How Johns Hopkins Created a Preferred SNF Network

Components of Johns Hopkins' SNF collaborative include a rigorous process for selecting partner facilities and establishing a management framework.

Johns Hopkins Medicine has established a skilled nursing facility collaborative to improve the quality and cost effectiveness of postacute care for its patients.

Transferring patients to skilled nursing facilities shortens length of stay in acute care settings but low quality of care at SNFs can lead to hospital readmissions. This dynamic is reflected in a 2013 Institute of Medicine report that found postacute care accounted for 73% of the variation in Medicare spending.

"One mechanism employed to improve transitions to SNFs and reduce associated readmissions is to create a preferred provider network. Increasing the concentration of hospital discharges to higher performing facilities is associated with lower rehospitalization rates, particularly during the critical days following discharge," Johns Hopkins staff members wrote recently for an article published in the Journal of Hospital Medicine.

There are three primary steps to establish a SNF collaborative, the article says.

1. Select appropriate SNF partners
 

The best SNF partners for health systems and hospitals are high-quality facilities and/or SNFs with historically high volume. In the latter case, the SNFs' name recognition with patients and providers can be capitalized and quality can be boosted through improvement initiatives if necessary.

There are several possible quality and clinical outcome criteria for picking preferred SNF partners:

• Centers for Medicare & Medicaid Services quality star ratings and Long-Term Care Minimum Data Set measures
   
• Rate of 30-day readmissions
   
• Satisfaction ratings from patients and family members
   
• Emergency department visits
   
• Primary care follow-up within seven days of hospital discharge to the SNF setting
   
• SNF impact on total cost of care

2. Craft the collaborative's framework
 

The Johns Hopkins Medicine Skilled Nursing Facility Collaborative features a management framework that established a system-level approach to SNF partnerships based on the shared goals of improving care and reducing costs.

The framework includes three primary elements:

• A steering committee that functions as the collaborative's governing body was drawn from all participating Johns Hopkins Medicine (JHM) players. When the collaborative was launched, the steering committed targeted three dozen SNF chains and freestanding facilities to participate in the initiative.
   
• A stakeholder group was formed with broader representation from JHM, including leaders with postacute care expertise such as rehabilitation and emergency medicine. The stakeholder group also included SNF partners and the local CMS-funded Quality Improvement Organization.
   
• Dedicated workgroups lead protocol-based initiatives, data management, and analytics. The initial protocol-based initiative for the collaborative was transitions of care, which featured all affiliated hospitals focusing on a harmonized approach to care transitions. Representatives on the workgroup included members of hospital leadership, Johns Hopkins HealthCare, Johns Hopkins Medicine Alliance for Patients, the JHM home care division, and members of SNF leadership.

3. Foster physician leadership
 

Enlisting physician leaders to help guide meaningful and broad change is an essential ingredient of an effective SNF collaborative, the Journal of Hospital Medicine article says.

"When devising system-wide solutions, incorporation and respect for local processes and needs are paramount for provider engagement and behavior change. This process will likely identify gaps in understanding the postacute care patient's experience and needs. It may also reveal practice variability and foster opportunities for provider education," the article says.

Investing resources
 

The lead author of the journal article told HealthLeaders that JHM invested considerable resources to build an effective SNF collaborative.

"The greatest upfront investment was likely the time and effort of individuals across our organization who crafted the vision for this collaborative in alignment with the institutional priority," said Sarah Johnson Conway, MD, medical director of the Johns Hopkins Infusion Center and an assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.

"The coordinating team had representation from population health, care management, hospital administration, health plan, and skilled nursing facility medical leadership. Once the framework was in place, initial investments went toward administrative infrastructure with project management, data and analytics, and medical oversight."