“Never NO” Has Unintended Consequences For Skilled Rehabilitation

          Skilled Nursing Facility (SNF) administrators are faced with some serious challenges when establishing policies for their admissions teams.
          The drive to increase revenue by accepting any and all admission referrals in order to maintain census, can lead to short-term goals with serious long range consequences.  Adopting a “never say no” policy regarding referrals to the SNF may make hospital discharge planners happy, but inappropriate admissions often leads to potential disaster.
          The facility must be able to meet the needs of the patient and the patient. The family must accept the capabilities and resources the facility can provide. When there is a mismatch between these, prepare for rough times ahead.
          For example, a 60-year-old patient is referred to the SNF status post fall and subsequent open reduction internal fixation (ORIF) of the femur. She is alert and oriented to person, place and time. Most SNFs can manage such a patient with little difficulty. However, a closer look at the referral indicates that the patient has a recent history of heroin abuse. Hospital social worker notes further indicate that family members have demanded the patient receive increasing doses of narcotics claiming that the patient is being denied the right to be free of pain. Nursing notes repeatedly refer to patient as non-compliant with safety instructions. Physician’s notes indicate a referral to psychiatry for a longstanding history of depression with multiple suicide attempts.
          While every individual should be able to receive the care necessary for optimum quality of life, this patient is a ticking time bomb that places a SNF at very high risk:

• Suicide risk requires additional supervision up to and including one-on-one observation to prevent further attempts. Providing such staffing is a challenge as well as an additional cost to the facility;
• Non-compliance with safety instructions may lead to falls with significant injury. The patient or family may seek litigation, and the facility quality outcomes will be adversely affected, impacting star ratings;
• Family members with unrealistic expectations require massive amounts of staff attention, and if not satisfied, will speak poorly of the facility. They may also file complaints with the department of health leading to an unannounced visit from state survey agencies. This further strains resources, and places the organization at risk for citation (most immediate jeopardy citations occur at a complaint survey);
• Managing drug addiction in the presence of pain is very tricky. It is not uncommon for these patients to have friends and family members provide the patient additional narcotics without informing staff. The consequences of overdose are high, leading again to litigation and possible state or federal scrutiny.

A policy of “never say no” has additional unintended consequences.

• Referral sources may view the SNF as a potential “dumping ground” for their hard to place patients, resulting in the SNF receiving primarily the most challenging referrals. A vicious cycle develops of high risk, complaints, potential citations and decreased ratings;
• Additional stress is placed on staff resources (both cost and time);
• The patient may frequently refuse physical therapy affecting patient outcomes as well as utilization driven reimbursement;
• Attention is taken away from other patients leading to complaints of unfair treatment;
• Decreased morale of staff leading to call-offs and increased turnover;

          As admissions teams are celebrating and being rewarded for high census numbers, clinical staff and leaders are pushed beyond capacity. As patient satisfaction plummets along with morale, staff turnover increases. Administrators look to clinical and human resource leadership for answers, only to find frustration and burnout. The leaders themselves may not even realize the root cause of the problem.
          The medical complexity of the average SNF patient has, and will continue to increase, placing significant demand on clinicians. Adding to the challenge by taking a “never say no” admissions policy is flirting with disaster.
          Administrators, admissions teams and clinical leaders must come to an agreement as to the care they can provide and the risks they are willing to share.