The Secret to Setting Up Shop in the SNF-at-Home Space

For years, diversion between home health providers and skilled nursing facilities (SNFs) has been a big part of the industry narrative.

On their end, home health providers have reworked their operations to handle more acute patients and individuals traditionally served in SNFs. Now, home-based care providers are being even more intentional in their efforts by leaning into the SNF-at-home model.

While the idea of SNF-at-home has been gaining plenty of buzz as of late, the concept isn’t a new one, according to Leslie Palmer, administrator and clinical director at Josephine at Home.


“[In-home care providers] have known that keeping people at home typically results in better clinical outcomes,” Palmer told Home Health Care News. “It’s less expensive. And it keeps people out of the hospital. I think what’s different now is we have the opportunity to enhance that concept. Now, we’ve named it ‘SNF-at-home,’ and we’ve formalized operational aspects.”

Josephine at Home is a branch of Stanwood, Washington-based Josephine Caring Community, a cross-continuum organization that offers transitional rehabilitation, assisted living and other long-term care services, plus early learning and child care.

The nonprofit organization’s Josephine at Home business line currently offers home care services, though it’s in the process of expanding into home health care.


Additionally, Josephine at Home has upcoming plans to roll out an SNF-at-home services line.

Currently, roughly 25% of short-stay SNF episodes can be cared for in the home setting, creating an opportunity for in-home providers, according to statistics from Lincoln Healthcare Leadership.

Complex wound care and intensive therapy patients are examples of cases that can be treated within the SNF-at-home model, according to Jenn Ofelt, COO of UnityPoint at Home.

“Both of those are examples of patients that may have traditionally gone to an SNF because of an IV antibiotic or the need for daily therapy,” Ofelt told HHCN. “Both of those can easily be provided in the home if the additional layer of support that was needed by a 24-hour setting can be provided by a caregiver.”

UnityPoint at Home, a division of West Des Moines, Iowa-based health system UnityPoint, is a company that offers a range of home-based care services.

Similar to Josephine at Home, UnityPoint at Home is in the process of developing a SNF-at-home service line — and those two aren’t alone. LHC Group Inc. (Nasdaq: LHCG) and Johns Hopkins Home Care Group reportedly have SNF-at-home models in the works as well.

The fact that more and more in-home care providers are developing SNF-at-home service lines should come as no surprise. In general, more seniors and their families are looking for higher acuity care in the home setting, according to Dr. Cleamon Moorer Jr., president and CEO of American Advantage Home Care Inc.

“Families are looking for assistance with going through the logistics of, ‘How do I get a ramp installed? How do I go about getting a ventilator from a [durable medical equipment] company?’” Moorer told HHCN. “We’re finding that whole ecosystem of … [creating] a high-acuity nursing experience in a loved one’s home seems to be a gap that we’re able to step in and start filling.”

Dearborn, Michigan-based American Advantage Home Care Inc. is a provider of home health care, medical social work and other services.

The first steps

For home health providers looking to get a new SNF-at-home product line up and running, having a strong basis in home care — either organically or through partnerships — will be crucial.

“If you’re an expert in home health but not home care, then maybe look at partnering with an existing home care agency,” Palmer said. “It’s the same thing with home care — either look into forming a partnership with a home health provider or having someone who’s an expert help launch your own home health service lines.”

Having a home care component is especially important because in order to implement a successful SNF-at-home program, providers will need to replicate the 24-hour care component of traditional facilities.

Other potential partnerships aspiring SNF-at-home operators should strive for are ones with home medical equipment providers and infusion pharmacies.

“A SNF-at-home patient likely needs to be admitted the same day they leave the hospital,” Ofelt said. “Some of the elements of their plan of care include home medical equipment, such as assisted devices, a hospital bed, oxygen and IV infusion therapy needs. That infusion therapy pump and drugs all need to be delivered the same day. Having these partnerships in place will allow you to meet the clinical needs, immediately upon discharge from the hospital.”

On the staffing side, having a strong team of physical therapists, occupational therapists and speech-language pathologists is also key.

“You need to be able to staff these positions at a SNF-type level,” Ofelt said. “Prior to last October, patients went to SNFs and needed to receive a very high level of therapy to qualify for that day and for those SNFs to bill at their highest therapy rate. That needs to translate into the home. You need to be able to provide that level of therapy service.”

Providers that are looking to thrive within this space need to make sure that, on the clinical side, nursing competency is functioning at an acute level, according to Palmer.

One potential barrier for providers looking to implement this service line is that SNF-at-home doesn’t have a clear reimbursement model.

“Of course home health is reimbursed, and there’s chatter that Congress is talking about reimbursing some home care, but not the SNF-at-home program,” Palmer said. “As leaders in health care, we’re just going to proceed forward regardless of what the reimbursement looks like. We can maybe patch some of the reimbursement together.”

Broadly, SNF-at-home will need a reimbursement model that addresses the combination of care patients need.

“Traditional home health care payment will not be sufficient given these individuals will require a mix of both skilled home health care services and also home care assistance with activities of daily living,” David Grabowski, a professor in the department of health care policy at Harvard Medical School, told HHCN in an email. “The model will have to recognize these enhanced service needs.”

Looking ahead, Grabowski believes that the unified site-neutral payment model that the Medicare Payment Advisory Commission (MedPAC) has been working on might be the right catalyst for the SNF-at-home model.

“Rather than focusing on payment by setting, the unified payment model focuses on payment by condition,” he said. “For example, an individual recovering from a hospitalization for a stroke would be associated with the same reimbursement regardless of where they were discharged. Site-neutral payment would allow the care of patients in the home who previously would have been discharged to a SNF.”

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