The Centers for Medicare & Medicaid Services (CMS) should consider implementing functional criteria for skilled nursing and rehabilitation service eligibility and a new payment model that better accommodates treatments occurring in homes and nursing homes, recommends Lewis A. Lipsitz, MD, director of the Institute for Aging Research at Hebrew SeniorLife in Boston. The actions would provide an alternative to the three-night hospital stay rule currently used to identify patients suitable for SNF and rehab services, says Lipsitz, writing in a JAMA opinion piece online.
A person’s acute mobility decline, activities of daily living impairment or delirium might be used to determine when SNF and rehab services would sufficiently address someone’s care needs, says Lipsitz, also a professor of medicine at Harvard Medical School. With hospitalizations—and related costs—reduced due to the use of lower-cost care settings in some cases, Lipsitz adds, the government would have funds to pay for home- and nursing-home based treatments.
Those receiving care at home or in a nursing facility could benefit from a shared-savings model that includes case management and quality controls, he says. Primary care physicians would have incentives to admit appropriate home-based patients to SNFs instead of hospitals for short-term care, and shared savings or fee-for-service payments would fund SNF medical and nursing care, which could be motivation for caregivers to keep residents out of the hospital and provide acute care in the home or at a nursing facility when appropriate.
“These and other payment models could obviate the 3-night stay requirement and hopefully would reduce the risks and high cost of unnecessary hospitalization,” Lipsitz says. Such models are in keeping with the government’s goal of eliminating excessive hospital stays and providing care in venues that are less expensive when appropriate, he adds, although controls would be necessary to ensure that skilled nursing benefits are not abused and care is not withheld.
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