When the COVID-19 pandemic struck, health systems had to re-think their post-acute care engagement strategies. Ronda Winans, director of continuing care clinical integration for 93-hospital Trinity Health, recently described the system’s seven-point strategy for working with skilled nursing facilities (SNFs) during the crisis.
Winans was speaking June 18 during a panel session at the spring meeting of the National Association of ACOs (NAACOS).
She set the stage by describing Livonia, Mich.-based Trinity Health. It is a nonprofit Catholic health system operating 93 hospitals in 22 states, including 120 continuing care locations encompassing home care, hospice, PACE and senior living facilities. Trinity has 16 clinically integrated networks with accountability of 1.6 million lives, and over $10 billion at risk, mostly in Medicare and Medicaid and BPCI. Part of Trinity’s strategy around alternative payment models is to move in the direction of greater accountability. The goal is to move into full-risk models, she said. “Post-acute care is something we do a lot of work around related to these payment models,” she said, “and also it is strategically tied to our mission of improving the health of the communities we serve.”
Winans holds a clinical M.S. degree in physical therapy and an M.B.A. in executive management. In her position, she works with Trinity Health's clinical integration, population health and care management national teams and the leaders of the regional clinically integrated networks to develop, integrate and ensure high performance of an effective continuing care network to support success in alternative payment models.
When the pandemic first hit, Trinity, like other health systems, was dealing with the difficulty of SNF acceptance policies. “Most skilled nursing facilities were initially not accepting COVID-19 discharges, plain and simple,” Winans said. “There was a lot of fear, so what was usually required was two consecutive negative tests following a positive or the time model of 14 days post-onset of symptoms and three days fever-free.”
In addition, the SNFs had serious PPE shortages that continue to this day, she said, as well as access issues and delayed turnaround times regarding SNF COVID-19 tests. “Patients who were already difficult to place — if you had a dialysis patient who was COVIV-positive, it made everything difficult,” she said. “Not only were COVID-positive patients difficult to place, even a COVID-naïve patient was a challenge and continues to be a challenge, especially in areas where there is a large concentration of COVID-positive folks.”
Initially Trinity’s headquarters team reached out to all the ministries across the nation to educate them about the number of waivers and flexibilities that came out from CMS after the initial spread of the pandemic. “We wanted the ministries to take those waivers and develop a post-acute transfer strategy specific to their ministry so that they were positioned well to safely and efficiently transition patients at discharge when the surge hit their area,” she explained. “Although our team was not tied to the work around testing access and turnaround time, it had a significant impact and continues to have a significant impact on the ease and efficiency of transferring patients out of our hospitals to SNFs.”
Winans outlined seven strategic steps Trinity ministries took to address the crisis:
No. 1: Assess the Landscape. In addition to educating staff around waivers and flexibilities, Trinity leadership charged them with establishing a local strategy for post-acute care to prepare for COVID-19. “We wanted them to assess their landscape. That assessment needed to extend beyond SNFs in their network to non-network SNFs and other independent assisted living, group homes and memory care — any facility that if it experienced an outbreak could cause an influx of patients into our EDs, we asked that they assess and be aware of them,” Winans said. “We wanted them to know what their testing capabilities were; what their acceptance policies were going to be regarding COVID-19; did they currently have any residents who were COVID-positive? What were their bed counts and ability to isolate a cohort? What was their PPE status and overall capacity? We were asking them to look at a lot of things outside of what they normally are used to looking at in terms of their own network.”
No 2.: Build on Established Relationships. Trinity wanted to leverage existing relationships between senior leadership and SNFs and other providers to discuss and review and plan around events and the fluid nature of COVID-19. “These proved to be considerably valuable for ministries that already had this structure in place,” Winans said. They had a history of working together and a history of trust. Those who had to establish these from scratch found them still valuable but they had a much shorter window of time to establish trust, she added. “For instance when there is a spike of cases, we heard of cases where the SNF might be fearful of sharing that issue, whereas an established relationship make those conversations easier.”
No. 3: Establish a Logistics Team and Model. Trinity began hosting daily calls with the SNFs to coordinate discharges and determine daily bed availability amongst the network, as well as looking at current and projected discharges. “The whole idea was to anticipate the need for COVID-19 transfers and facilitate them as soon as possible,” Winans explained. “It was ironic that CMS did provide that 3-day waiver flexibility outside the ACOs. In my experience it didn’t really have a significant impact on efficiency because there were so many challenges and fears around the transition of these patients that it was long after that 3-day period many times before we could get them placed.”
No. 4: Focus on Acute Care. If ministries had a situation where they were furloughing outpatient therapists because of low-volume issues due to the pandemic, Trinity asked that they consider supplementing the acute-care therapy offered in the hospital with the goal of avoiding the need of placement in a SNF.
No. 5: Connect to Public Health. “We wanted them to engage with their city and county public health officials on a post-acute strategy,” Winans said. In the event of a local surge, it might require a community-level response. In New York and Connecticut, for instance, they established some COVID-only sites — you need the coordination of local public health to do that, she added.
No. 6: Work With National SNF Providers. Trinity has a number of SNFs, but it does not have SNFs in all its markets. It wanted to supplement SNF access for COVID-19 patients in markets where Trinity Health doesn’t have a SNF. They did an assessment of the largest national SNF providers. The goal was to look at the extent to which the markets for those national SNF providers overlap with Trinity Health markets. They looked at Life Care Centers, HCR ManorCare, Genesis HealthCare, Sava SeniorCare, Ensign Group. For instance, HCR had 110 facilities in markets where we have hospitals. Genesis had 182 sites where Trinity has 22 ministries. “We connected the national SNFs leadership with the ministry-level acute care management leaders as well as senior leadership, and helped them develop both an escalation mechanism and a process for expediting referrals of COVID-positive patients into these SNFs,” Winans said. “That was an interesting process. We have had pretty good success. We have at least six or seven major markets where these SNF providers played a role in helping to transition these patients.”
No. 7: Drop Team Strategy. Drop teams can “drop in” to SNFs to offer support. Winans acknowledged that their approach closely followed the work done at MultiCare in Washington, which adopted it as a result of work that the University of Washington Health System did with LifeCare Centers, which was the nursing home that initially had a significant outbreak that made the national news. She said she likes this model because it is proactive.
“Ultimately, one of the big issues is SNFs, assisted living, group homes, were ill-prepared for COVID-19, in many cases because they didn’t have PPE and also because they just don’t usually have that level of infection control needs,” she said. “They also had issues — and continue to have issues — with access to testing and supplies. We would have residents transferred to the emergency department to be tested because of the lack of supplies. If a patient tested positive but didn’t really meet inpatient criteria for an admission, the SNF or independent assisted living facility wasn’t in a position to accept them back safely. Trinity did not want folks to be discharged back to a facility that couldn’t safely accept them. Ultimately, that would result in more infections and an influx into our EDs, impacting care for others who needed it as well.”
The drop team had two components: the proactive part was around education of the care providers in care facilities on infection control, cohorting and isolation. In areas that were experiencing a surge, these partnerships with hospitals could ease the burden on the public health departments there, so they could focus on other folks who didn’t have that type of support. “Ultimately, the desire was to eliminate unnecessary transfers,” Winans said.
While looking back at the changes that have been made, Trinity executives also are looking ahead at what they would want to preserve. “A common thread is the whole concept of integration,” Winans said. “The crisis forced all these entities to work together efficiently and creatively to meet the needs of patients. All of our agendas were put aside. It has shown us what is possible for our patients.”
