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In the News: Discharge to Home vs SNF?

In the lead story of its September 2019 issue, the American College of Physicians Hospitalist describes how few tools and competing incentives create challenges for clinicians and health care organizations making hospital discharge decisions.

VSSL member Dr. Joshua Liao was quoted in the study discussing frontline discharge decisions from a clinical perspective:

Making a sound decision about where to discharge a patient is complicated by the lack of standard protocols and insufficient time before discharge for careful evaluation. As a result, SNFs are often viewed as a safety net or default option when it is not clear whether patients would be better off in a SNF or at home, according to a study in the November 2017 Journal of the American Geriatrics Society, in which researchers interviewed 25 clinicians at three hospitals. Hospitalists reported having little knowledge about the inner workings of SNFs, no formalized criteria for making selections, and no follow-up data on outcomes related to their decisions. Deciding where to refer patients can be more cut and dried after surgical procedures like a joint replacement, noted Joshua Liao, MD, MSc, FACP, associate medical director of payment strategy at the University of Washington in Seattle. “However, patients with chronic conditions, such as chronic obstructive pulmonary disease or heart failure, can require more time to recover and regain function. It can be harder to identify clear end points,” he said.

Dr. Liao also weighed in on the potential differences in financial incentives facing hospitals and SNFs.

However, while SNFs are driven to work with hospitals in order to increase and maintain referrals, they can operate under different financial incentives, noted Dr. Liao. In the most prominent, widely adopted bundled payment models, hospitals are ultimately held accountable for any savings or losses from an episode of care, which are driven in part by SNF length of stay. However, when SNFs are paid per diem by Medicare and not specifically engaged or rewarded for reduced costs (for example, by sharing of financial savings between hospitals and other entities involved in episodes of care), they may not share the financial incentive to reduce patients' postacute stays.

Learn more about Dr. Liao's research on bundled payments and SNF care as part of the value-based payment model.


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