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The Critical Role of Skilled Nursing Facilities in Care Transition (and Why HealthHive Chose to Start There)

May 16, 2022


The role of Skilled Nursing Facilities (SNFs) is frequently maligned in the market (and unloved by Venture Capitalists), but they play a critical role in the care continuum. While staffing is currently the most significant challenge faced by SNFs, the care transition from SNF to home is crucial. Approximately 25% of Medicare patients hospitalized for acute medical illness are discharged to a SNF, but only 48.6% of patients successfully returned to their home or community following a short stay in a SNF. Evidence suggests that older adults with multiple chronic conditions are particularly vulnerable to breakdowns in care and therefore have the greatest need for transitional care services. Poor “handoff” of these older adults and their family caregivers has been linked to adverse events, low satisfaction with care, and high rehospitalization rates. Let's look at why this unpopular path is both important to our healthcare ecosystem and a key initial focus for HealthHive.

About the SNF to Home Market Need: 

In 2013 the Centers for Medicare & Medicaid Services (CMS) created a bonus and penalty system designed to reduce the 2.6 million seniors who are readmitted to hospitals within 30 days, at a cost of over $26 billion every year. Approximately 25% of Medicare patients hospitalized for acute medical illness are discharged to a SNF.  And while the transition from SNF to home is critically important, most of the new patient coordination solutions are solely focused on the transition from the hospital.

According to CMS, only 48.6% of patients successfully returned to their home or community following a short stay in a SNF, highlighting a sizeable gap for targeting quality improvement efforts. The measure of success was defined as patients that returned to home or community from the SNF and remained alive without any unplanned hospitalizations in the 31 days following discharge from the SNF. 

“High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers. These patients typically receive care from many providers and frequently move within health care settings. A growing body of evidence suggests that they are particularly vulnerable to breakdowns in care and thus have the greatest need for transitional care services. Poor “handoff” of these older adults and their family caregivers from hospital-to-home has been linked to adverse events, low satisfaction with care, and high rehospitalization rates.

These patients typically receive care from many providers and frequently move within health care settings. Based on this data, the need is great, and the financial impact significant.

About the SNF to Home Market Opportunity: 

We view the SNF as the most important “orphan” within the care transition world. According to a survey published in August 2020, prior to the pandemic, only 10% of responding health systems were exploring partnerships with SNFs, 38% had partnerships without financial risk, 8% partnerships with financial risk, and 23% owned a SNF. In other words, as the market moves towards value-based care, the SNFs tend to be excluded.

Another recent survey identified that while 90 percent of patients indicated that they had felt prepared to go home from a SNF, responses to specific questions indicated serious gaps in transition planning. 

  • Only 52% of patients responded that they had received information about symptoms and problems they may experience.
  • 40% of patients surveyed stated that they had received help from the SNF in arranging a follow-up appointment with a primary care provider.
  • 42% of patients and caregivers reported that they had received sufficient medication instruction while at the SNF.
  • Patients reported they were not frequently asked about concerns related to social needs (e.g., food, housing, transportation, affording care), and even when asked, close to half were not referred to services to help mitigate those concerns.
  • More than 40% of patients and caregivers reported that they did not receive a follow-up call from the SNF after they were discharged. Post-discharge follow-up calls are considered a best practice that can help identify and address problems early and possibly avoid more severe complications, acute care utilization, and patient and caregiver stress.

You’ve Told Me About the Market, But Why Focus There?

There are three core reasons we chose to begin building HealthHive within this market:

  1. Data, Resources, Information & Communication Gap: Many of the deficiencies identified above can be significantly impacted by a technology solution that allows people to highlight and address these areas of concern which are critical for the participation of SNFs in the at-risk world.
  2. Feature Development: Focusing our solution on this specific care transition allows us to build a core product addressing a particular issue with large financial and social impact. However, this focus also provides us with the necessary building blocks from which we can expand to address the broader market gaps.
  3. Market Entry Challenges: Many of the challenges associated with the creation, implementation, and feedback of a complex, integrated health tech solution can more efficiently be tested within the SNF Market.

Data, Resources, Information & Communication Gap:

HealthHive addresses these issues by holistically looking at the health system. A key challenge is bringing together data, resources, information & communication into a central place and integrating it with other solutions. These challenges have been addressed outside of healthcare, but they haven’t yet been brought to healthcare. We created our Hive and Portal structure to do this. 

HealthHive centralizes this in a patient-centered Hive that integrates into existing clinical systems. Importantly, this means that any individual with an interest in the patient can see what is going on with that individual. We enable authorized parties to participate regardless of their organization and minimize or eliminate changes in the clinical workflow. We’re early, but we’ve already proven we can do this by taking the first steps in each area. 

  • We pull in health data through a back-end integration with PointClickCare (the primary health data participant within the SNF space). We further empower Hive owners to add their health portal data from 14,000+ providers through our FHIR platform integration.
  • We make resources available through our integration with FindHelp, which allows users to search for a broad range of free or subsidized social support resources.
  • We enable SNFs to make relevant information available to Hive members through various tools, including Care Plans, which allow complex documents to be provided as simple Tasks and To-Dos indicating what should be done and why it matters. This information is digestible and available through alerts, push notifications, emails, or within our app, It can be assigned to the patient, members of their care team, and/or family.
  • We’ve currently included three forms of asynchronous communication within HealthHive, all centered around the Hive. 
  1. We allow the SNF to “broadcast” information to cohorts of Hives.
  2. We enable members of the Hive to have discussions and information within the Hive (think of it as a less sophisticated Slack).
  3. We provide a way for individuals from the formal care team to interact with individuals in a structured way, essentially empowering the upskilling of staff by allowing them to work off of their checklist to ensure that they are quickly getting the information they need during a visit.

Feature Development:

Creating a technology that solves a problem is just a small step in the success of a health tech company. The biggest challenge is engagement which is addressed by providing value to the user, based on what they need. This value differs based on role and individual in the complex healthcare environment.

Starting with care transition, we know that it is a time when the required features to deliver value are more defined than in other use cases. Therefore, we have allowed this use case to guide our initial feature set, developed a long list of features that are needed to meet our long-term goal, and we will allow our users to direct the prioritization of many of these features. 

Market Entry Challenges:

Building the first version of a broad-based health tech solution is difficult. While every health tech solution requires HIPAA compliance, a secure infrastructure, and solving a problem that matters, the most important element is understanding the range of users and building for them. Despite all of the interviews and conversations, nothing speaks louder than actual behavior. 

The SNF care transition provides the most significant opportunity to learn. Let’s highlight how.

  • Nobody likes change, but when a patient enters a SNF, we know that life for them and their family has changed. Therefore, it is a time when there is maximum focus on the individual, their family or support (if they have any), and their team. HealthHive is not asking people to change, their situation has forced them to change, and HealthHive is viewed as a facilitator which eases that change.

  • We have begun our early days focused on PointClickCare facilities. With our back-end integration, when a Resident arrives at the facility, the entire process of Hive creation is automated. As the Resident is registered within PointClickCare, it triggers the creation of the Hive. The Hive creation sends an invitation out to the Resident and their Authorized Parties to join the Hive. With the simple click of a button, the invitation can be accepted, and demographic and clinical data from PointClickCare can begin to populate the Hive. We require no change to staff behavior, with the possible exception of the Social Worker responsible for the transition, and we are simplifying their job.

  • Although our core product value is upon transition from SNF to home, by enabling the family to have visibility with regards to the stay of their loved one, they are familiarized with HealthHive during the Resident’s stay. The challenge of introducing the technology and getting people to engage is made much easier than if we needed to insert our technology at the point of Resident discharge,

  • When the Resident is discharged, that process within PointClickCare triggers the assignment of a Care Plan to the Hive. Currently, workflow within the SNF (and regulatory mandates) requires that a care plan be created, discussed, and shared with the Resident, so HealthHive facilitates an existing step rather than introducing a burden.  And on the Resident and family side, rather than being handed a bunch of papers that few people will read, they are receiving a plan which shows what steps they should take to continue their recovery, why these steps matter, and a means of asking questions if they arise. This also means that this knowledge can be shared with family and caregivers who are known influencers in the care management of the individual.

Throughout this process, HealthHive has the opportunity to learn about the behaviors of the parties and what we should do to provide increased value and engagement in other environments.

Lessons Learned:

We have a long way to go, but we’ve learned a lot. While we know that the lifetime value of a single SNF is low, it has served as a great place to better understand the needs and behaviors of a broad range of users. These lessons allow us to position ourselves with confidence as we move forward. Here are some key learnings:

  • Unique workflows exist, and we must, and can, accommodate them;
  • Once these workflows are established, standardization of implementation and application within the organization provides substantial benefit;
  • Automation is a must;
  • The ecosystem needs to consider the SNF as a critical element in its formula; and
  • The features and values that matter to the enterprise are entirely different from those of the patient and care team. We must solve both problems to succeed.

The learnings in the SNF space have informed our product plans as we move toward our goal to create something that makes healthcare better for all participants — starting with the patient and their families while integrating into the health system.

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