The baseline SNF utilization rate (using data from July 1, 2015–June 30, 2016) within the Medicare population was 39.5% (70/177), with an overall (all payers) rate of 22.9% (192/838). This SNF utilization rate was higher than the national benchmark, underscoring the need to focus on a preoperative “plan for home” message. In addition, review of Medicare fee-for-service data from 2014 to 2016 revealed that Grant Medical Center utilized 83 different SNFs over the course of approximately 2 years. In this context, staff saw an opportunity to develop stronger relationships with fewer SNF partners, as well as OhioHealth Home Care, in order to improve care by standardizing functional recovery in post-acute care management.
In sum, the gap analysis found that a lack of standardization, follow through, and engagement in daily multidisciplinary rounds often led to a plan for SNF discharge instead of home. As such, it was determined that the pilot program would target the preoperative and post-acute phases of care and that its primary endpoint would be the reduction of the SNF discharge rate among Medicare fee-for-service patients.
Literature Review
Targeting the SNF discharge rate as the endpoint was also supported by a recent study that showed that most of the reduction in spending for total joint replacement within BPCI hospitals was linked to reduced use of institutional post-acute care.1 Other studies in the joint replacement literature have delineated the specific aspects of care redesign that allow hospitals to provide more efficient and effective care delivery during an episode of care.6-8 A review of these and similar studies of joint replacement quality improvement interventions yielded a number of actionable findings:
- Engaging and educating patients and families is critical. Families and other caregivers must be identified preoperatively, actively engaged, and committed to helping the patient recover.
- Providers must build the expectation in patients that they will return home as soon as it is safe to do so. This includes working to restore physiologic function, managing pain with oral medication, and restoring the physical capability of adapting to a home environment.
- Relationships must be established with post-acute care providers who are able to demonstrate best practices and be willing partners on performance outcomes.
- Providers need to invest in personnel to coordinate care transitions initiated preoperatively that continue through the post-acute phase of care.
- Providers must promote processes that allow patients to more fully own their recovery through coaching and improved communication.
A total joint replacement initiative undertaken at another hospital within the OhioHealth system, Riverside Methodist Hospital, that incorporated these aspects of care redesign demonstrated a significant reduction in SNF utilization. That success informed the development of the initiative at Grant Medical Center.