During the height of the COVID-19 pandemic, patients battling other serious health issues were reluctant to be discharged to skilled nursing facilities in Omaha, spurring hospital leaders there to consider alternatives.
Whether weak from cancer treatments or recovering from fractures, SNF-bound Medicare patients are usually well enough to leave the hospital but still require medical care as they attempt to heal.
Last year, COVID-19 took an unprecedented toll on skilled nursing facilities around the country, claiming the lives of thousands of patients, while leaving families with distressing accounts of their loved ones dying alone as facilities shut out visitors to prevent the spread of disease.
"In the throes of last year, patients were doing everything they could to try and avoid post-acute facilities for obvious reasons," Scott Ptacnik, president of CHI Health Partners, a division of CommonSpirit in Nebraska, said in an interview.
That reluctance forced Ptacnik and his team in Nebraska to come up with other options. And leaders of parent CommonSpirit, one of the nation's largest health systems, are keeping an eye on the Omaha program, using it as a pilot to see if it can be replicated throughout the rest of its markets that span a significant portion of the country.
The industry has been moving toward providing more care in the home, a trend that only accelerated during the pandemic. The momentum may gain greater speed as President Joe Biden's administration is looking to pump $400 billion into the home health field, to provide even more care at home amid an aging population that will require more resources.
'Right ingredients in place'
CommonSpirit leaders in Omaha created a SNF at home program, which for now targets traditional Medicare patients, allowing them to bypass post-acute facilities entirely, instead returning straight to their homes for care.
The program was able to get off the ground because of elements already in play in the Omaha market, leaders said.
First, the system — which continues to go by CHI Health in Nebraska — leaned on its network of geriatric-focused nurses who worked in traditional SNFs. Plus, there was already an established health at home program, which provides a range of at-home services, under the division of CommonSpirit Health at Home.
"We had a lot of the right ingredients in place," Ptacnik said.
By marrying these two groups, the system was able to stand up a SNF at home program in the Omaha metro area, which accepted its first patient earlier this year. So far, the program, which has graduated 12 patients, seems to be a good fit for oncology patients and those who have sustained fractures after a fall.
But the program isn't meant for every SNF-bound Medicare patient.
The program is geared toward patients with short-term needs, typically those needing a 14-day window of follow-up care. The patient must have a reliable caregiver; without one patients are ineligible. And the patient needs to be able to go to the bathroom independently.
The program is not meant to deliver care around the clock, seven days a week. Patients may receive telehealth, nursing care or rehabilitation daily depending on their needs.
For CommonSpirit and others potentially looking to the model, one drawback to the program is how the system is reimbursed. Currently, the program targets traditional Medicare patients and bills for services under the home health program, Ptacnik said.
"With the intensity of the resources that are necessary to provide this care, I'm not sure that would be a sustainable model on a standalone basis," Ptacnik said. Being part of a large system allows his team to try out this pilot, he added.
The system is currently in discussions with Medicare managed care organizations about reimbursement and coverage in the future. Ptacnik said the program makes the most economic sense in a risk-based arrangement.
Shifting to care at home
The pandemic upended normal life, forcing millions to shelter at home to hide from the deadly disease, pinching the economy and countless businesses, including healthcare providers. Either out of necessity or fear, patients and providers turned to virtual care and many may expect the convenience of care at home to continue.
The shift to SNF at home coincides with larger industry trends already at play.
"The whole issue of where most older people go after they leave a hospital has been in the process of changing pretty dramatically, particularly over the last, I would say five to 10 years," said Robert Applebaum, a professor at the Scripps Gerontology Center at Miami University in Ohio.
"The number of admissions from hospitals to nursing homes were going up, up, up and up, and now they actually started to go down," Applebaum, also director of Ohio's Long-Term Care Research Project. said. "COVID made that happen even faster."
Over the past 25 years, short-term admissions of Medicare patients to SNFs in Ohio increased dramatically, rising from just 30,000 in 1992 to more than 147,000 in 2017, according to Applebaum's latest research. Once a place primarily for long-term stays, SNFs, at least in Ohio, are now largely used for short-term rehabilitative stays, the research shows.
The trends playing out in Ohio are representative of similar trends nationwide, Applebaum said. Ohio has the sixth largest population of people over the age of 65 in the country.
Two major elements are shaping the shift to home: bundled payments and managed care.
Some hospitals are now given a bundled payment to treat a particular patient during an acute episode and after. And in many instances, after the acute episode, such as a hip or knee replacement, the patient is sent home instead of to a skilled-nursing facility as the payment incentivizes the hospital to care for that patient through the entire episode.
Another factor at play is managed care squeezing nursing homes. Many more seniors are now using Medicare Advantage, which tries to get people to stay for a shorter amount of time or go straight home, Applebaum said.
Nursing home care is big business. In 2019, the Medicare program spent $29.3 billion for SNF care, according to a report from the Medicare Payment Advisory Commission. Almost all of that care was delivered in a freestanding facility. In 2018, about 96% of stays were in freestanding facilities, according to the same report.
On the other hand, 3.4 million Medicare beneficiaries used the home health benefit in 2018, reaching $17.9 billion in total payments.