Why Not Home? Identifying Areas of Opportunity for Reducing Skilled Nursing Facility Utilization

Skilled nursing facilities (SNFs) are vital to a patient’s post-acute care journey; but for some, getting care in the home may be more desirable and may result in better outcomes. In 2018, Massachusetts had the 6th highest SNF stays per 1000 Medicare enrollees nationally. A Medicare Accountable Care Organization (ACO) patient admitted to a SNF is followed by a Transitional Care Manager (TCM), who tracks the patient’s stay from admission to discharge and reports this information in a post-acute care tracking (PACT) tool.