Next Steps in Improving Healthcare Value: Postacute Care Transitions: Developing a Skilled Nursing Facility Collaborative within an Academic Health System
Hospitals are under financial pressure to shorten hospitalizations and reduce readmissions. Current evidence suggests that postacute care-associated rehospitalizations could be reduced by focusing on a concentrated referral network of preferred high-quality skilled nursing facilities (SNFs). Hospitals, health systems, and health plans have taken several approaches to creating preferred provider networks to streamline and improve the quality of SNF discharges. We propose a collaborative framework for the establishment of a preferred postacute care network based on the experience of the Johns Hopkins Medicine Skilled Nursing Facility Collaborative and review early implementation challenges.
© 2019 Society of Hospital Medicine
PROPOSED HEALTH SYSTEM FRAMEWORK FOR CREATING A SKILLED NURSING FACILITY COLLABORATIVE
Here we propose a framework for the establishment of a preferred provider network for a hospital or health system based on the early experience of establishing an SNF Collaborative within Johns Hopkins Medicine (JHM). JHM is a large integrated health care system, which includes five hospitals within the region, including two large academic hospitals and three community hospitals serving patients in Maryland and the District of Columbia.14
JHM identified a need for improved coordination with PAC providers and saw opportunities to build upon successful individual hospital efforts to create a system-level approach with a PAC partnership sharing the goals of improving care and reducing costs. Additional opportunities exist given the unique Maryland all-payer Global Budget Revenue system managed by the Health Services Cost Review Commission. This system imposes hospital-level penalties for readmissions or poor quality measure performance and is moving to a new phase that will place hospitals directly at risk for the total Part A and Part B Medicare expenditures for a cohort of attributed Medicare patients, inclusive of their PAC expenses. This state-wide program is one example of a shift in payment structures from volume to value that is occurring throughout the healthcare sector.
Developing a formal collaboration inclusive of the five local hospitals, Johns Hopkins HealthCare (JHHC)—the managed care division of JHM—and the JHM ACO (Johns Hopkins Medicine Alliance for Patients, JMAP), we established a JHM SNF Collaborative. This group was tasked with improving the continuum of care for our patients discharged to PAC facilities. Given the number and diversity of entities involved, we sought to draw on efforts already managed and piloted locally, while disseminating best practices and providing added services at the collaborative level. We propose a collaborative multistakeholder model (Figure) that we anticipate will be adaptable to other health systems.
At the outset, we established a Steering Committee and a broad Stakeholder Group (Figure). The Steering Committee is comprised of representatives from all participating JHM entities and serves as the collaborative governing body. This group initially identified 36 local SNF partners including a mixture of larger corporate chains and freestanding entities. In an effort to respect patient choice and acknowledge geographic preferences and capacity limitations, partner selection was based on a combination of publically available quality metrics, historic referral volumes, and recommendations of each JHM hospital. While we sought to align with high-performing SNFs, we also saw an opportunity to leverage collaboration to drive improvement in lower-performing facilities that continue to receive a high volume of referrals. The Stakeholder Group includes a broader representation from JHM, including subject matter experts from related medical specialties (eg, Physical Medicine and Rehabilitation, Internal Medicine, Emergency Medicine, and various surgical subspecialties); partner SNFs, and the local CMS-funded Quality Improvement Organization (QIO). Physician leadership was essential at all levels of the collaborative governing structure including the core Coordinating Team (Figure). Providers representing different hospitals were able to speak about variations in practice patterns and to assess the feasibility of suggested solutions on existing workflows.
After establishing the governance framework for the collaborative, it was determined that dedicated workgroups were needed to drive protocol-based initiatives, data, and analytics. For the former, we selected transitions of care as our initial focus area. All affiliated hospitals were working to address care transitions, but there were opportunities to develop a harmonized approach leveraging individual hospital input. The workgroup included representation from medical and administrative hospital leadership, JHHC, JMAP, our home care group, and SNF medical leadership. Initial priorities identified are reviewed in the Table. We anticipate new priorities for the collaborative over time and intend for the workgroup to evolve in line with shifting priorities.
We similarly established a multidisciplinary data and analytics workgroup to identify resources to develop the SNF, and a system-level dashboard to track our ongoing work. While incorporating data from five hospitals with varied patient populations, we felt that the risk-adjusted PAC data were critical to the collaborative establishment and goal setting. After exploring internal and external resources, we initially elected to engage an outside vendor offering risk-adjusted performance metrics. We have subsequently worked with the state health information exchange, CRISP,15 to develop a robust dashboard for Medicare fee-for-service beneficiaries that could provide similar data.
