Connected Care Model Reduces Readmissions from SNFs

Study looks at impact of frequent follow-up visits

With about 20 percent of hospitalized Medicare beneficiaries discharged to skilled nursing facilities (SNFs) for post-acute care, readmission rates within 30 days are common and costly. In an effort to deliver quality care, Cleveland Clinic’s Center for Connected Care started the Connected Care SNF program in 2012. Luke Kim, MD, and colleagues from Cleveland Clinic’s Center for Geriatric Medicine, recently conducted a study to look at the impact of more frequent provider visits.

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Some background

Patients discharged to SNFs generally have more complex illnesses, lower functional status, and higher one-year mortality than patients discharged to the community. Despite this, SNF patients might have infrequent contact with physicians. Federal regulations require only that patients discharged to SNFs be seen within 30 days and then at least once every 30 days thereafter.

According to the 2014 Office of Inspector General report, one-third of Medicare beneficiaries in SNFs experience adverse events from substandard treatment, inadequate resident monitoring and failure or delay of necessary care, most of which are thought to be preventable.

The intervention

To address this issue, Cleveland Clinic developed a program called “Connected Care SNF,” in which hospital-employed physicians and advanced practice professionals visit patients in selected SNFs four to five times per week, for the purpose of reducing preventable readmissions.

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The aim of this study was to assess whether the program reduced 30-day readmissions, and to identify which patients benefited most from the program.

During the study period, 13,544 patients were discharged to SNFs within a 25-miles radius of Cleveland Clinic’s main campus. Of these, 3,334 were discharged to seven intervention SNFs and 10,201 were discharged to 103 usual care SNFs.

This Connected Care intervention did, in fact, reduce 30-day readmission rates among patients discharged to SNFs. While all subgroups had substantial reductions in readmissions following the implementation of the intervention, patients at the highest risk of readmission benefited the most.

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During the intervention phase, adjusted 30-day readmission rates declined at the intervention SNFs (28.1% to 21.7%, P < 0.001), while there was a slight increase at control SNFs (27.1 % to 28.5%, P < 0.001). The absolute reductions ranged from 4.6 percent for patients at low risk for readmission to 9.1 percent for patients at high risk, and medical patients benefitted more than surgical patients.

The study concluded that this program of frequent visits to patients by hospital-employed physicians and advanced practice professionals at the SNFs can reduce 30-day readmission rates. But Dr. Kim notes that further study is necessary to know whether Connected Care can be reproduced and whether it reduces overall costs.

For more details on the study, see the published the article, “Impact of a Connected Care Model on 30-Day Readmission Rates from Skilled Nursing Facilities,” in the Journal of Hospital Medicine.