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How SNFs Can Partner with Local Hospitals for Post-Acute Admissions

Updated: Jan 31, 2022


There is a slice of the census pie out there that has opened again and SNFs are asking themselves what they can do to get their portion of it. As hospitals ease restrictions on elective surgery moratoriums, there is a spike in the number of patients leaving hospitals but still in need of post-acute care.


Another Result in the Wake of Covid

This spike in patient need is because of a few reasons:

  • We are now in the see-saw days of the pandemic. Case rates are up and down as we pass from one variant to the next.

  • Healthcare professionals are getting better and better at managing those who get sick from Covid-19. Patients are recovering quicker, and quarantine times have been reduced.

The result is that more and more hospitals and healthcare systems are removing their temporary ban on elective surgeries. Bariatric surgeries, knee replacements, hip replacements, and other types of elective surgeries are on the rise again. One orthopedic surgeon recently said, “If I could physically do it, and the hospital would let me, I’d be performing knee replacements 24/7.”


The Answer for SNFs

Skilled Nursing Facility leadership teams are finding they need to partner with local hospitals to discover what they can do to partner with them and serve these patients. Health insurance carriers are also interested in the SNF alternative when it is applicable too. Everyone in the industry knows that the most expensive site of care is in the hospital. The properly equipped and properly staffed SNF can care for the post-acute patient for 25% of the cost of a similar stay in a hospital.


Getting Post-Acute Care Out of Hospitals and Into SNFs

For many of these patients, the elective procedure is often day surgery, or at the most one or two nights in the hospital. Then it is home to be taken care of by family. There are those patients who don’t have family support networks, however, or they have other special needs. For these individuals, hospitals and insurance companies would like to see them go to a post-acute care facility.


Capturing these patient admissions into your SNF means doing some detective work. It means reaching out to the local acute-care hospitals and asking them what they look for when referring a patient.


A recent article in Skilled Nursing News quoted Andrea Areskog of Novant Health, a 15-hospital health system based in Winston-Salem, NC. Said Areskog, “For us, a good partner is someone who cares for a patient in the skilled nursing home for just the right amount of time, so the patient is there for as long as they need to be. . .. We want all of our patients to be able to have a good place to go that’s high quality, and that’s regardless of payor source.”


SNFs to the Rescue: Saving Patient Beds

Jenn Leitch, MN, RN, CCM, CGS, nurse manager in the department of care management at Oregon Health & Science University (OHSU), took it a step further in an interview with Relias Media. “When we worked with the SNF, we created a list of patients they could provide specialized clinical care pathways for. They put a lot of effort into the education of their nursing staff to make sure they could care for complex wound patients, patients needing IV antibiotics, and patients needing trach care, and who had diabetes, strokes, traumatic brain injury, cognitive weakness, dialysis, and substance use disorder.”


Leitch added that OHSU saved 2,382 hospital days during the fiscal year of July 2019 to June 2020 because they were able to transition some patients to capable SNFs sooner.


This is not easy for many SNFs coming out of the pandemic, grappling with lower patient census issues and labor shortages, but for those in a good position, this knowledge opens up possibilities. Some of the measures are not all that costly, either.


Turning an empty room or two or three adjoining two empty rooms gives SNFs a space that can be turned into a physical therapy center. They can either source contract physical therapists, or the hospital might send their PT staff over as part of the partnership arrangement.


This is likely to be a continuing trend. More and more, SNFs will find themselves taking on more clinically complex patients, and it is a hurdle for many. As healthcare models continue to evolve and SNF’s look for different ways to increase their census, and hospitals look for a way to free up patient days, SNF leadership will be compelled to entertain and invest in new services and capabilities.


What Do Hospitals Look for in an SNF Partnership?

Andrea Areskog of Novant Health offered several markers they evaluate a partnership with an SNF. These include

  • Being able to take patients 24/7.

  • Having a smooth discharge process.

  • The ability to take on more clinically complex patients. Patients that need IV therapy, bariatric patients, or dialysis patients.

“Another challenge can be payer source I think,” said Areskog in the Skilled Nursing News article, “because a lot of skilled nursing facilities are for profit. They’re looking to have a certain payer mix within their patient panels, and we serve all patients. We have been fairly transparent about how the patients that we have coming into our facilities are changing and that we’re looking for partners who are willing to serve the same patients that we do.”


CareWork Can Help

The first step for SNFs in partnering with acute-care hospitals is to recognize the trends and opportunities in the resident types that come through their doors as referrals from the hospitals. CareWork’s software merges siloed information and gives SNF leadership teams the analytics on resident types so they can get a 360-degree view. They can see the commonalities, allowing them to discover patient types that they should be getting more of. They can see where their SNFs might have gaps in acuity needs and require different training or staffing. Armed with this information, they can communicate with acute-care hospitals and make sure they are both on the same page.


Are you ready to start seeing the steps you need to take to team up with your local hospitals? If so, contact us today.







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