A Proven Program for Managing 3-Day Rule Waiver Patients

This is the first in a two-part series on 3-day waivers. Stay tuned for the next post on how to manage data to make improvements to your program over time.

Under traditional Medicare fee-for-service, a patient must spend at least three days as an inpatient at a hospital to qualify for coverage at a skilled nursing facility (SNF). But some of the newer models of ACOs (NextGen, Medicare Shared Savings Program) give health systems flexibility around this rule, allowing ACO patients to be admitted to a SNF after a shorter hospital stay or even directly from the community. Participating in the 3-day rule waiver program can help health systems decrease hospital length of stay, and by extension, reduce the cost of care for the ACO population. However, any initiative that decreases length of stay also increases the risk of premature discharge—as well as the risk of rehospitalization and other downstream costs. Below are the core components of a program that has been proven to mitigate these risks and to help health systems effectively manage their 3-day rule waiver patient population.

Step 1: Develop pathways to SNF

A 3-day rule waiver patient can get to a SNF through three possible pathways:

  • an observation stay or hospitalization of less than 3 days
  • the emergency department (ED)
  • the community

For each of these pathways, staff will need to be able to identify which patients are part of the ACO, know the criteria for applying the waiver, have access to information on which SNFs can accept 3-day rule waiver patients, and be familiar with how to create and send a SNF referral. These steps should be a bit easier at the hospital, where staff are already familiar with the process of referring patients to SNF.

The community pathway, in which a SNF referral is made by a primary care provider, is slightly more complicated, as staff may not have referred patients to a SNF before. The pathway requires additional staff training and workflow considerations to be successful.

Step 2: Select the right SNFs for your preferred network

A successful 3-day rule waiver program also requires close collaboration with SNFs, which function as the health system’s partner in reducing risk under the program. Health systems that we work with use the following questions to assess SNFs:

  • What is the SNF’s rehospitalization rate? Choose facilities that already have a low rate to mitigate risk of an increase in rehospitalizations.
  • How many of your hospital’s referrals does the SNF receive now? To improve the likelihood that the selected SNF will actually be sent 3-day rule waiver patients, choose facilities where a lot of your patients go already.
  • What is the SNF’s CMS star rating? The star rating takes into consideration a variety of different measures related to the quality of care provided at the SNF, including the percent of patients that are successfully discharged from the SNF to the community.

Once the preferred network is established, clearly communicate which SNFs are included in the program to the appropriate staff in each pathway making SNF referrals.

Step 3: Build a robust transitional care management program

With value-based care models placing greater emphasis on coordinated care across the continuum, health systems have begun allocating more dedicated resources to care management infrastructure, including designating transitional care managers (TCMs) to work with SNFs during their patients’ stays at these facilities. Along with the previous steps, TCMs can contribute to the success of a 3-day rule waiver program by providing these additional checks:

  • Ensuring successful SNF discharge: The TCM is made aware of all SNF discharges, is informed of all medications and appointments, and is equipped to reinforce the discharge education that was presented at the SNF to the patient. The TCM follows up with the patient after discharge.
  • Monitoring SNF length of stay: The TCM functions as an extra set of eyes on SNF length of stay, making sure patients are staying for an appropriate amount of time. CarePort provides risk-adjusted SNF length of stay benchmarks to provide guidance to TCMs.
  • Prevent unnecessary rehospitalizations. The TCM can intervene in the ED and potentially prevent a hospitalization by coordinating with a SNF to provide care once the patient is stabilized. Health systems working with TCMs need to develop a system to notify them when a 3-day rule waiver patient is in the ED.

Through careful planning and resource allocation, health systems can develop programs that effectively manage their 3-day rule waiver patients in a way that capitalizes on its intended benefits while mitigating the risk of downstream costs and improving patient satisfaction with care.

Learn how CarePort Insight can help strengthen your 3-day rule program by providing the tools and insight you need to build and manage your post-acute provider network.