Navigating CMS Scrutiny: Strategic Changes for Skilled Nursing Facilities

Nursing homes are under increased scrutiny as the Centers for Medicare and Medicaid Services (CMS) intensify expectations on post-discharge care efficiency, pressuring skilled nursing facilities (SNFs) to demonstrate cost management and rehospitalization reduction.

This heightened focus by CMS is part of a broader move towards value-based care models, like the Transforming Episode Accountability Model (TEAM). Jennifer Edwards from Therapy Management Corporation underscored these expectations during a recent webinar, noting that hospitals are now under pressure to partner with high-quality post-discharge facilities. This partnership is crucial as hospitals strive to manage post-acute care costs effectively.

Understanding the TEAM Model

The TEAM model is focused on Medicare beneficiaries undergoing specific surgeries, spanning coronary artery bypass grafts to spinal fusion. It currently involves 720 hospitals. SNFs have a pivotal role to play, needing to identify TEAM patients upon admission and begin immediate discharge planning. A critical aspect highlighted by Edwards is the need for SNFs to independently recognize relevant diagnoses, as hospitals might not identify these details during patient referrals.

Artificial intelligence (AI) is anticipated to significantly aid SNFs in monitoring performance metrics, identifying opportunities for reimbursement, and expanding clinical services. SNFs are advised to leverage their electronic medical records to track key data points like patient outcomes, length of stay, and quality measures, which are pivotal for identifying improvement areas.

Upcoming Models and Their Implications

Looking beyond the TEAM model, SNFs must prepare for future care frameworks, such as the ACO LEAD Model set to start in 2027. This model aims to support smaller and rural practices and includes a three-day SNF waiver. Another upcoming model is the Comprehensive Care for Joint Replacement Expanded (CJR-X) scheduled for 2028, which covers joint replacements within a 90-day episode framework.

• ACO LEAD Model: Commences January 1, 2027, supports smaller and rural practices, includes a three-day SNF waiver.
• CJR-X Model: Starts January 1, 2028, covers 90-day episodes for joint replacements.
• Sustaining skilled census requires alignment with these models and effective communication with TEAM-model hospitals.

Strategic Adaptations for SNFs

Edwards emphasized that outcomes from these models will be closely scrutinized by hospitals and physician groups. SNFs must meet these outcomes to sustain or grow their skilled census. Communication with hospital coordinators and early discharge planning upon patient admission are essential strategic adaptations for SNFs in this evolving landscape. The TEAM model includes a waiver that allows certain SNFs to bypass the traditional three-day inpatient requirement if they maintain a high CMS star rating.

Providers should recognize that while the TEAM model may open new referral opportunities, it might also reduce traditional SNF census sources. The rising preference for outpatient procedures and home health care services could notably alter referral patterns, as fewer patients might choose SNFs for post-acute care.