Immense pressure on hospitals from the COVID-19 pandemic prompted CMS to waive its three-day rule for skilled nursing facility (SNF) care. Effective March 1, 2020, this waiver allowed patients to transfer to SNFs without the usual inpatient criteria or a three-day hospital stay. A recent study by Northwestern Medicine published in the Journal of American Geriatrics Society explores the trends in hospital discharges to SNFs during this period.
Join study authors Lee A. Lindquist, MD, MPH, and Marianne Tschoe, MD, on this episode of the Better Edge podcast as they discuss their research and findings.
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Trends in Hospital Discharges to Skilled Nursing Facilities
Marianne Tschoe, MD | Lee Ann Lindquist, MD, MPH, MBA
Marianne Tschoe, MD is a physician associated with Northwestern Medicine.
Learn more about Marianne Tschoe, MD
Lee Ann Lindquist, MD, MPH, MBA is the Chief of the Division of Geriatrics at the Northwestern University Feinberg School of Medicine.
Trends in Hospital Discharges to Skilled Nursing Facilities
Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and we have two Northwestern Medicine physicians for you today to highlight hospital discharges to skilled nursing facilities during and after the COVID-19 pandemic.
Joining me is Dr. Lee Ann Lindquist, she's the Chief of the Division of Geriatrics; and Dr. Marianne Tschoe. She's an Assistant Professor in the Division of Hospital Medicine. Doctors, thank you so much. As we get into this interesting topic, Dr. Lindquist, I'd like to start with you. Can you describe the most significant challenges hospitals faced when discharging patients to skilled nursing facilities during the pandemic? How have hospitals discharge practices evolved from the height of the pandemic to the current post-pandemic era?
Dr. Lee Ann Lindquist: I've been doing Geriatrics now for about 20 years, and Dr. Tschoe has been a hospitalist for about the same time. And so, one thing that we have been working forever with is that she is a hospitalist and she has patients that are being discharged from the hospital. After a person is in the hospital for a bit, they oftentimes need to have physical therapy or occupational therapy or further care done. And sometimes, we'll see patients being transferred to a skilled nursing facility or some people think of them as nursing homes to get further care. And as a geriatrician, this is where a lot of our seniors end up. And as a geriatrician who also works in the nursing home and skilled nursing facility, we really want the right patients to be coming to the skilled nursing facility. So, we don't want people that should be going home to be coming to the nursing home, and everybody wants to return home. And so, it's all about finding the right person and the right fit.
What we saw during COVID, COVID really was monster to people who worked in the nursing homes and to people who were moving into nursing homes, that nobody wanted to come to a nursing home. So, people were saying, "You know what, no matter what happened to me in the hospital, I want to go home." And so, that was one thing that we saw during COVID. Nobody wanted to go to the nursing home just because there was so many things that were happening as far as the infection, as far as the mortality, as far as people dying from it. And so, they were returning home. And it's natural. Everybody wants to go home.
But what we saw afterwards, and this continues with our study, is that people have been coming to the nursing homes, but they're a lot less sick. And so, that's what we did the research on, just because from a clinical standpoint, we were seeing this, and it was head-scratching to us.
Melanie Cole, MS: So, then, Dr. Lindquist, expand a little on your research itself and the models that you used.
Dr. Lee Ann Lindquist: Yeah. So, because clinically we are seeing a lot of different patients coming to the skilled nursing facility after being discharged from the hospital, we pulled all of the patient information of people who are being discharged from the hospital and being sent to the skilled nursing facilities during COVID and then the years that are following COVID. And we looked at different variables amongst the people being transferred over. We're looking at age, we were looking at medical illness, how sick were these people that were coming over, how many of them had an ICU stay. And that's where the information got really interesting.
Melanie Cole, MS: Dr. Tschoe, what were the key findings? How did the number of hospital discharges to SNFs change over the three-year course of the COVID pandemic? What strategies proved most effective in ensuring seamless coordination between hospitals and skilled nursing facilities?
Dr. Marianne Tschoe: One of the key findings in the study was that hospital discharges to skilled nursing facilities were lowest during the first year of the pandemic. That was actually when older hospitalized patients were the sickest. But over the course of the pandemic, we saw the hospital discharges to skilled nursing facilities actually increase, but the patients that were going there were healthier and had less severe illness.
Melanie Cole, MS: Dr. Tschoe, expand for a minute, if you would, on how infection control protocols influenced that discharge decision. As Dr. Lindquist was saying, people were afraid to go. So, how did what we all came up with and developed change how these protocols were maintained or adapted for now?
Dr. Marianne Tschoe: One of the biggest changes from the hospital side and also the skilled nursing facility side were that there were there visitor restrictions now. So to kind of limit the spread of the virus, patients were generally not allowed to have visitors; only in certain cases, such as if it were an end-of-life situation. And so, that helped to prevent the spread of the virus. But then at the same time, I think it took an emotional toll, not just on the patients, but then their loved ones, because they could go for long periods of time without seeing friends or family.
Melanie Cole, MS: That certainly was a big part of all of this. And Dr. Tschoe, can you explain the trends that you observed in the proportion of patients who had an ICU stay before being discharged to an SNF, the factors that contributed to the trends versus people who were not in the ICU and went to a nursing home, a skilled nursing facility?
Dr. Marianne Tschoe: So, I think that the trends kind of go against what you would think. So at the beginning of the pandemic, that's when the patients tended to be the sickest. And you would expect that older patients who had been in the ICU, those would be the ones who would really need to go to skilled nursing facilities. But what we saw was actually the opposite, that in the beginning, there were not a lot of discharges to skilled nursing facilities. But over time, over the course of the pandemic, that's when the discharges started to rise and that the patients who were actually less sick were going there.
Melanie Cole, MS: Dr. Lindquist, what role did telehealth play in facilitating followup care for patients discharged to SNFs and how is it being leveraged today? How did that kind of change with the pandemic?
Dr. Lee Ann Lindquist: Well, what we've seen now is that seniors are being offered and are using telehealth services more now than ever. And at Northwestern, we've established a telehealth memory service so people can call in and get an appointment if they're in the state of Illinois, and have received telehealth virtual memory care if they have memory loss and they're interested in figuring out what's going on.
Here at Northwestern Geriatrics, we have a telehealth program, specifically for patients who are experiencing cognitive loss. And these all came out of the pandemic because people were being offered and people were using more electronics for telehealth. So, there are a lot more things that we can be doing in the home, which makes you think why can't we get more of our patients who are older adults home instead of to the skilled nursing facility?
Melanie Cole, MS: Dr. Tschoe, how are you seeing telehealth and the findings of this study and the discharges changing over time now? What do you think is the most exciting part of all of this?
Dr. Marianne Tschoe: I think that the most exciting part from the hospital side is that a lot of times prior to the pandemic when telehealth wasn't used as frequently, that patients might miss appointments or have trouble scheduling followup appointments after leaving the hospital, but telehealth has really expanded the availability of providers. And so, it's easier for patients to access care after they leave the hospital.
Melanie Cole, MS: Well, it certainly has changed the landscape of how doctors and patients connect. I'd like to give you each a chance for a final thought here. So Dr. Tschoe, what would you like the key message to be about your research, about the studies? And why you think that SNFs had fewer admissions and how you explain the increase after the pandemic to skilled nursing facilities?
Dr. Marianne Tschoe: I think that during the pandemic, like we talked about, that initially patients were very afraid of going to skilled nursing facilities because they were afraid of catching the virus or because of visitor restrictions. I think one interesting point is that, at the beginning of the pandemic, when hospitals were very overburdened, the Center for Medicare and Medicaid Services, they actually lifted some of the restrictions that they had previously had on who could go to a skilled nursing facility. So, there were restrictions like you had to be in the hospital for three midnights, or you had to meet certain severity of illness criteria in order to go to a skilled nursing facility after discharge.
In order to help hospitals with their patient loads and lift some of that burden, they removed those criteria during the pandemic. And so, you could really see that's why I think in part the number of discharges increased over the course of the pandemic as it became less deadly, that now, you know, patients didn't have to meet those previous restrictions. And I think that that leads into Dr. Lindquist's question about whether patients always need to go to a skilled nursing facility after discharge or could some of those patients actually go home.
Melanie Cole, MS: This is an interesting topic. And Dr. Lindquist, what implications do you see that your findings might have for the care and discharge planning of older adult patients as we see it now? Take us from bench to bedside with this, because the recommendations that you make to improve decision-making regarding discharge locations for older adults after hospitalization affects not only the patient but the family as well. And when we look around the communities and see these skilled nursing facilities for people, the convenience and the cleanliness and the infection protocols all come into play here. Speak about your implications and what you see happening as a result.
Dr. Lee Ann Lindquist: We have all had some seniors in our lives that have been discharged to the hospital and they went to a nursing home and maybe they didn't do as well as they could have, or maybe they got weaker, or maybe things didn't pan out because many times I think we are automatically thinking of this older adult looks bad, they need to go straight to a skilled nursing facility, which may not be the best place for them. And many times in the hospital setting, it's a physical therapist or a social worker that makes the decision as to whether or not this person can go to a skilled nursing facility or should go home.
What we saw with our research and what we saw during COVID is that there was a lot of questioning. So, families questioned, physicians questioned, does this person really need to go to a skilled nursing facility after hospitalization? Can we get this person home? And what our research showed is, yes, you don't necessarily always have to go to a skilled nursing facility after hospitalization. There's a lot of people, especially seniors, who do just fine going home, if they've got proper support, if they've got proper care at home, and if their needs are met by the support that's in their home.
So, what we've seen is that if you question whether or not a person, an older adult, needs to go to a SNF, they might be able to go home instead of going to a SNF, and that might be the best place for them. Now that we're post COVID and we're seeing more people come to the SNF as a clinician, I'm seeing more patients that potentially could have gone straight home, whether it's somebody who's coming to the SNF because they had a left arm fracture, and they could have gone home if they had somebody to help them around the house. These are things that we need to consider, is an older adult going home a bad thing from the hospital? And actually, no, I think it is a good thing. We need to support our seniors and to try to get them home, if it's the right setting, if it's the right place. And we need to be questioning whether or not patients do need to go to a SNF after a hospital stay.
Melanie Cole, MS: Thank you, doctors, so much for joining us today. That was a great discussion. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/geriatrics to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.