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During the height of the COVID-19 pandemic, several new at-home care models were thrust into the spotlight.
One of the models — skilled nursing facility care at home, or SNF-at-home — gained a lot of attention as traditional SNFs struggled.
Enthusiasm for that model has since waned, especially in comparison to others, like hospital at home.
“When we did the National Healthcare at Home Best Practices study in 2021, we had 63% of agencies say they were looking at getting into SNF-at-home in the next 24 months,” Lindsey Doak, BerryDunn’s national study leader, told Home Health Care News. “That was the highest ranking — ahead of hospital at home and palliative care.”
BerryDunn is an accounting and consulting firm that publishes an annual study examining trends in multiple industries, including home health care.
When Doak went to check back in with a number of the providers who said they were interested and planned to implement SNF-at-home, she heard some surprising feedback.
“We’re seeing the much more progressive home health organizations – that are in these Medicare Advantage, risk-sharing agreements – are the ones really getting into these models because this is the way to reduce the total cost of care,” Doak said. “But there’s probably 90% of agencies that aren’t anywhere near being in that spot.”
The SNF-at-home journey
In the early days of the pandemic, occupancy rates at brick-and-mortar senior facilities plummeted. It’s taken a few years for those numbers to rebound.
“Pre-pandemic, our occupancy rates in our senior living facilities were in the high [80% range],” PruittHealth CEO Neil Pruitt told HHCN. “That dipped down to around 67%. Since then, our skilled nursing facilities have recovered and our home health admissions have remained strong.”
The Norcross, Georgia-based PruittHealth is a skilled nursing and senior living provider. It also offers home health and hospice, and it has its own care management plan. The company operates over 180 locations in Florida, Georgia, North Carolina and South Carolina.
As a response to pandemic-related challenges, PruittHealth decided to aggressively lean into its “PruittHealth at Home” business.
Three years later, the company is still bullish about the SNF-at-home model.
“I still see a big future for the SNF-at-home program,” Pruitt said. “We’re moving aggressively to be able to take on risk, specifically in our Medicare Advantage program that serves dual-eligibles. So we’ll have a financial incentive to keep those patients in their home.”
In order to make SNF-at-home care viable, PruittHealth has invested significantly in its clinical capabilities.
“There are certain patient populations that absolutely can be served at home, so we’ve increased the clinical competencies of our staff to be able to handle those patients,” Pruitt said. “Our investments in our meds-to-home program is a key part of that because maintaining a proper medication regimen is vital to maintaining a patient’s health status. When someone is in the aging process, it gets very difficult for them to manage. If they miss taking medication for high blood pressure, hypertension or anything else, they’re going to go back to the hospital.”
For a provider to win at SNF-at-home, all of these worst-case scenarios need to be avoided.
In addition, that provider has to be willing to take on risk.
“Once [patients and family members] choose PruittHealth, we want them to be sticky customers and stay with us through all of our service lines,” Pruitt said. “I think you’re going to see a more holistic approach to this kind of care compound and accelerate. I think the providers that are willing to take risks – like we are – are going to be the ones that really thrive in this economy.”
The challenges to SNF-at-home
Operating a SNF-at-home program, particularly for providers not involved in the SNF business, is a tall task.
“Other organizations that had said that they wanted to get into this did back down because they did see that SNF was rebounding and they just couldn’t get there,” Doak said. “Between finding the staff for these programs, caregiver fatigue and payment — there are a number of things creating barriers.”
Staffing is the biggest hurdle. Home health agencies are having enough trouble filling home health cases as is.
Payment is another barrier. SNF-at-home models are not covered by Medicare fee-for-service.
“That did not change during the pandemic,” Fred Bentley, managing director at ATI Advisory, told HHCN. “I think it’s interesting that for all the flexibilities that were introduced — and appropriately so — during the pandemic, CMS did not start paying for SNF-at-home services through the Medicare fee-for-service program.”
The Washington, D.C.-based ATI Advisory is a health care research and advisory services firm.
When you take out Medicare fee-for-service, the payment avenue for SNF-at-home becomes Medicare Advantage plans, thus limiting the growth.
Remaining optimism
There are still plenty of executives who see SNF-at-home as one of the models that will prevail.
“I think that there’s really terrific growth ahead,” Rick Matros, CEO of Sabra Health Care REIT (Nasdaq: SBRA), told HHCN. “With the caveats being, ‘Are you going to have enough staffing to accommodate the growth that is inherently there?’ And then secondly, ‘Are you self-regulating enough that you’re not either taking people that you shouldn’t taking care of them for longer than you should?’”
Irvine, California-based Sabra is a real estate investment trust and one of the largest owners of skilled nursing facilities in the United States.
From his perspective, Matros believes the future health of SNF-at-home programs is tied to acuity.
“Generally, it’s cost prohibitive in most places to build skilled nursing,” Matros said. “So, I think it’s incumbent upon us from a societal perspective to have other options available. My primary concern is staying at home too long. I think it’s all really a function of acuity — because taking on patients that you might not be able to handle exacerbates your staffing issues, too.”
Occupancy rates have mostly rebounded in Sabra’s facilities, but there is no denying the demand for home-based care.
A recent study, for instance, found that 55% of nursing homes are turning away patients and 48% have waitlists of at least a few days.
Executives believe there’s room for models like SNF-at-home, which combine the capabilities of home health, skilled nursing and end-of-life care providers.
But for now, for most providers – especially in home health care – SNF-at-home only represents an opportunity.
“I don’t see strong growth right now,” Doak said. “I see people experimenting more with this model. It’s mostly the larger organizations – that can share their overhead – that can get into these risk-sharing contracts. There’s research that shows it will reduce the cost of care, but then when you bring in all of the other factors that balance that out, is that scaleable?”
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