centered is about answering call lights timely, having staff with a smile and an element of concern, a presence by management on the floor, and a level of engagement that says we “care about you”.  Measure satisfaction, solicit input and hold focus groups.  Pay attention to the details!

As always, questions are welcome.  Feel free to drop me a note in the comment section or via e-mail. My e-mail contact is available on the Author’s page.  Remember, if you wish a personal reply, please provide a working e-mail address.

May 12, 2015 - Posted by | Skilled Nursing | , , , , , , , ,


  1. I always love your blog posts. They are very informative. As an owner-operator of a Post Acute Care center with a majority of revenues from Medicare/HMO, I think the title is accurate that a “new era” may be in the horizon, but that new era MAY be any thing but positive for the industry. Shorter lengths of stay, higher turnover (requiring more staff), extremely high expectations for care outcomes leading to higher (but unreimbursed) cost of care, while adding to profits of the managed care companies, will be financially very painful for the SNF. The ACO’s and managed care companies are going to make big bucks, way more than the paltry sums they will save the federal government. Patient care will suffer to some degree as patients are forced to comply with the length of stay expectations imposed by the managed care companies. The SNF industry better get busy and insist on fair and reasonable Medicaid reimbursement as Medicare slowly is transitioned to managed care. No other industry I know of quietly provides 50-80% of its services (depending on the SNF) at 10-30% less than its costs! I’d love to see a hotel or other service business do that. The only positive glimmer is the potential for the elimination of site specific reimbursement allowing post acute providers to earn higher reimbursement for similar services provided at other settings (such as acute rehab etc.). Of course those providers have much bigger lobbyist than our industry has and they will fight that tooth and nail. Thanks for the interesting posts!

    Comment by Stanford Leland | May 12, 2015 | Reply

    • Stanford:

      Thanks for reading and I agree with many of your points. While a new era is evolving, I agree that “new” doesn’t mean better – merely different. As always, some will fare well, others will not. The ability to manage costs and risks and maintain low to moderate fixed costs is where the crux of success and to a certain extent, profitability lie. The major challenge for the industry as I see it, is three fold.
      1. Medicaid reimbursement – it needs to improve.
      2. Regulation – need to move toward common sense regulation and deemed status. This will help control costs to a certain extent.
      3. Medicare payment reform – move away from pure fee for service, RUGs based. Right now, the current system of RUGs does not adequately reflect the changes discussed in the post. Payment must meet the way care is required and delivered.

      Really appreciate the comment!


      Comment by Reg Hislop III | May 13, 2015 | Reply

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