What the End of the PHE Means for ACOs and the SNF 3-Day Waiver

The post-COVID-19 healthcare landscape is continually shifting, and the end of the Public Health Emergency (PHE) on May 11, 2023 is a prime example of this. Many provisions of the PHE granted exceptions to standard operating procedures in order for providers to deliver quick and lifesaving care. With the end of the PHE, those flexibilities will transition back to pre-pandemic status. For organizations like skilled nursing facilities (SNFs) and accountable care organization (ACOs), the end of the PHE means ACOs that are taking advantage of the leniency around the SNF 3-day waiver rules will be impacted.

During the PHE, Centers for Medicare and Medicaid Services (CMS) waived the need for ACOs to meet certain criteria to utilize the 3-day waiver, but now those requirements will go back in place. Faced with these rule changes, organizations that wish to avoid challenges with timely transfer of patients to SNFs must make process adjustments to apply and qualify for the waiver. Accurate and timely identification of patients who are eligible for appropriate SNF transfer can be supported by the right technology solutions, improving patient care transfers and saving costs.

What is the 3-day waiver?

Under traditional coverage rules, Medicare will cover a SNF stay only if the patient has a qualifying inpatient stay of at least three consecutive days. The SNF 3-day waiver “waives” this requirement—allowing patients to be directly admitted to a SNF from a one or two-day inpatient stay, observation stay, emergency department (ED), physician office, or home.

Only ACOs participating in downside financial risk tracks are eligible to apply for the waiver. These ACOs must submit a CMS application that includes detailed descriptions of how they will operationalize the waiver, as well as a list of SNF affiliates and agreements with each facility. Eligible SNFs must have an overall CMS quality rating of three stars or higher.
During the PHE, ACOs were not required to apply for or meet these criteria to allow beneficiaries to move out of overcrowded hospital beds into the SNF without waiting for the standard inpatient admission period to end. This represented cost savings for ACOs, improved transitions of care for patients, and eliminated the need for identifying eligible beneficiaries.

Impact of the end of the PHE on the 3-day waiver

Now that the PHE is ending, many ACOs cannot directly admit patients to SNFs without first having insight into whether they have met the criteria for admission. If an ACO wishes to apply for the 3-day waiver benefit in order to continue using it outside of the PHE, they are required to certify that they have a process in place for identifying eligible patients.

These are some of the criteria that would need to be identified by the ACO:

• SNF services can only be provided to patients that have been previously identified as having a relationship with the ACO according to specific criteria within a set period
• The patient cannot already live in a SNF or long-term care setting
• The patient must be medically stable
• Diagnosis of the patient’s condition must be confirmed
• The patient cannot require new or ongoing inpatient hospital care
• Within three days prior to the admission, the patient must be evaluated and approved for SNF admission by an ACO-affiliated physician

Ensuring your organization is equipped to operationalize  these requirements can be challenging without leveraging appropriate technology. With the end of the PHE here, these organizations now have an urgent need to be able to identify whether patients meet criteria for the waiver or have met the 3-day inpatient requirement for SNF admission.

How technology can support identification of patient criteria and qualifying SNFs

A robust technology solution can help ACOs identify patients and SNF partners eligible for the SNF 3-day waiver in order to avoid penalties beyond the end of the public health emergency in 2023. When an ACO is looking for the best solution, there are some key features that can especially support the challenge of clearly defining eligible patient populations.

Value-based care (VBC) solutions

ACOs need technology solutions that drive value-based care, and solutions built to support VBC also include insights that can help an ACO rapidly identify patients during transitions of care. An ideal suite of VBC solutions includes features like:

• Real-time encounter alerts that allow you to track your patients as they move across the continuum
• Data and insights that support care coordination leading to improved transitions of care
• Risk-stratification to ensure care teams can identify and prioritize their high-risk patient populations

All these data points can help an ACO identify if patients are stable, have a confirmed diagnosis, require new or ongoing inpatient treatment, and other key information needed to track eligibility for the 3-day waiver provision. Combining this data into a single identifying use-case flag that pinpoints patients who are eligible for SNF admission enhances insights even further.

Solutions that provide real-time visibility into your post-acute network

Another key focus of ACOs looking to utilize the SNF 3-day waiver is having the data they need to identify high-performing skilled-nursing facility partners that qualify. As a part of the waiver, SNFs must be rated 3-stars or above under the Medicare star-ratings.

If ACO’s are looking for this data as well as having a way to track performance in real-time, they need a technology solution that supports:

• Real-time visibility into key performance metrics
• Real-time insight into SNF partner quality metrics and Medicare star ratings
• Real-time visibility into active SNF stays in order to prevent avoidable readmissions and collaborate with SNF partners to improve performance

Adaptability along with the changing healthcare landscape

Combined, these technology solutions give ACOs the real-time data that they need to implement a strategy to successful utilize the SNF 3-day waiver with the goal of improving patient outcomes while also reducing the overall cost of care.