In the U.S., Skilled Nursing Facilities (SNFs) provide care for patients who need medical, nursing, or rehabilitative services usually after a stay in an acute-care hospital. The cost of post-acute care is not insignificant—accounting for approximately $60B of Medicare spending.1

For patients with chronic diseases, such as chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD), high utilization drives high spend. In fact, beneficiaries with 6 or more chronic conditions account for nearly 70% of post-acute costs.2

During COVID-19, hospital utilization seemed to trend down, while SNF days rose— a result, in part, due to a relaxing of requirements by CMS. A report from the Kaiser Family Foundation found that although there were 200,000 fewer traditional Medicare beneficiaries who used SNF services in 2020 than in 2019, the length of stay was longer—26.3 days vs. 24.7 days, respectively.3

What drives the length of stay in SNFs?

SNF utilization is necessary and delivers significant value. Although Medicare beneficiaries can stay in a SNF for 100 days in a benefit period, many facilities are shortening their stays and discharging patients before 20 days. Here’s why.

Too often, length of stay in the SNF has less to do with individual care needs, and more to do with benefit design and reimbursement rules. A 2019 study found that beneficiaries were more often discharged on day 20 than on days 19 or 21.4

There are also consistent patterns when analyzing total SNF days. Patients tend to discharge on days 8, 15, and 21—which are all tied to a 7-day approval cycle driven by historical reimbursement mechanisms rather than what patients require.

With the appropriate clinical oversight and an individualized approach to authorizations and reimbursement, care teams can determine the length of stay that meet the patient’s needs and the transition home can happen sooner.

Focus on Transitions of Care

After a hospital stay, discharge to a SNF may not always be appropriate for every patient, especially for those with complex needs that require more intense levels of post-acute care services. Those with greater chronic illness are still more likely to be hospitalized 30 days after discharge if the right transition isn’t put in place, a 2020 study found.5

When care is effectively coordinated, and patients, physicians, and caregivers are engaged before hospital discharge, the right path of care for the patient can be determined from the start. This may or may not result in a SNF stay. With the right care coordinated at home, many patients can go home without a SNF stay at all.

In fact, research shows that 80% of Medicare Advantage members6 who are transitioned to a sub-acute facility could recover at home with the same or better outcomes.

The Path to Effective Post-Acute Care Management

Payors that effectively manage post-acute care can bend the cost curve and improve patient and caregiver lives. Here are some tips for health plans to keep in mind:

  • Evaluate whether your current clinical and reimbursement guidelines are driving increased SNF utilization and delaying patients’ transition
  • Understand what can and cannot be done at home, and how care transitions to the home are coordinated.
  • Work closely with discharge planners, SNFs, and home health resources, such as nurse practitioners and community health workers. Coordinating resources to support the patient in achieving independence as quickly as possible—at home—and avoiding unnecessary readmissions.

Post-Acute Care: The Shift to Home Health

As payors look to improve outcomes, reduce the total cost of care, and achieve their CMS Star goals, leveraging health at home is increasingly becoming an integral part of a post-acute care plan.

A survey by McKinsey shows that up to $265 billion worth of care services for Medicare fee-for-service and Medicare Advantage beneficiaries could shift from traditional facilities to the home by 2025 without affecting quality or access.7

To learn more about CareCentrix’s post-acute care, home health, and palliative care solutions, request a consultation.


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  1. Health Affairs, 2019
  2. CMS, 2011
  3. Kaiser Family Foundation, 2022
  4. Center for Medicare Advocacy, 2019
  5. Journal of the American Geriatrics Society, 2020
  6. CareCentrix HomeFirst Analytics Data, 2022
  7. McKinsey, 2022