The “super SNF,” an insider term used for nursing homes that serve mostly high acuity patients, is evolving to enhance its specialized function, and leaders in the space believe it will be a replacement – or at least a supplement – for long-term acute care hospitals (LTACHs) and inpatient rehabilitation facilities (IRFs).
The latest changes include major bed adaptation to accommodate for high acuity rehabilitation, with some super SNFs not having long-stay patients whatsoever, and between 80% and 100% utilizing higher acuity rehab.
Moreover, the new super SNF has a high level of physician engagement and additional ancillary services on site, including pharmacy services, labs and radiology, or treatment for chronic kidney disease with wraparound services. For payers, all of these services come at a lower price tag than an LTACH or IRF stay, but operators must think outside of traditional payers to make the model work.
Avamere Living, which has super SNFs in its portfolio, added the ability to manage infectious diseases to the list of its super SNF services after seeing high rates of rehospitalization related to sepsis and infections, according to its president and CEO, Carl Tabor.
Also, this wide array of service offerings and enhancements by super SNFs is a reflection of the complexity of cases coming through the doors of nursing homes, experts said.
“It’s not necessarily a single diagnosis or episode that you see. Formerly, you would have a cardiac episode, very pocketed, very specific in how you look at the clinical education model,” said Nicole Kaufman, chief transformation officer for Genesis HealthCare. “Now it’s about agility. You have to be able to manage all of those things, give or take a few depending on what you’ve seen coming through from the hospital.”
Tabor and Kaufman spoke at a panel for LTC100 recently, along with Kimberly Green, COO for the Diakonos Group, and Tim Fields, CEO and co-founder at Ignite Medical Resorts. Tim Craig, managing director for LTC100, moderated the panel. The term “super SNF” refers to a skilled nursing facility that cares for more medically complex patients than your traditional nursing home, using the criteria mentioned above.
In the next five years, the super SNF needs to continue to look “upstream,” Fields said, in terms of acuity. When it comes to markets where the super SNF will work, the panelists had differing opinions. Fields said super SNFs should ideally be near large health systems, or in primarily urban areas.
Kaufman, on the other hand, sees an opportunity in some markets where there isn’t as much of a saturation of dense hospital access.
“People are having to schedule surgeries and drive 50 miles to the nearest hospital that can deliver that care, there’s no trauma hospital around. Because Genesis has a breadth of clinical experience that can deploy training, we’ve been able to become the higher acuity model,” she said.
Those operators looking to explore the option of developing super SNFs should figure out what speciality services are needed or are provided by an LTACH or IRF in their market, train their staff, and set up programs to meet these needs. Operators can then “sell” these services to local health systems or payers and showcase the fact that they offer the same level of care as an LTACH or IRF, but for less money, he said.
Funding a super SNF
When comparing the typical offerings at most nursing homes compared to the super SNF, it’s clear the latter is a “very, very different beast” and is considered to be a replacement for the LTACH or IRF.
For payers, super SNFs make a compelling case, with the average payment being much lower than an LTACH or IRF. In the Philadelphia, Pennsylvania market, the average payment for a comparable episode was $10,513 in a super SNF compared to $48,048 in an LTACH or IRF, according to data provided by Genesis for the panel.
In other words, the cost of care is significantly less in a super SNF compared to these two other settings. In terms of the right payer mix for a super SNF, Tabor said the patient-driven payment model (PDPM) is oftentimes not adequate, and operators must consider if they will do only Medicare and no Medicaid.
Fields said that payers may be more on board for super SNFs in the next couple of years as cost of care for the same episodes becomes more clear, with consistent data.
“We’re on the low end of the totem pole in terms of innovation, contracting innovation and partnership programs. Nationally, it’s not there yet. I think that’s where we can start truly being linked to the payers. Financially, there are solutions, and not just being paid on a per diem basis,” said Fields.
Green said Fee-for-Service Medicare is currently the best payer for super SNFs, but beneficiaries represent only 40% of the market right now. It would be in the best interest of super SNFs, and the skilled nursing industry overall, to put limits on Medicare Advantage plans. Already, Genesis’ super SNFs have had to limit MA beneficiaries to keep finances afloat.
“That desperately needs to happen now,” Green said of putting the pressure on MA plans. “I think it will happen in five to 10 years, and we’ll have a lot more control, we’ll be paid more fairly. However, right now, Medicare A is the best payer. And it’s not enough, which is why I’m contracting hospitals and leasing out beds and talking to plastic surgeons – it is not enough.”
But, the super SNF model is where the industry needs to be in the next five to 10 years, she said. There will always be a need for the more traditional nursing home buildings, but society “wants and needs these buildings,” she said, referring to the super SNF.
Meanwhile, there’s been a slow erosion of lower acuity out of the nursing home space, with services like orthopedics moving to other care settings. Some patients that would normally be treated in an LTACH or IRFs are being pushed into the skilled nursing space, effectively replacing this erosion of typical residents with higher acuity patients.
What that means is that over the course of time, the acuity needs in the skilled nursing facility has shifted, and is continuing to shift higher, according to Craig.
For Kaufman, the shift has made the relationship between the super SNF and hospital system feel like a “teaching hospital,” where the SNF needs to be agile with what they’re seeing on the floor and share resources.
“They’re sending their team and their physicians to partner with ours to make sure that we’re able to care for the patient,” said Kaufman. “What does that do? It takes away some of the worry that we have, if we don’t have the clinical knowledge right there on staff, we have a partner that’s going to work with us if there is a return. [The hospital partner] understands why, and they put a system in place that allows for us to not have that happen again.”
Building a successful super SNF
Green said working with acute-care providers in the area is a key factor to success as a super SNF provider. Many hospital systems have a lot of beds full of people they have to continuously pay for, she said, sometimes upwards of $1,500 a day and are very open to bed lease programs.
“We went to them and said, we have all of these services, we can take care of all of these people and take that away from you,” said Green. “They lease beds from us, our super SNFs. We get rent on these beds, whether they’re filled or not … we do have first right of refusal, so we don’t get those people that we cannot take care of.”
Diakonos has tested out this model in Oklahoma, where reimbursement is very challenging, she said. It was a way of getting creative with the model when reimbursement isn’t aligned.
In New Mexico, local hospital systems require Genesis to opt for the bed lease agreements and the hospital turns into the payer. This is for patients that don’t have any managed care or Medicare benefits, said Kaufman.
Involving bariatric surgeons, plastic surgeons, and orthopedic specialists, the Diakonos super SNFs exuded a “medical resort” feel, Green noted, with the leased beds being reserved ahead of surgeries. This has added a stream of revenue Diakonos needed outside of the Medicare scope to make this model work in Oklahoma.
As for Avamere, Tabor said bed lease programs with hospitals could be good for the super SNF if the contract is favorable and the facility already has a lot of wraparound services and support from the hospital systems.
As far as the number of clinicians and service providers needed, for some of Avamere’s facilities, there may be three or four providers, plus physician extenders at any given time, said Tabor.
“These are high acuity, high comorbidities with a lot of challenging social determinants of care,” said Tabor. “In my Seattle market, if a facility has a high number of trauma, gunshots accidents, because it’s a regional trauma center, those are not your typical geriatric patients that you’d see and you can’t take care of them on your typical PDPM or Medicaid rate.”
Medicaid rates in Oregon and Wasington are pretty good, he said, but you still can’t deliver the super SNF level of care without some sort of additional wraparound services.
