Reducing Readmission Rates through Skilled Hospitalist Care

One of the key focal points of the Affordable Care Act has been to reduce the overall cost of healthcare by reducing hospital readmission rates. Hospitals with excessively high readmission rates see their Medicare reimbursements fall as a result. Tying reimbursement rates to readmissions provides incentive for facilities to improve the care they provide.

The entire system can be encapsulated in the phrase ‘outcome-based medicine’. Rather than focus solely on a fee-for-service arrangement, healthcare providers now have to put effort into making sure outcomes are as positive as they can be. In terms of hospital readmissions, they want to see fewer patients returning for treatment of the same condition over and over again.

Some hospital groups are now tackling high readmission rates by combining their hospitalists with services provided by skilled nursing facilities (SNFs). As the thinking goes, if care at the SNF can be improved by having hospitalists follow their patients to such facilities, the cost of such a program would be outweighed by consistent Medicare reimbursements.

An Old Model Reborn

Hospitalists following their patients to SNFs is apparently not a new idea. A Team Health story that ran in July 2019 profiled one hospital group that spent two years having its hospitalists follow patients after discharge. During the years the program ran, they were able to cut readmission rates by 50%. However, the program eventually ran out of money. It was too costly to keep sending hospitalist jobs to SNFs, so the program was allowed to lapse at the end of its last funding cycle.

A couple of years later, the model seems to be reemerging. Team Health says that hospitalist groups already offering SNF coverage are finally beginning to report that they are having trouble keeping up with demand. Moreover, the SNFs themselves are picking up the tab.

What’s the difference between now and a few years ago? SNFs are no longer able to bounce Medicare patients back to hospitals without repercussions. Their Medicare reimbursement rates now suffer right alongside hospitals. So it is in their best interests to help cover the cost of hospitalist care and subsequently reduce readmission rates.

How It All Works

Under the typical model, a hospitalist treats patients during their regular hospital stays. Those patients released to SNFs receive at least one follow-up visit from the hospitalist a few days after admission. The hospitalist works with a nurse practitioner to ensure that the patient’s experience at the SNF is positive.

If one visit will do the trick, that’s the end of it. But there are times when hospitalists have to make multiple repeat visits. Numerous visits provide a continuity of care that hopefully prevents the patient from returning to the hospital for treatment of the same condition.

The SNF is Now a Partner

Having hospitalists follow their patients to SNFs has created a new dynamic that makes the SNF an equal partner in patient care rather than just the next healthcare facility down the line. Whether or not this was something regulators had in mind when they came up with the outcome-based model is unclear. But in the end, it doesn’t matter too much.

If making SNFs an equal partner reduces hospital readmissions by 50%, that’s the real story. That is what the healthcare industry should be focusing on. As for the hospitalists themselves, a system that works this well gives them even more opportunity to ensure that outcome-based medicine actually works for patients. Their ability to follow patients to an SNF gives them greater opportunity to make sure the quality of care is there.


Team Health –