From Floor to SNF with 6 Clicks

Functional measurement tool helps avoid needless delays before SNF transfer

Experience with Cleveland Clinic’s 6 Clicks functional measurement tool over the past couple of years has largely been a tale of two numbers: 1,000 and 75 percent.

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The first number represents the burgeoning nationwide adoption of the tool: More than 1,000 hospitals and health systems have now licensed 6 Clicks for use.

The second number sheds light on a key reason for such widespread embrace of 6 Clicks — the potential power the tool holds for promoting more appropriate utilization of rehabilitative therapy services. In this case, 75 percent is the approximate reduction in precertification therapy visits that 6 Clicks helped achieve in a 12-month pilot study of a Cleveland Clinic “floor to SNF” initiative. The initiative allows prompt patient discharge from hospital to skilled nursing facility (SNF) without a follow-up insurance precertification visit if the patient meets a specified 6 Clicks score threshold and is recommended for discharge by a physical therapist.

The pilot’s success has been followed by expansion of the floor-to-SNF initiative, including its use by insurer Anthem in its Medicare Advantage Plan (Anthem Senior Advantage) in Ohio and some neighboring states.

Additionally, Cleveland Clinic’s Medicare Accountable Care Organization (ACO) has received from the Centers for Medicare & Medicaid Services (CMS) a waiver from the requirement for a three-day inpatient hospital stay prior to Medicare-covered care at designated SNF affiliates for traditional Medicare beneficiaries transferred under the floor-to-SNF initiative.

“We’re finding that the floor-to-SNF initiative is not only reducing patients’ length of stay in the hospital but reducing their SNF length of stay as well,” says Mary Stilphen, PT, DPT, Senior Director of Rehabilitation and Sports Therapy at Cleveland Clinic. “It’s helping patients get the right care at the right time for the right reason, and they’re benefiting.”

6 Clicks essentials

Getting patients the right care at the right time is a core principle of the 6 Clicks instrument itself. As detailed in earlier posts on this site (here and here), 6 Clicks is a validated tool developed through Cleveland Clinic’s Department of Physical Medicine and Rehabilitation (PM&R) as a short form of the AM-PAC™ (Activity Measure for Post Acute Care™) instrument developed by Boston University researchers.

The tool’s creation was prompted by a recognition on the part of Cleveland Clinic Professor and Department of PM&R Chair Frederick Frost, MD, that traditional methods of patient assessment in the acute care hospital did not accurately assess burden of care and discharge potential. This led to the design of 6 Clicks as an instrument intended to be minimally burdensome to providers and patients alike. The tool consists of two six-item questionnaires administered electronically to assess patients’ mobility and self-care abilities. Physical therapists (PTs) and occupational therapists (OTs) complete 6 Clicks at each evaluation and follow-up visit for hospitalized patients for whom a PT/OT consult is requested by a physician.

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Initial objectives were to determine appropriate referrals for PT/OT, guide discharge recommendations and optimize allocation of therapy resources in the acute care hospital. The tool has since been introduced in multiple Northeast Ohio SNFs to help staff efficiently gauge patients’ progress during their SNF stay.

Floor-to-SNF rationale and design

Transfer to the SNF has been a recent focus of interest. The pilot was conducted to test the workability of the floor-to-SNF concept, which was premised on information suggesting that precertification therapy visits for transfer were sometimes unnecessary, needlessly delaying SNF transfer and prolonging hospital stays.

The floor-to-SNF program allows for medically stable inpatients with an initial 6 Clicks score of 18 or below (out of a possible 24) and a therapist recommendation for SNF transfer to be eligible for transfer without an updated PT/OT note. The pilot confirmed the concept, reducing precertification visits by 75 percent over a 12-month period. Length of stay in both hospital and SNF declined as well, as did administrative burden for hospital, SNF and payer.

Data starting to accumulate

Broader rollout of the floor-to-SNF initiative ensued, including the rollout under Anthem Senior Advantage.

Accumulation of data on the initiative followed as well. “In our most recent reporting period, we achieved 100 percent compliance with CMS Chapter 8 criteria for appropriateness for transfer to SNF care,” says Stilphen.

This created momentum to apply for the CMS “three-day rule” waiver for Cleveland Clinic’s ACO. Under the waiver, ACO patients can be sent to a SNF directly from an emergency department (ED) or an outpatient setting as well as from an inpatient floor.

The waiver took effect in January 2018 and runs through 2020. It currently applies to 13 SNF affiliates that collaborate closely with Cleveland Clinic and meet a CMS-designated quality threshold. More SNF affiliates will be added in 2019.

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Early data on experience with the waiver include the following:

  • 147 waiver discharges took place in the first 7 months of 2018.
  • Of the 147 discharges, 12 were from EDs, 67 were from inpatient nursing floors, 42 were from observational nursing floors and 26 were from rapid decision/clinical decision/observation units.
  • Among the 37 waiver discharge cases in the first quarter of 2018, the readmission rate was 13.3 percent.
  • Among the 37 waiver discharge cases in the first quarter of 2018, average SNF length of stay was 21 days.

“Cleveland Clinic is among the earliest ACOs to be granted this waiver,” says Stilphen. “Our base of experience with the floor-to-SNF initiative internally and with Anthem has made operationalizing the waiver easier for us than for some other ACOs.”

What’s next?

As Stilphen and colleagues look to build experience with the SNF three-day rule waiver and fine-tune their process accordingly, they’re working to standardize programs to forgo unnecessary precertification therapy visits in the commercial payer setting as well.

Meanwhile, interest around 6 Clicks itself continues to grow. Stilphen says a number of 6 Clicks users are collaborating on formation of a user group to pool data from the tool. Additionally, two user conferences around AMPAC and 6 Clicks have been held to date, and she expects more soon.

Stilphen adds that she gets daily inquiries from hospital systems about ways to get the most out of the tool. She notes that 6 Clicks users seem to especially value the way the tool visually displays the functional profiles of patients in a given unit and how it helps screen for patients who are the most appropriate therapy candidates. “It’s all about promoting a culture of mobility and thinking critically about how best to use our therapy resources,” she concludes.