The Cost of Inaction: Why Safe Returns Matter for the Success of Skilled Nursing Facilities

Imagine this Scenario

Mrs. Thompson, a patient discharged from a skilled nursing facility (SNF) with orders for home health services, initially receives care from a home health agency (HHA). However, despite the care, Mrs. Thompson's mobility fails to improve, and she experiences additional falls at home. Unfortunately, the SNF's key stakeholders are not informed about these developments, leading to a lack of timely coordination for a safe return to the facility. Without this critical coordination, Mrs. Thompson suffers another severe fall, which necessitates emergency room intervention and ultimately results in her readmission to acute care for surgery. This breakdown in care coordination causes significant harm to Mrs. Thompson and has profound consequences for the healthcare providers involved. The SNF risks noncompliance with F627 and F628 guidelines, potentially leading to financial penalties and reputation damage.

The Looming Crisis: Challenges in Safe Transitions

Safe transitions from Skilled Nursing Facilities (SNFs) to home and back are critical for patient safety and well-being. However, challenges arise when discharged patients experience complications at home, such as declining health, delayed home health services, or lack of caregiver support. The Centers for Medicare & Medicaid Services (CMS) has intensified its focus on protecting residents' rights and safety during transitions with the new F627 and F628 guidelines. These guidelines mandate that discharges be safe, justified, and well-documented while coordinating care with receiving providers.

‍Key Statistics:

• Nearly a quarter of patients discharged from SNFs to home are readmitted within 30 days.
• More than 35% of patients discharged with home health orders fail to access these services.

The Why

Safe returns matter significantly due to their impact on patient safety and financial sustainability. Studies have shown poor transitions can lead to increased emergency room visits or hospital readmissions, harming patients' physical and emotional well-being while driving up healthcare costs. For SNFs, poor transitions negatively affect Value-Based Purchasing (VBP) quality measures and Managed Care Organizations' HEDIS scores, making it harder to build strong relationships with hospitals and payers. Noncompliance with F627 and F628 guidelines can result in citations during surveys, further affecting SNF's reputation and financial stability.

The Stark Reality

Many Skilled Nursing Facilities (SNFs) face significant challenges in managing safe transitions to home with home health services. Common obstacles include:

• Delayed Home Health Services: Home health agencies may delay initiating care, leaving patients vulnerable to adverse outcomes. This delay can increase the risk of hospital readmissions.
• Decline in Health: Patients under home care services may experience worsening conditions due to inadequate support or medical oversight.
• Lack of Caregiver Support: Residents discharged home with home health services without family or informal caregiver assistance may feel unsafe and unable to manage daily tasks. This lack of support can lead to increased stress, decreased patient safety, and unplanned emergency room visits or hospital readmissions.

These scenarios compromise patient safety and increase the likelihood of regulatory penalties under F627 and F628. The regulatory aspect is critical, as noncompliance can lead to significant financial penalties and damage an SNF's reputation.

What's Changing?

The healthcare landscape is shifting towards more integrated and patient-centered care models. Implementing F627 and F628 guidelines underscores the importance of coordinated discharge planning and stakeholder collaboration. This proactive approach enhances patient safety, supports regulatory compliance, and reduces the risk of hospital readmissions.

The Hidden Dangers

The transition from a Skilled Nursing Facility (SNF) to home health care involves several hidden dangers that can compromise patient safety and increase the risk of patient harm and hospital readmission. Two significant challenges are the lack of visibility into whether a patient or home health agency has refused care after discharge and the inability to effectively monitor a patient's condition at home.

Lack of Visibility into Care Refusal

1. Refusal of Care: When a patient or their family refuses home health services, SNFs must be informed promptly. Without this information, SNFs may be unable to intervene early enough to prevent complications. This lack of communication can lead to delayed responses, increasing the risk of adverse outcomes and hospital readmissions.
2. Impact on SNFs: The absence of a clear process for care refusal can expose SNFs to regulatory risks. If a patient's condition deteriorates due to refused care, and the SNF is unaware, it may be held accountable for not ensuring a safe transition, potentially leading to citations and financial penalties under F627 and F628 guidelines.

Inability to Monitor Patient Condition at Home

1. Decline in Health: Patients under home care may experience a decline in health due to inadequate support or medical oversight. SNFs cannot identify early warning signs of complications without regular patient status updates, such as increased falls or worsening chronic conditions.
2. Delayed Interventions: The inability to monitor a patient's condition at home under home healthcare services can lead to delayed interventions. For instance, if a patient is experiencing increased falls or showing signs of declining mobility, timely intervention is crucial to prevent further complications. Without this information, SNFs may be unable to coordinate a safe return to the facility, resulting in higher readmission rates and adverse outcomes.

The Cost of Inaction

Failing to establish a process for safe returns has severe consequences:

1. Patient Harm: Inefficient transitions can lead to adverse patient outcomes, including increased risk of medical complications, decreased quality of life, and heightened risk of emergency room visits or hospital readmissions.
2. Financial Penalties: Noncompliance with F627 and F628 can result in citations for harm or immediate jeopardy during surveys, leading to significant monetary penalties.
3. Reputation Damage: Poor post-discharge outcomes can erode trust among hospitals and payers, making it harder for SNFs to secure referrals and contracts.
4. Increased Readmissions: Inefficient transitions lead to higher rates of hospital readmissions—a costly outcome for both patients and providers.

The Solution You Need

To navigate the complexities of safe returns effectively, SNFs require a comprehensive approach seamlessly integrating multiple strategies. This includes:

1. Pre-Discharge Planning: Conduct thorough assessments of residents' needs and preferences. Develop a comprehensive discharge plan with contingency measures.
2. Coordination with Receiving Providers: Confirm home health agencies' acceptance before discharge and promptly share detailed medical information.
3. Post-Discharge Monitoring: Address any issues immediately to prevent complications.
4. Safe Return Processes: Establish clear protocols for safely returning patients to SNFs when needed, ensuring timely coordination with home health agencies and other stakeholders.
5. Partnership Evaluation: Assess the timely initiation of care, the effectiveness of care coordination, and the quality of engagement between SNFs and home health agencies (HHAs).

Implementing these strategies requires specialized expertise and resources. Utilizing a care coordination platform like OLIO can provide SNFs with the necessary tools and support to enhance patient outcomes while maintaining regulatory compliance.

‍Call to Action

As the healthcare landscape continues to evolve, the importance of safe returns for Skilled Nursing Facilities (SNFs) has never been more critical. The consequences of inaction are stark: patient harm, financial penalties, and reputation damage. By implementing robust, safe return processes, SNFs can protect their patients and safeguard their financial stability and reputation.

The time to act is now. With implementation of F627 and F628 guidelines, SNFs must prioritize compliance and patient safety. Don't risk compromising patient safety or your SNF's reputation. Contact us today at OLIO to discover how our care coordination platform can help you navigate the complexities of safe returns and thrive in a rapidly changing healthcare landscape. Don't wait—reach out now to ensure your SNFs lead the way in delivering safe and effective transitions.