Advancing Innovation in Skilled Nursing Facilities through Academic Collaborations

Abstract

There is growing recognition that acute hospitalization contributes to marked functional decline in older adult populations. Nearly 20% of all hospitalized older adults in the United States are discharged to skilled nursing facilities (SNFs) to address these functional deficits. However, current approaches to care in SNFs may not adequately restore function, which may contribute to low community discharge rates and high hospital readmission rates. Barriers to rehabilitation innovation in SNFs include management, staff, patient, and researcher-level factors. This clinical commentary builds upon clinical innovation strategies in other health care settings by describing barriers in the context of the SNF environment. Fostering collaboration between academic clinical researchers and SNFs may be the answer to advancing rehabilitation practices and care delivery, thereby improving outcomes in this vulnerable population.

Introduction

For many older adults following hospitalization, a skilled nursing facility (SNF) stay provides short-term rehabilitation and medical services to address the functional deficits stemming from hospitalization.^1–4 Considerable evidence exists for hospital-associated deconditioning in older adults,^5,6 which contributes to reduced physical performance^7–9 and difficulty performing activities of daily living upon discharge from the hospital.^10–13 Moreover, older adults who are hospitalized are 60 times more likely to develop disability than those who are not.¹⁴ Numerous studies have documented that recovery of function during a SNF stay is inadequate under usual care^15–29 and is likely a major reason that 63% of SNF patients do not discharge back to a community setting.³⁰ Similarly, for patients who are able to return home from a SNF, low levels of physical function and medical complexity often persist as poorly addressed portents of failing health,^31–33 re-hospitalization,^32,33 or death.³⁴ The 2017 Medicare Payment Advisory Commission (MedPAC) reported no change in functional outcomes as measured by a patient’s ability to perform bed mobility, transfers, and ambulation.³⁵ The poor outcomes described continue to occur despite the fact that Medicare spending in post-acute care is rapidly outpacing all other health care costs, which places rehabilitation services under considerable scrutiny.^35–37 Specifically in SNFs, annual expenditures comprise 50% of the $60 billion US allotted to post-acute care.^{30,36 35}The discrepancy between high levels of spending in SNFs^35,38,39 and suboptimal outcomes^35,38,39 strongly suggests the need for innovative clinical research designed to advance models of care delivery and assert the value of SNF rehabilitation therapists.

The call for innovation in SNF rehabilitation comes at a critical time when post-acute health care reform is causing potential shifts in hospital discharge patterns away from SNFs towards less costly home health or outpatient services. ^40–43 This shift has created an impetus for SNFs to differentiate themselves in the market place by affirming their value in producing optimal patient outcomes at reduced cost.^{44,45 46} Other post-acute venues, including home health and outpatient clinics, traditionally had greater incentive to innovate and seek academic partners compared to SNFs, due to dependence on referrals to drive patient volume. A patient’s choice of SNF tends to be dictated by geographical area⁴⁷ or the patient’s Medicare Advantage plan of in-network SNF providers,⁴⁸ rather than recommendations about, and evidence to the quality of care provided at, a particular SNF. Thus, for many years, SNFs have not relied as extensively on referrals or needed to demonstrate and report a high level of value based care.

More recently, innovations aimed at improving SNF care and outcomes are increasingly necessary for marketability. First, the rise in Medicare Advantage enrollees has triggered the need for SNFs to contract with payers to establish themselves as in-network providers.⁴⁸ Second, current policy changes and penalties are now holding SNFs accountable for readmissions (i.e., Protecting Access to Medicare Act of 2014 [PAMA]),⁴⁹ which threatens to reduce SNF revenue. Finally, the onset of bundled payments across the spectrum of post-acute care, which proposes shared risk and potential cost-savings, has shifted how SNFs market themselves to hospitals seeking preferred post-acute providers who demonstrate quality outcomes and reduced hospital readmissions.^50–52 Thus, SNFs that demonstrate improved care quality and outcomes at lesser cost will likely attract a greater share of the market through increased Medicare Advantage plan contracts⁴⁸ and larger visibility as preferred providers for hospital systems.^50,53

Clinical researchers in academic settings are also tasked with differentiating their research in the face of reduced funding for research initiatives. ⁵⁴ Additionally, clinical researchers are under increased pressure from funders and publishers to include stakeholders—who are important but may lack formal research knowledge--on the research team. Finally, clinical researchers tend to experience a limited capacity to effectively and timely translate research into practice.^55,56 An academic collaboration between clinical researchers and SNFs may provide innovative solutions to ongoing threats to the sustainability of SNFs and provide clinical researchers a vehicle to rapidly implement research directly in the SNF for faster translation to patient outcomes.

Broadly, health care innovation can be described as the implementation of a new approach, service, process, or product designed to improve quality of care at a lesser cost.⁵⁷ Thus, innovation encompasses quality improvement initiatives in addition to the development of new products or services.^58–60 Innovation in SNF rehabilitation has the potential to take on many different forms that leverage relationships between clinical researchers and SNFs. The purpose of this clinical commentary is to identify and summarize modifiable barriers to SNF rehabilitation innovation at the management, staff, patient, and researcher levels. While many of the barriers appear intuitive, the unique challenges within the SNF culture⁶¹ impedes implementation of innovative care models in SNF rehabilitation and may account for the paucity of evidence related to the value of rehabilitation in this costly, post-acute setting. Importantly, this clinical commentary outlines potential solutions to creating a culture of innovation in SNFs through formally establishing academic-SNF collaborations.

Barriers to innovation in SNFs

Management-Level Factors

Barriers to innovation at the management level in a SNF include an unpredictable workforce within leadership positions and discordant priorities between short-term revenue generating activities and long-term sustainability of SNFs through innovative approaches to care. Rehabilitation innovation in the SNF is hindered by variability and frequent turnover in organizational leadership.^62,63 This creates difficulty identifying the facility decision-maker who can approve or reject innovative initiatives and provide leadership support for the duration of the project. The authors’ experiences in SNFs suggest the decision-maker on the local level ranges from the medical director to facility administrator, executive director, or vice president of clinical care programming, but permissions may also be required from the corporate headquarters. Since local leadership must advocate and receive approval at corporate and national levels, obtaining such approval can be a significant challenge. Furthermore, long-term care nursing home literature has suggested a high-turnover of administrative staff impacts the delivery of quality care and, thus, potentially the adoption of innovative models of care.^62,64

Corporate or facility management policies that emphasize productivity create disincentives to adopting or developing innovative rehabilitation approaches.⁶⁵ For example, a rehabilitation therapist’s productivity is typically based on the number of minutes providing billable patient care per day compared to the total number of minutes the therapist is at the facility. Thus, therapists in SNFs are paid a collective sum of money to achieve a certain number of billable treatment minutes per week.^30,66 Work-time spent on new initiatives such as clinical research is often non-billable time, which potentially reduces incentive for innovation.

Staff-Level Factors

A few key staff-level barriers to rehabilitation innovation in SNFs include the high stress environment, assumptions and perceptions of risk versus benefit to applying advanced models of rehabilitation practice, and communication barriers. Staffing shortages and high rates of staff turnover are pervasive in SNFs and long-term care settings across multiple discplines,⁶⁷ both of which can be linked to work stress and burn-out.^68,69 Studies conducted in hospital and long term care environments indicate that emotional exhaustion and work stress negatively impact research utilization, which may undermine opportunities for innovation.^70,71

A risk-averse culture in SNFs⁷² may foster concerns about safety (e.g., falls, further decline in function) or decreased patient satisfaction, which may further limit application of innovative rehabilitation strategies. Falls are a particular concern given the increased health care utilization and costs of care associated with a fall in the SNF.⁷³ From a SNF facility and rehabilitation therapist perspective, the perceived risk of falls may outweigh the risk of implementing innovative models of care.⁷⁴

Poor communication or the lack of open communication can result in poor quality of care in skilled and long term care settings.^75–80 The SNF environment is multi-disciplinary and dynamic, which can lead to difficulty communicating between the right persons at the right time. Many SNFs operate with two electronic medical record (EMR) systems: one for the medical team (e.g., nursing, physicians) and one for rehabilitation therapists. Nursing and rehabilitation therapist care practices can be siloed within a facility, which may contribute to potential gaps in communication, poor care delivery, and compromised patient safety. These communication barriers limit a facility’s ability to adopt innovative, interdisciplinary practices that often require complex coordination of information to inform patient care delivery.

Patient-Level Factors

Patient-level barriers to innovation in SNF rehabilitation have not been directly studied.^81,82 However, based on literature extrapolated from similar patient populations and the authors’ experience, a significant barrier to successful delivery of innovative rehabilitation strategies is lack of patient engagement, which may be further complicated by transient or permanent cognitive impairment. Nursing home literature suggests patient motivation to participate in treatments, such as physical therapy, is linearly correlated to patient perceptions of and satisfaction with support from peers, family, and staff.⁸³ During a time of crisis after hospitalization, patients find themselves outside of their familiar support system and further isolated by the institutional culture of SNFs.⁸⁴ A related issue is the cognitive dysfunction that may have developed during an acute hospitalization or may be a long term organic problem. In addition to influencing patient engagement, changes in cognitive status can present challenges to offering informed consent to clinical research or providing education on why an innovative practice will benefit the patient.^85,86 The ethical obligation to honor a patient’s autonomy under these circumstances means SNFs may be unable to fully implement a research protocol designed to evaluate an innovative model of care.

Researcher-Level Factors

Clinical researchers also face challenges to implementing innovative iniatives in SNFs including delays in patient recruitment,⁸⁷ limited personel who are skilled healthcare clinicians to carry out the interventions, and the lack of networks to more efficiently translate evidence into practice. First, delays in patient recruitment often occur due to limited availability, access to potential recruits and the above mentioned challenges with informed consent. Clinical research trials that do not achieve targeted recruitment goals have grave implications regarding the relevance and validity of results. ^88,89 Additionally, delays in recruitment can detrimentally impact funding by prolonging the trial beyond the funding period or from retraction of funding by the funder due to failure to reach enrollment targets. Second, clinical research trials often necessitate clinical expertise and skills to most effectively implement an intervention or approach, which the clinical research team does not always have the bandwidth or resources to provide. Finally, clinical researchers want effective interventions to advance SNF innovation through rapid integration of evidence into current practice. However, uptake in practice can take upwards of seventeen years due to the lack of networks, resources, and knowledge of clinical application of evidence.⁵⁶

Establishing academic-SNF collaborations

For establishment of academic-SNF research collaborations, research in similar settings recommends engaging stakeholders at all levels including clinical researchers, clinical leadership and management, staff, and patients.^60,90–94 The previous sections outlined modifiable barriers to rehabilitation innovation in the SNF at each stakeholder level, and the following section will link each barrier to a solution provided by an academic-SNF collaboration (Figure 1).

Figure 1.

Modifiable barriers to innovation in the SNF and solutions through an academic-SNF collaboration at each stakeholder level.

Management-Level Solutions

Robust leadership engagement and support is important for successful implementation of clinical research initiatives,^95,96 particularly in unpredictable environments that are fraught by high staff turnover and frequent ownership changes.⁹⁷ While establishing a collaboration can be an intimidating task due to the difficulty navigating the SNF management structure, a joint venture has a high likelihood of benefiting both academic and SNF participants.^60,65 At the management level, successful engagement can be achieved by aligning SNF and academic collaborators’ respective missions and goals to foster a synergistic relationship while promoting the collaboration as a differentiator in the marketplace.⁶⁰ Innovative models of care may facilitate acquiring Medicare Advantage plan contracts and recommendations as hospital-preferred SNF providers.

A potential strategy to spur interest and engagement between academic clinical researchers and SNFs is to propose solutions and innovative models of care that better prepare facilities for imminent legislative changes including bundled payment initiatives (e.g., Bundled Payments for Care Improvement [BPCI] and the Comprehensive Care for Joint Replacement Model [CJR]), penalties for potentially avoidable rehospitalizations (PAMA), and new quality reporting guidelines (Improving Medicare Post-Acute Transformation Act of 2014 [IMPACT]). These legislative vehicles provide opportunities for new health care delivery arrangements that include SNFs (e.g., accountable care organizations), but also threaten long term sustainability through penalties for poor quality of care (Table 1).

Table 1.

Description of Innovations in Models of Care and Their Impact on SNF Sustainability

Innovative Models of Care		Description	Impact on SNF Sustainability
The Patient Protection and Affordable Care Act (ACA) of 2010 (P.L. 111–148) 115			• Encourages collaboration across the continuum of care • Innovations in care to minimize cost have the potential to attract more business (i.e., patients and Medicare Advantage contracts). • If SNFs meet set goals for cost-containment and coordination of care, they share in the cost-savings. If set goals are not met, they can also share in the net loss.
	The Centers for Medicare and Medicaid Services (CMS) Innovation Center (Section 3021)
	Bundled Payments for Care Improvement (BPCI) 52,116	• Medicare reimburses providers for individual episodes of care using separate payment systems, which leads to fragmented payments and poor coordination of care.117 • Seeks to determine if the use of bundled payments within a single episode of care (e.g., from the hospital to the SNF) leads to better coordination of care and improved outcomes.116,117
	The Comprehensive Care for Joint Replacement Model (CJR)51,118	• Focuses specifically on bundling payments for episodes of care following lower-extremity joint replacement to potentially reduce the high volume of health care utilization and spending in this population.119
	Accountable Care Organizations (ACOs) (Section 3022) 113,120
	• Established under the ACA as formal arrangements between providers (e.g., doctors, hospitals, and SNFs) to help incentivize providers to coordinate care through collective accountability.121 • Hospitals and SNFs can also form informal to coordinate services, referrals, and financial savings.
Protecting Access to Medicare Act (PAMA) of 2014 (P.L. 113–93) 49		• In an effort to hold SNFs accountable for the care they provide and the subsequent link to patient outcomes, PAMA amended the Social Security Act to penalize SNFs for potentially avoidable rehospitalizations within 30 days of SNF admission beginning in October, 2018.49 • Under the new provisions of PAMA, the Department of Health and Human Services estimates that Medicare could potentially save $2.2 billion by 2027.122	• SNFs are incentivized to improve care for patients to prevent 30-day readmissions and future monetary penalties. • Has the potential to improve quality of care for patients and thus SNFs’ competitiveness in the post-acute marketplace
Improving Medicare Post-Acute Transformation Act (IMPACT) of 2014 (P.L. 113–185) 123		• Legislated to require all SNFs participate in a SNF Quality Reporting Program (SNF QRP) beginning in 2018. • The SNF QRP will use data from the Medicare fee-for-service claims dataset to determine the percentage of short-term patients who are discharged to the community, the number of potentially avoidable rehospitalizations within 30-days post-discharge to a SNF, and Medicare spending per beneficiary with SNF care.124	• The longitudinal data collected through the SNF QRP will allow SNFs to see their trends in quality measures and to use that data to better coordinate care and thus, improve outcomes for patients. • Has the potential to improve SNFs’ competitiveness in the post-acute marketplace

Finally, academic institutions with professional therapy education programs also can benefit from a collaborative arrangement that provides an opportunity to influence the number and quality of internships available for their students at the SNF.

Staff-Level Solutions

At the staff level, academic-SNF collaborations engage rehabilitation therapists by creating clinical champions, reducing staff burden, and providing shared resources.^96,98 In a collaboration, rehabilitation therapists can provide clinical researchers insight into clinical processes and the best methods to successfully integrate research procedures into daily practice to reduce stress and minimize the impact on productivity. Meanwhile, clinical researchers can develop or implement training materials, provide oversight of applied clinical research, and analyze workflow processes to maximize efficient communication and documentation.

To streamline this process of incorporating innovation into practice, clinical champions may be identified to serve as liaisons between clinical researchers and clinicians, while also engaging in on-site problem solving tailored to the individual SNF. On-site clinical champions, in partnership with clinical researchers, can provide support for the application of current evidence into clinical practice to alleviate concerns with safety, thus minimizing the perceived risk versus benefit of applying innovative models of rehabilitation. The responsibilities of clinical champions are ideally integrated into their routine tasks to minimize additional burden. Conversely, clinical researchers can provide the SNF with paid, external research staff to decrease the amount of burden on facility staff by taking over all aspects of the clinical research project. Clinical research staff implement all or some aspects of the project, thereby eliminating concerns about staff time constraints and variations in knowledge and skills. Use of external academic support has been successfully utilized in SNFs, because it drastically reduces the work burden on facility staff while allowing innovation to take place in a real-world setting.^99,100

Sharing resources is essential to sustaining a collaboration by furthering engaging rehabilitation therapists. Clinicians often value research endeavors as a way to advance practice, but cite lack of resources and inadequate knowledge of research skills (e.g., study design and statistical analysis) to pursue research independently.^101–104The transition from research in traditional laboratory settings into clinical settings provides a tremendous opportunity to advance practices by rapidly integrating evidence and innovation into current rehabilitation practice. In addition, clinical researchers may provide the SNF facility access to large databases and journals, as well as professional connections, to assist rehabilitation therapists in staying up to date on evidence-based practice and prompt ideas for further innovation.¹⁰⁵ Additionally clinical research can improve the quality of care delivered, which may in turn lead to greater staff-retention and higher work-satisfaction.^106–109 By sharing resources between SNFs and academics, a collaboration has the tremendous potential to advance rehabilitation innovation in SNFs to promote therapist value in post-acute care.

Patient-Level Solutions

At the patient level, engagement can be achieved through the development of patient-led advisory boards and integration of evidence-based strategies to increase patient engagement in their own care. Patient engagement has become an increasingly important element to ensuring innovative care models reflect patients’ needs, expectations, and perspectives, but does require extra time and resources to develop.^110,111 An academic-SNF collaboration may have the collective resources to quickely develop and integrate evidence-based strategies to improve patient engagement in rehabilitation and subsequently increase the likelihood for success with the implementation of innovative care models.

Despite the complexity of the SNF environment, patient engagement through focus group discussions has been successfully accomplished in similar patient populations (i.e., long-term care residents) by groups such as Plane Tree. ^112,113 Researchers may have a larger bandwidth to conduct assessments of patient engagement that will inform innovative approaches that foster patient-relevant outcomes. In light of this approach, the authors’ team has recently initiated a stakeholder advisory board for long-term care and SNFs that consists of administrators, facility staff including rehabilitation therapists, and patient or family representatives (unpublished work from RSB).^47,113 The group was first exposed to introductory material on the research process and asked to participate in moderated discussions to identify key issues regarding research and safety of human subjects in long-term care facilities and SNF. The program has continued to grow with researcher and community clinicicans comprising a steering committee that oversees the patient stakeholder advisory board. The board predominantly advises collaborations between clinical researchers and long-term care facilities, particularly on issues of informed consent, privacy, and research priorities. The advisory board is an effort to promote interprofessional communication that includes the patient in a shared-decision making model.

Researcher-Level Solutions

Researcher-level solutions include establishing a network of community SNFs and developing an infrastructure to facilitate a synergistic relationship between academic clinical researchers and SNFs. While clinical researchers have the skills to develop a study designed to answer clinical questions, they also need appropriate clinical settings and engaged providers to accomplish aligned goals for improved patient care.

At the University of Colorado, the Post-Acute Care Research and Team Science group was founded to troubleshoot issues related to conducting research in SNFs, home health care and long-term care settings. The group aims to create a practice-based research network to connect clinical researchers from a variety of disciplines with community-based post-acute and long-term care settings. The infrastructure of the group is still being developed with the desire to increase interest in post-acute care research across academic environments as well as industry to create a large, collaborative network of clinical researchers and post-acute care companies. The objectives include creating a formal framework to connect clinical researchers with post-acute care companies, identifying resources needed for a successful collaboration (e.g., time, funding, data sharing, patient protection), and navigating partnership priorities (e.g., data rights and usage, ownership of results, tangible outcomes). Access to networks of facilities and an infrastructure to collaborate between academia and clinical settings creates an opportunity for increased patient recruitment and wider availability of skilled clinicians who can potentially refine and implement research initiatives.

Additionally, academic-SNF solutions may foster rapid translation of research into practice as research occurs concurrently in the context of the real-world setting. Observations of, and feedback from, clinical staff involved in a study can inform how researchers apply their methods so that they will be acceptable, appropriate, and feasible in the SNF.

Innovation with academic-SNF partnerships: the final frontier

Academic-SNF collaborations are innovative in themselves as they create a different business model that promotes bi-directional integration of ideas and resources between SNFs and academia-based clinical researchers. Resources can include personnel time (capital) for data entry and analysis, providing training and ongoing problem-solving, and executing interventions or process flow changes. A synergistic and supportive collaboration means that SNFs and smaller academic institutions can engage in collaborations without the need for extensive external funding, which broadens the number of innovative initiatives that could be pursued in SNF rehabilitation. Integration of resources will involve developing infrastructures between SNFs and clinical researchers for data sharing and ownership; patient protections regarding privacy and consent; and creating an organizational culture that adopts and maintains a commitment to application of evidence-based clinical practices to improve patient outcomes. Successful collaborations between clinical researchers and SNFs has the potential to evoke innovative approaches to delivering quality care at low cost, across rehabilitation and interprofessional practices.

Technological advances including the ability to teleconference and increased access to distance-based learning platforms will allow these collaborations to grow outside of single geographical locations to create and connect networks of SNFs and clinical researchers across the country. Overall, collaborations may incite faster adoption and dissemination of evidence-based practice compared to a traditional, randomized-controlled trial, which typically excludes medically-complex populations often seen in the SNF setting.¹¹⁴ Collaborations can create a synergistic relationship where SNFs provide the patients and data, while clinical researchers provide the systematic rigor needed to evaluate and modify the effectiveness of innovative approaches to care.

Conclusion

The steady state of poor outcomes in SNFs may be perpetuated by the lack of rehabilitation innovation in this unique post-acute care setting. Thus, a significant gap in knowledge exists between the effectiveness of current SNF rehabilitation practices and subsequent efforts to advance clinical practice through innovative models of care. Current barriers to rehabilitation innovation in SNFs include engagement at the management, staff, patient, and researcher levels. To advance rehabilitation practices in SNFs, this clinical commentary summarized evidence from similar health care settings to provide a framework to address solutions to modifiable barriers to innovation through academic-SNF collaborations. Innovation in the SNF through academic collaborations has the strong potential to improve patient outcomes and assert the value of rehabilitation in post-acute care reform. Further qualitative and quantitative research is needed to assess the implementation and adoption of innovative models of rehabilitation in the SNF.