Nursing Homes Must Expect 3-Day Rule, Other CMS Requirements Will Return – Skilled Nursing News

Skilled nursing facilities have benefited from some Centers for Medicare & Medicaid Services (CMS) rule changes that came into effect over the pandemic — but providers should expect these waivers to be removed.

While provisions related to telehealth might be lasting, Harvard Medical School Healthcare Policy Professor Dr. David Grabowski does not expect some of these rule changes to be in effect forever for the post-acute care industry.

“CMS did introduce a number of waivers within the different post-acute care sectors all of which were geared towards allowing greater discharge of Medicare patients from the hospital to the different post-acute care settings,” he said during a webinar last week sponsored by the Blue Cross Blue Shield of Alabama Endowed Chair in Health Economics and Lister Hill Center for Health Policy.  

Some of those rules included the three-day stay rule, which stipulates that a patient must have a three-day inpatient hospital stay for Medicare to cover the subsequent stay in a skilled nursing facility.

At the time, then administrator of the CMS, Seema Verma, described the waivers as a way to allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities.

The three-day hospital stay requirement will likely return, and the waiver was prominently used in the markets that were hit worst by COVID-19, Fred Bentley, managing director of Avalere, told Skilled Nursing News.

Grabowski agreed.

“All of these rules are about greasing the skids and getting individuals out of the hospital to different post-acute care settings,” Grabowski said. “I’ll say right now, I don’t think any of these types of rules are going to be permanent.”

The original rules were established to guard against overuse and “wasteful care,” he said and making sure individuals coming from the hospital to these different post-acute care settings were appropriate.

“All of these rules are in place for a reason … I think all these rules are coming back post-pandemic,” Grabowski added.

That should help bring some patients back to SNFs, as the temporary rules allowed for some additional discharges to inpatient rehabilitation facilities (IRFs) and long-term acute care hospitals (LTACs). But bringing back the three-day stay rule would slow SNF admissions.

On the other hand, Grabowski felt that the improvements made to telehealth may be here to stay, though he admitted there were limits to the service.

“How do we encourage the right kinds of telehealth services and discourage the wrong kinds,” he said. “The right kinds are those higher-value services that are benefitting older adults, potentially substituting for in-person care.”

Improving nursing homes for the long run

No matter if, or when, CMS decides to rescind some of these waivers, Grabowski thinks it’s time for nursing homes to learn from the past year and adjust accordingly.

Earlier during the pandemic, he described working in a nursing home as the most dangerous job in America.

“The traditional, really institutional models of nursing homes … I don’t think any of us wants to be cared for or have a family member cared for there,” he said.

Out of nearly 500 SNFs surveyed by the American Health Care Association and National Center for Assisted Living, 72% did not expect to last another year at the current pace, according to a recently released report from Plante Moran.

“Far too many of these buildings are very institutional, they look like hospitals, they don’t look like somebody’s home, they rarely have doctors in the building,” Grabowski explained. “We know nursing homes need a lot of work … A lot of the problems during the pandemic are going to persist.”

He suggested that better staffing and making nursing homes feel more like a home and less like an institution were both musts moving forward. He pointed to what other countries are doing, such as a Japanese model that integrates nursing homes into the community, as possible blueprints.

“I think the smaller home models, investment in staff and then integration of nursing into the communities is key,” he said.