SNF-to-Home Care Gaps Still Prevalent, Likely Magnified During COVID-19

Although awareness of care gaps in the health system has generally increased over the last decade, pain points still exist in a significant way. They also exist in areas where home-based care providers specifically can help.

Notably, gaps in care are especially prevalent when patients are being discharged from a skilled nursing facility (SNF) and going back into the home, a new report from the United Hospital Fund (UHF) found.

The report’s key findings included a lack of the following: inquiries into patient’s social needs, follow-up calls and further education on symptom management.

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“I think that the most important finding is that, despite the best efforts of SNFs in preparing patients for the transition to home, the care for this population can be very complex,” Joan Guzik, the director of quality improvement for UHF and an author of the report, told Home Health Care News. “And particularly in the area of medication management and addressing social needs, there are some really considerable gaps.”

Based in New York City, UHF is an independent nonprofit organization that analyzes public policy to inform decision makers of the best ways to innovate and improve the health care system.

The report’s findings came from surveyed patients and family caregivers during a two-year learning collaborative with eight SNFs. The report was supported by the Mother Cabrini Health Foundation.

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On the positive side, over 80% of patients reported that they received and understood instructions upon discharge; over 70% of patients and caregivers said they obtained the right equipment, medications and help; and over 75% of patients reported that home care services were delivered on time.

“I definitely think that things are getting better,” Guzik said. “As a matter of fact, some of these survey results were used to inform quality-improvement projects, specifically to improve coordination of care, discharge planning processes and follow-up. And there has been some improvement.”

But there is still a long way to go.

On the negative side, patients and caregivers – at least two-thirds of them – reported needing more help understanding medications and potential side effects. Additionally, they often weren’t often on the receiving end of follow-up calls after discharge.

“I was surprised that there were a lot of patients that reported they had not received any follow-up,” Guzik said. “Less than 60% of patients said that they had received a follow-up call.”

Half of patients also needed more help understanding signs and symptoms of their condition post-discharge, and frequently reported they were not asked about potential social needs, such as food, housing and transportation concerns.

They also frequently reported they were not referred to services that could help address those needs.

That is where home-based care providers come in, especially the ones that have become increasingly involved in activities of daily living (ADL) support over the last few years.

“Absolutely those providers could help, because those are the people interfacing with the patient once they are discharged home,” Guzik said. “I think one of the issues that came out of the survey was that it’s very difficult for the SNFs to impact processes that occur outside of their four walls. So to the extent that the home health providers are involved in addressing these gaps, I think that’s kind of critical.”

The next step, of course, is reaching those patients, and making sure those providers are able to make themselves available to them post-discharge from a SNF or hospital.

It’s also important to note that the report was conducted during the pandemic, which could have exacerbated the issues that were found. For instance, staffing woes could have affected outreach to patients, or the amount of time spent with them on the verge – or after – discharge.

“Providers need to be thinking about [care gaps] from a person-centered approach, and considering what the specific needs of the individual and their caregivers are,” Guzik said. “What is really important to them, what’s really going to make a difference to them, and where the greatest risk points are. Because ultimately, while we did not look at readmissions, that’s what we want to avoid when making these transitions to the home.”

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