For years, skilled nursing providers have been jockeying to participate in narrowing health care networks, as hospitals and other referral sources have raised the bar on what they need from post-acute partners. In this competitive environment, some of the nation’s largest SNF providers continue to up their game.
A case in point can be found in Texas. National chains The Ensign Group (Nasdaq: ENSG) and Brookdale Senior Living (NYSE: BKD) both have a presence in the state capital of Austin, where they have partnered with a firm called Loopback Analytics to meet new expectations around data.
At the same time, these companies are providing the more targeted and robust care that is now demanded of SNFs. Brookdale specifically has increased admissions by launching a high-acuity unit at one facility.
A failed data model
The 2010 Affordable Care Act, as well as subsequent laws and regulations, put incentives in place for acute and post-acute providers to coordinate care. For instance, hospitals now face Medicare penalties tied to readmission rates, motivating them to work with post-acute providers that can help prevent rehospitalizations.
In the early days of this shift toward more coordinated care, hospitals and health systems generally asked SNFs to bring self-collected data on metrics such as readmissions and length of stay, using that data to determine whether to include a skilled nursing provider in a network. But those days might be coming to an end.
“I think if you went back two years, you would see a lot of effort and energy in SNFs gathering their readmission data and trying to present a better case to their referral partners upstream. This is a failed model,” Loopback Analytics CEO Neil Smiley told Skilled Nursing News.
The issue, according to Smiley, is that self-reported data is inadequate. Executives with Brookdale and Ensign told SNN that they agree with this assessment. One problem is that the claims data released by the Centers for Medicare & Medicaid Services (CMS) is nine to 12 months old, they said.
“[A provider] may say readmission rates are 8%, then Medicare claims [data] come out and the hospital finds out the rate is 22%, but they’ve been spending nine months referring to that building. It can be very skewed,” said Kara Copeland, vice president of care continuum and strategic alignment at Keystone Healthcare, a subsidiary of the Mission Viejo, Calif.-based Ensign.
Ensign has a portfolio of more than 230 skilled nursing and other post-acute health care facilities in 15 states.
In addition, comparing data across different providers can be difficult, Copeland pointed out. One provider might calculate readmissions by looking only at post-acute patients, while another might include long-term care residents as well, for example.
One answer to this dilemma is to get all providers in a network on a shared data platform. This allows for apples-to-apples data comparisons and better patient tracking through the whole care continuum. Loopback Analytics is one such platform, and Seton Hospital in Austin is requiring that providers be on the Loopback system to have preferred status.
Loopback is betting that this, rather than each provider self-reporting data, is the model of the future. Copeland agrees that it’s becoming more common, and she said that being required to get on a certain data system is generally not a burden on Ensign. The cost is worth it, in order to win referrals and be a good partner overall, she said. Exceptions can occur when the referring entity — such as an accountable care organization (ACO) — asks the SNF provider to to take a payment cut on top of investing in new technology. Still, overall, she sees benefits in being on a shared network.
“The platforms really help us to see patients we’ve discharged to home health … what happened to them readmission wise, et cetera?” she said. “This helps us analyze, are we having failed discharges? Are we referring downstream effectively and appropriately?”
A new operational model
Of course, to maintain preferred provider status, SNFs need to do more than get on shared data networks. Their numbers have to impress.
Brentwood, Tenn.-based Brookdale, the nation’s largest senior living provider as well as a major skilled nursing company, first worked with Loopback in 2012 on an initiative to improve care transitions. The company has continued the partnership with Loopback in certain markets, including Austin. There, Brookdale has also launched a high-acuity unit at one of its continuing care retirement communities, Brookdale Lakeway, which is driving improved metrics and supporting its hospital partnerships.
The unit opened in March 2017 and is meant primarily for patients rehabbing after a hospital stay who are at high risk for readmission, explained Todd Mackenzie, Lakeway’s executive director and Brookdale’s Austin market leader.
The high-acuity patients might have experienced exacerbations in the past at other SNFs or at home, or have other risk factors for hospitalization. Enhanced staffing in the high-acuity unit is intended to improve outcomes. In addition to the unit having 24-hour registered nurse coverage, physicians affiliated with the two major Austin hospital systems also do daily rounds. Brookdale absorbs the associated costs.
“You wouldn’t think that [a company] would want to pay out of pocket for doctors to round on patients, but the benefits have been a significant reduction of readmissions and a significant increase in [patient] volume, and satisfaction and quality outcomes,” Mackenzie said.
About 70 to 80 patients a month are coming through the high-acuity unit at Lakeway, he said. His 2017 year-end calculations showed SNF admissions at Lakeway were up 29.6%, compared with 13% for the Brookdale communities across the Austin market. He attributes Lakeway’s success in this area to the new operational model, and he suspects that it is a glimpse of what the future may hold for the skilled nursing sector as a whole.
“I think outcomes are going to drive everything,” he said. “SNF providers are going to have to drive outcomes — high satisfaction rates, low readmission rates, good survey outcomes — and if they don’t, there’s not going to be a place for them in these networks.”