88% of Critical Access Hospitals (CAHs) as of July 2018 provided swing bed services. The Medicare Benefit Policy Manual has many examples of the types of patients that qualify for swing bed and the care provided, including but not limited to nutrition management, medication management, IV therapy and wound care. These patients are often able to receive services in a location closer to home with easier access to their non-clinical support network.
In HealthTechS3’s recently hosted webinar dated February 8th on Strategies for Growing Your Swing Bed Program with Carolyn St. Charles, RN, BSN, MBA and Jennifer LeMieux, CRCR, MBA, we discussed such topics as regulatory changes, swing bed qualifying criteria and marketing efforts that when understood well will help to improve a CAH’s swing bed program. We wanted to reiterate this information in advance of another swing bed webinar dated May 3rd on Implementing Trauma-Informed Care.
In October 2018 there were revisions to the State Operations Manual in Appendices A and W. Most interpretive guidelines are still contained within Appendix PP for Long-Term Care. New regulatory language addressed:
- Timelines for reporting abuse
- Providing culturally-competent and trauma-informed care (see above webinar for May 3rd)
- Reconciliation of pre-discharge medications with post-discharge medications
- Information at discharge and ombudsman notification
In order to bill for swing bed services, there are several criteria that must be met for Medicare. Our focus is on Medicare because the majority of patients are in this population; Medicaid, Medicare Advantage, etc. may have slightly different criteria. Conditions include:
- Patient has Medicare Part A with benefit days available
- Medicare age and disability/disease eligibility requirements met
- MUST have 3-day qualifying stay; observation does not count
- Admission criteria is same as qualifying stay condition
- Patient is admitted to swing bed within 30 days of discharge from acute care
- Patient’s condition meets criteria to necessitate inpatient skilled nursing services
As it relates to the last point above, teaching a patient how to manage their treatment requires skilled nursing staff and is included in swing bed services. Such activities can include teaching or training on:
- Self-administration of injectable medications
- Gait training and prosthesis care
- Post-op care from colostomy or ileostomy
- Care and maintenance for central venous lines, such as Hickman catheters.
According to the Medicare Manual, a patient must need these services on a “daily” basis, i.e., essentially 7 days a week but not less than 5.
With a limited number of swing bed patients, CAHs need to actively pursue referrals. External referrals mean creating relationships with case managers at urban and PPS hospitals or tertiary care centers in the community. Depending on where you are located in the US, community can be a distance of 15 minutes to 3 hours. The goal is creating a relationship so that your CAH is the first location considered when swing bed services are needed. Internal referrals are those influencers inside your CAH that determine readiness to accept swing bed patients.
Departments that can be checked daily for ability to receive swing bed patients include: pharmacy, business office, rehab, and central supply. For instance, you would want to understand a patient’s medication needs and their costs. You should ensure the pharmacy has these medications onsite or how long before they will receive them. With the business office, you will need to confirm prior authorization, qualifying admission, and sufficient Medicare days as indicated in the criteria above. With central supply, you will need to confirm any supplies and/or equipment needed by the patient such as IV therapy, bariatric equipment, lifts, etc.
When expanding your swing bed program to include a larger referral network, you should expect the process to be time-consuming and complex. Relationships do not get built quickly. A few key items include:
- Create/confirm a recognized care scale for your swing bed patients
- Identify a swing bed coordinator to manage the process – internally
- Publishing a list of relevant contacts, email and phone, will be helpful
- Invest in a swing bed marketing program
Challenges in expanding your program include:
- Premature or no relationships with external, referring providers
- Relationships with providers has been damaged due to acuity of patients accepted
- Hours of accepting patients is limited
- No agreement on type of patients to accept (care scale)
- Do not have a dedicated swing bed coordinator
When thinking about the marketing of your program, be sure to address key aspects, including:
- Care is close to home for patients with recovery remaining in a hospital setting
- Benefits to each referring provider – e.g., quality of care, ease of patient monitoring
- Emphasizes CAH’s role as “provider of choice” in local area
HealthTechS3 has been providing swing bed consulting services for more than 45 years. If you’d like more information on what’s happening in this area of clinical care or want to discuss how we might support your organization, please contact Carolyn St. Charles at Carolyn.firstname.lastname@example.org