Deciding whether a patient can safely recover at home, at a skilled nursing facility, a hospital or other setting can be crucial for recovery. Routing patients to an inappropriate site of care can entail costly and avoidable hospital readmission.
Making the best site of care decision means combining thorough documentation, communication across hospitals, skilled nursing facilities (SNFs) and home-based care providers, as well as outcomes data, patient preferences, caregiver support and coordination of services, industry experts said during a PAYER Summit in June.
“Site of care transitions are incredibly complex,” Arun Dahiya, principal of SNF innovation and advancement strategy at OneHome, said on a panel. “We can all agree — patients prefer to recover at home, but that’s not always an option. That’s where us working collectively, especially as SNF operators, to ensure a responsible discharge.”
Miramar, Florida-based OneHome works with health plans to coordinate home-based healthcare, medical equipment and infusions through a coordinated provider network.
OneHome uses a data-driven approach to determine where a patient should receive care, whether at home or elsewhere. OneHome will then work to enable providers to enter risk-based arrangements based on their size and current healthcare interoperability.
Making the decision also goes beyond data. Brandi Cunagin, vice president of case management at Signature HealthCARE, utilizes the “Friday night test.”
The “Friday night test” consists of a simple question, Cunagin said: “If I send a patient home on Friday at 4 p.m., am I comfortable that they’re going to have everything they need and not return to the hospital before Monday morning?”
Louisville, Kentucky-based Signature HealthCARE provides home health, assisted living and other services.
The question often simplifies complex situations, Cunagin said, but it still helps determine whether the patient has access to critical care needs, such as support, medications, home health scheduling and transportation.
“If we would just keep things very simple and basic, we can really cover all of the bases for the patient,” Cunagin said.
Despite these measures, not all patients can be discharged to the optimal place, Dahiya noted. As a result, healthcare providers and coordinators must work within the patient’s circumstances to find the best path forward.
“We’ve discharged members to their cars because we couldn’t get in their way of wanting to get out of the SNF in the first place,” Dahiya said. “It’s our job to respect the patient, to come up with creative solutions, touch points. Maybe they are housing unstable, but we also check in on them. We find the community partners that are willing to be with them, offer those solutions.”
For home health providers, helping to determine the best site of care for a patient means improving documentation and educating staff on the best documentation practices, Cunagin noted.
Dahiya echoed the importance of thorough documentation, adding that providers should come prepared to show outcomes data and margin and spread between standard Patient-Driven Groupings Model (PDGM) rates.
“That’s where we could be valuable partners in a renegotiation if your outcomes data is superior to your peers, like we will send a referral volume your way,” Dahiya said.