by James C. Sherlock

Sentara Healthcare in October announced an important initiative to improve the quality and availability of primary care. It will double number of advanced practice providers (APPs) in its primary care facilities.  

APP refers to nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, or certified nurse midwives.

In order to shift administrative duties away from physicians and APPs, the teams will also include medical assistants, clinical pharmacists, and others. Hopefully the others include dietitians.

It is a great idea.

I have a suggestion that can leverage that investment in a way that offers to both:

• benefit patients, hospitals and skilled nursing facilities; and
• save a great deal of patient, payer and facility time and money.

Hospital-to-nursing facility transitions are a deadly mess.

A 2017 study found:

• One in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF);
• 23% of these patients are readmitted to the hospital within 30 days.
• The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers.

One of the problems is that patient assessments are by federal law and regulation performed twice, once at the hospital attendant to discharge and a second time at the SNF within five days of admission.  

Another is lack of qualified multi-disciplinary staff at the hospitals and especially the SNFs.

Nursing facilities report both payroll-based daily staffing and patient admissions to the Centers for Medicare and Medicaid Services (CMS) quarterly. My reviews of those reports show that many of Virginia’s disproportionately and chronically understaffed SNFs do not report enough of the right skilled practitioners on their payrolls to be conducting those patient assessments within the timeframe and with the personnel required. More about that in a future series.

With Sentara’s new provider mix in its primary care facilities, it will be in a position in Norfolk and Virginia Beach (it owns all of the hospitals there) to pioneer a nationwide solution to the patient transfer problem. Sentara can:

• provide patient assessment services to both hospitals and nursing facilities;
• conduct them with the right mix of skills; and
• do each assessment once not twice.

I counted the net admissions on the days in which the patient population increased in Norfolk and Virginia Beach nursing facilities in Q2 of 2024. In that specific subset of days, there were almost 1,100 net admissions. Since there is no way with the data available to count total admissions (days with both admissions and discharges mask those admissions), that will have to suffice.

The point is that, say, 90% of those patients were admitted into SNF beds of the facilities since the NF beds by definition are long-term stays. So, as a working estimate, there were significantly more than 1,000 hospital discharges and 1,000 SNF admissions in three months in Norfolk and Virginia Beach alone.

If Sentara were to initiate a program to participate with its hospitals and primary care practices, the government agency funding the test would have to:

• work with Sentara to identify participating SNFs,
• hire a contractor to act with participation of the principals to design, size and conduct the test; and  
• pay the participants for their work.

Sentara, if agreeing to participate, will wish to limit the SNF participation in order to limit participation of its new primary care teams in the project, but it could truly break important new ground for the nation’s sickest patients and their healthcare providers.

CMS, which rarely is offered opportunities to improve care while saving money, should pay for the trial without hesitation. The solution offered for testing will not be replicable everywhere, but in metro areas it holds great promise. CMS funds a lot of things without nearly the potential payoff of this idea.

Virginia Medicaid has a stake in the success of both Sentara’s current initiative and this potential new one. Commercial insurers, including Sentara’s own Optima, should be happy to participate in a test.  

I hope Sentara, VDH, Virginia Medicaid, VHCA (the nursing home lobbyist) and private insurers will join to pursue such a test with a joint proposal to CMS.  

Regardless, I offer my congratulations to Sentara for the primary care expansion initiative.