Creating improved medical management in community Skilled Nursing Facilities

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Creating improved medical management in community Skilled Nursing Facilities

< 1 minute read

Scott & White Memorial Hospital & Medical Center improved medical management in SNFs to reduce hospital readmissions.

The Issue

Readmission is the primary metric now used to determine the effectiveness of a medical center’s discharge planning and transition model, along with being part of Value-Based Purchasing in Medicare. As we noted in our reports, our highest level of readmissions was coming from patients who were sent to community Skilled Nursing Facilities (SNF) – 24 percent. We determined that was an area we wanted to examine and try to improve our numbers.


Location- Temple, Texas.

Type- Academic and regional referral hospital.

Number of Beds- 626 beds.

Setting- Rural.

Payer Mix- The system has its own health plan, Scott and White Health Plan, which has a commercial, Medicaid, Medicare supplement and a large self-funded model for all employees and dependents. As a result, Scott and White Health Plan is the largest non-government payer by a wide margin (15 percent) with other commercial plans having 1 to 2 percent each of the payer mix, equaling a total of 26 percent. Medicare is the largest payer (42 percent) and Medicaid (managed in Texas at 9 percent) is also significant with 7 percent self-pay or uninsured. Health exchange plans are only 1 percent. It is also important to note that there are no Medicare Advantage Plans in this region of Central Texas.

Population Served- Elderly, independent and rural patients who are referred to the hospital from multiple areas in Central Texas that are often 80 or more miles away.

One important aspect of the health care system particular to Temple is that all physicians who practice at the hospital and in the clinics in the region are employed by Baylor Scott and White. There are no private physician practices that come to the hospital. The model utilized for transitional care is the triad model of care management. There is a utilization review nurse, a RN care manager and a social worker assigned to a geographic area within the hospital.

What We Tried

Our first step was to make sure we had good metrics (i.e., metrics based upon Medicare claim data that is not subject to manipulation by individual hospitals) to see if we could measure improvement. Readmissions can be tracked when they come back to our hospital, but what if they go to another hospital? We worked with our local QIO (Quality Improvement Organization), which is the Texas Medical Foundation (TMF). TMF created a partnership with us to regularly share metrics and hold meetings. We then decided that one of our strengths was our employed physician model but we were not utilizing it in our community SNFs. Our hospital’s Department of Geriatrics (which is primarily physicians trained in Gerontology along with some nurse practitioners) are now becoming the medical directors of the community SNFs and we are bringing our physician support to the SNFs as well. This allows the SNF to gain access to the hospital’s electronic medical record, begin jointly working on protocols that extend from acute to skilled, better communication with specialists involved in the care and can share treatment modalities across the various settings. Our main intervention became the maximization of our employed physician model in local SNFs which we arrived at due to the partnership of the hospital, QIO and local SNFs.


Within the first 6 months of making the changes in the medical management in the local SNFs, we noted a 3 percent reduction in readmission rates for the local SNFs, which is now at 21 percent. Our own internal SNF, which is also staffed by Baylor Scott and White Health physicians, is at 14 percent, even given a higher acuity of the patient population. TMF has expanded the model now to the Waco region and is planning on additional areas. Baylor Scott and White physicians are now being directly contacted by SNFs in other areas of Texas trying to replicate the numbers. For the first time in several years, SNF transfers no longer are the number one disposition location leading to readmissions.


In many hospital and health care systems, the way problems are resolved is assembling some smart people in the organization together and work on the issue. The people often left out are members of the community where the patient actually lives. The partnership with the local QIO along with local SNFs created the new model, which is showing promise. We learned to include the community (SNF, QIO, physicians) when trying to solve problems that are in the community.

Organizational Background

Organization Name: Baylor Scott and White Health

Location: 3500 Gaston Avenue, Dallas, TX, United States

Organization Type: Hospital