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ACOs Describe What's Involved When Implementing a SNF Waiver Program


Leaders from several different accountable care organizations (ACOs) describe their experience of creating programs to care for Medicare beneficiaries using the skilled nursing facility (SNF) waiver process.

What are the considerations that an accountable care organization (ACO) should consider when implementing waivers for skilled nursing facilities (SNF)?

Five years ago, CMS changed the so-called 3-day rule for Medicare beneficiaries enrolled in an ACO that chooses to apply and receive a waiver from the rule. Typically, Medicare beneficiaries must be admitted to a hospital for 3 nights before receiving coverage for 100 days of skilled nursing coverage.

ACOs can apply for a waiver if they can demonstrate to CMS that it has the capacity to identify and manage beneficiaries who, under the waiver, would be either directly admitted to a facility from the community or admitted to a SNF after an inpatient hospitalization of fewer than 3 days.

Chris Butters, the manager of network development for post-acute care services for UnityPoint Accountable Care, described how its Next Generation ACO, covering 104,000 lives, implemented benefit enhancements, including the SNF waiver. UnityPoint operates in Illinois, Iowa, Nebraska, South Dakota, and Wisconsin.

“I feel we’ve been pretty successful,” he said during a presentation at the National Association of ACOs (NAACOS) 2020 Virtual Spring Conference. Successful implementation needs to ensure that everything related to patient care is captured, tracked, and monitored, both for utilization and quality purposes, he said.

A major part of the process is ensuring that the beneficiary is eligible for care for the waiver. Since moving from a decentralized process to a centralized one, the number of referrals for care has increased and the process is much more streamlined, he said.

For instance, before there were different electronic medical record (EMR) systems involved among different care agencies and clinics, and different regional variations posed other challenges. That contributed to a low number of referrals, Butters said. A centralized approach would include having nurses proactively identify high-risk patients who would benefit through data analytics. In addition, using the same EMR in different regions reduces variation and has increased the volume of referrals.

Sharon Kimball, MSN, MBA, RN, the executive director of Care Management/Continuing Care Network at UNC Health, said there are 4 reasons to use a SNF waiver, all of which fit into the drive for value-based care: to improve care quality; to decrease the total cost of care; to support beneficiaries and families; and to eliminate need for 3-day hospital stay, which supports hospital capacity.

There is no “cookie cutter method” for developing these processes, said Cindy Yeager, the care gaps and quality data manager for Keystone ACO, a collaboration between Geisinger Clinic and 3 other health care systems.

“What works for one ACO may not necessarily work for yours,” she said.

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