In May, the office of Senator Susan Collins (R) of Maine called and asked if Beacon Health would provide testimony before the Senate Committee on Aging.
Beacon Health, one of the remaining 19 Pioneer CMS accountable care organizations (ACO) has been participating in a three day skilled nursing facility (SNF) waiver for the past three years. The pilot program is an attempt to see if patients and their families have better outcomes if they can receive the right care, at the right time, in the right place, and if medically stable, can avoid a three night hospital stay and go directly to a SNF.
The Beacon Health Pioneer ACO began in 2012 with just more than 9,000 Medicare beneficiaries. We are now in our fourth year of the five year program caring for nearly 29,000 Medicare beneficiaries.
"The three day SNF waiver program allowed us to expand our network and partner with more caregivers in order to truly make a difference in patients' lives. What the waiver does is allow our primary care teams to partner with caregivers across the care continuum," explains Tori Gaetani, RN, Beacon Health director care coordination.
Beacon Health partnered with 15 SNFs including swing beds in four critical access hospitals across our state all which were required to have a quality rating of three or more stars under the CMS 5-Star Quality Rating System, as reported on the Nursing Home Compare website, and must commit to quality of care measures beyond the Nursing Home Compare reports. The SNFs also agreed to admit our patients 24/7 in order to allow for safe transitions no matter the time of day or night. This was not easy feat - it required a true spirit of collaboration between Beacon Health Pioener primary care practices, the qualified SNFs, and hospitals, creating a truly seamless transition across the care continuum for our patients and families.
Pioneer patients can be referred directly from a primary care practice, emergency department, or after one or two day stay in a hospital. To date 183 patients have benefited from the waiver.
For Mr. Smith, an 86 year old gentleman who was living with his wife at home, it's meant a better quality of life. Mr. Smith had found himself in the local emergency department for weakness and falls at home. The emergency department assessed him and sent Mr. Smith back home with home care services for physical and occupational therapy. However, Mr. Smith continued to fall at home so the homecare therapist contacted the patient's primary care provider to update them on the continued problems he was having and recommended more intense daily therapy.
The primary care practice reached out to Mr. Smith and asked him to come into the office for a visit. Mr. Smith and his family came in for his appointment when his provider saw a general overall physical decline, with increased weakness, which was leading to his frequent falls. Mr. Smith, his family, and his provider wondered if the medications he was taking was contributing to his falls. They decided to make some adjustments to his medications and they also agreed some time in a skilled nursing facility for more intensive rehabilitation could support him living at home safe and independently.
The family took Mr. Smith to the SNF of his choice where he stayed and participated in therapy for 13 days. Mr. Smith returned home to his wife with out-patient services. Since Mr. Smith's discharge from SNF in March, he has had no falls, met his therapy goals and remains living independently at home with his wife. Mr. Smith was never admitted to the hospital; he got the appropriate level of care directly after a visit with his primary care provider.
Because of Mr. Smith and the countless other patients who continue to benefit from our program, Beacon Health is looking to expand the number of participating SNF facilities to offer our patients more choices at approved facilities throughout our state, keeping patients as close to home and family as we can. We will continue to communicate and educate patients, home healthcare, emergency departments, hospitals, and primary care providers regarding the SNF waiver eligibility to make sure all our Pioneer Medicare patients are offered the appropriate level of care that will improve their health outcome and overall quality of life.
The healthcare world calls it achieving the Triple Aim. Beacon Health sees it more as doing what is right for our patients. By always putting patient and family needs at the center of our care, Beacon Health providers are able to build strong relationships with our patients; they trust us and turn to us to support their health. We use best practices to guide our care plans coupled with our trusting relationships with our patients and families which have increased their satisfaction, improved outcomes, and lowered the cost of healthcare.
In conclusion, Tori strongly urged the Senate Special Committee on Aging to recommend to Congress to eliminate the three hospital overnight requirement as an antiquated and artificial barrier for Medicare beneficiaries access to skilled nursing facility level of care.