120 Skilled Nursing Facility 3-Day Waiver Pilot: Direct Admission to Skilled Nursing Facilities From the Emergency Department Avoids Hospital Admissions and Decreases Costs

The SNF 3-Day Rule requires that Medicare beneficiaries have an inpatient hospital stay of at least 3 consecutive days within the past 30 days to be eligible for coverage of skilled nursing facility (SNF) admission. There is opportunity within the Centers for Medicare & Medicaid Services (CMS) Shared Savings Program for waiver of this rule for eligible beneficiaries who are prospectively assigned to an ACO and who receive care from an eligible SNF. Under the Shared Savings Program and the Track 1+ Model, CMS enters into an agreement with participating ACOs, rewarding them when they lower growth in Medicare Parts A and B fee-for-service costs (relative to their ACO-specific benchmark), while still requiring them to meet performance standards on quality of care. The objective of this pilot study was to determine the impact of the SNF 3-Day Rule Waiver on Medicare cost through ED to SNF direct admission compared to usual care (mandatory 3-day admission). Design: Retrospective review of process improvement project data from January 1st, 2018 through March 31st, 2018. Setting: Eligible ACO patients (∼101,000 attributed lives where the ACO is financially and clinically responsible for this population’s outcomes) presenting to Cleveland Clinic health care system emergency departments. Waiver-eligible ACO patients were identified through the prospective list sent by Medicare quarterly that was electronically interfaced through our EMR using discrete identifying fields. The SNF 3-Day Rule waiver was approved for Cleveland Clinic Medicare ACO’s use under the Track 1+ (downside risk contract) on 1/1/2018. We chose to engage only our 13 Connected Care (health system employed physician presence) SNFs in the waiver network. Embedded nurse case managers working with emergency physicians, identified appropriate ACO eligible patients who had medical or therapy needs, did not require hospital admission, and met Medicare criteria for SNF admission (medically stable, not requiring further inpatient care, and identified as having skilled nursing or rehabilitation needs warranting SNF placement). It is standard for all SNF admissions within the health system to be managed via the AllScripts care management IT network. AllScripts data for our ACO was queried from January 1st, 2018 to March 31st, 2018 to identify all emergency department ACO patients transferred directly to SNF. The 12 patients identified were then validated as members of the ACO by comparing to the CMS prospective assignment list. Our cost savings were compared to our 2017 Cleveland Clinic Medicare ACO data provided to each individual ACO by CMS. Twelve eligible ACO patients were identified during the study period who were able to be discharged directly from the ED to a SNF. Using a revenue savings-per-admission avoided of $9,594 based on 2017 Cleveland Clinic Medicare ACO data, we saved approximately $115,128 through avoided admissions. If this data were annualized, total Medicare ACO savings would be approximately $500,000, resulting in ∼$250,000 earned savings for the health system ACO based on a 50/50 risk sharing rate. None of the 12 patients admitted to the SNF’s under this program were readmitted to a hospital within 30 days. This pilot project suggests that implementation of the SNF 3-Day Rule Waiver from ED’s that are part of a CMS participating Shared Savings ACO is feasible and can result in shared savings for participating downside risk Medicare ACOs.