Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Patient workflow

Linda Kowalski · Hip fx, POD-3 (S72.001A) · assigned pathway with step status
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Active pathway · SNFhigh riskmatch 90%

SNF skilled rehab

Hospital → Medicare-certified SNF for 7–30 days of short-term reconditioning, then home with outpatient PT/OT. The most common post-acute pathway after hip fx, CABG, sepsis debility.

Matched on: disposition=SNF · services=OUTPATIENT_PT_OT · rules=rule-medicare-snf-skilled,rule-hip-fx-snf-rehab

LACE+ 11 (HIGH) + HOSPITAL 4 (LOW) → HIGH. · bumped by: HRRP-tracked condition

← Back to library
6 / 16 steps
6 done2 in progress8 blocked0 pending
Service stack
  • · Outpatient PT / OT
  • · Outpatient pharmacy
Evidence basis
  • · CMS Medicare Benefit Policy Manual Ch. 8
  • · 42 CFR §409.30 (Medicare SNF benefit)
  • · AAOS Hip Fracture CPG
  • · ACCP CHEST 2024 (VTE prophylaxis 28–35d)
  • · InterQual / MCG SNF criteria
  • · Project RED + IDEAL Discharge
Outcome metrics
  • · SNF acceptance within 48h of medical readiness
  • · Successful return-to-home from SNF (vs. long-term placement)
  • · 30-d post-SNF readmission to acute care
  • · Functional gain (Barthel / FIM) from admit to SNF discharge
Disposition reference
  • · UB-04 03 · Skilled Nursing Facility (SNF)

Pre-discharge

3 of 10 done
  1. #1T-3d·Case Managercost coverageBlocked
    Verify 3-night Medicare qualifying inpatient stay (LOS ≥3 midnights in inpatient status — NOT observation). If MA plan, check whether the 3-day rule is waived for this plan.

    The #1 SNF denial reason is observation-status time counted as inpatient. Catching this pre-DC avoids retroactive denial after SNF stay.

    CMS Medicare Benefit Policy Manual Ch. 8 §20.1·Evidence: Qualifying-stay confirmation in EHR; MA waiver flag if applicable
  2. #2T-3d·PTfunctionalIn progress
    Complete PT eval — Barthel + TUG + transfer-assist level. Document skilled daily need (PT/OT/SLP or skilled nursing) per CMS criteria.

    SNF coverage requires daily skilled need. PT eval doubles as the SNF intake document.

    42 CFR §409.31 (skilled daily need)·Evidence: PT eval note + Barthel score in EHR
  3. #3T-3d·HospitalistmedicalDone
    Hospitalist 'medically ready for SNF' attestation — no pending IV med titration that needs inpatient acuity, no active sepsis/CHF crisis.

    SNF will refuse referrals if hospitalist hasn't attested medical readiness. Attestation timestamp starts the operational clock.

    InterQual SNF criteria + MCG Level of Care·Evidence: Hospitalist attestation note
  4. #4T-2d·Case ManagerresourcesHITLDone
    Build SNF referral packet — H&P, last 5 days of labs/vitals, med rec, PT eval, infection screen (MRSA/COVID/CRE), code status, advance directives, PASRR Level I if behavioral hx.

    SNFs reject ~30% of referrals for incomplete packets. PASRR Level I is required by 42 CFR §483.20 for any patient with MI/IDD history.

    42 CFR §483.20 (PASRR) + InterQual / MCG packet requirements·Evidence: Complete SNF referral packet ready to send
  5. #5T-2d·Case Managercost coverageHITLBlocked
    Submit MA / commercial prior auth concurrently with referral packet — InterQual or MCG criteria attached.

    PA submission has a 24–72h SLA. Submitting concurrently with the referral avoids serialized delays.

    CMS-0057-F (PA streamlining) + plan-specific SLA·Evidence: PA submission acknowledgment + tracking number
  6. #6T-2d·Patient / Caregiverpatient agreementBlocked
    Family ranks SNF preferences from Resource Hub list (filtered by payer in-network, distance, capacity, CMS star rating).

    Family decision lag is the #1 quietly-tolerated avoidable day driver. Ranking 3 options pre-empts 'we couldn't decide' Friday-afternoon delays.

    IDEAL Discharge Planning (AHRQ) + 42 CFR §482.43(c) patient choice·Evidence: Family-submitted SNF preference ranking in portal
  7. #7T-1d·Case ManagerresourcesHITLDone
    Confirm SNF bed acceptance from top-ranked facility; warm 2nd-choice backup; document bed-hold time window.

    SNF beds released at 3 PM Friday are gone Monday. Backup confirmation is the only protection against weekend collapse.

    Industry SNF intake practice + Case Management Society standards·Evidence: SNF bed-acceptance confirmation + backup
  8. #8T-2d·HospitalistmedicationBlocked
    VTE prophylaxis plan documented — enoxaparin or apixaban for 28–35d post-op (hip fx) or per indication. SNF cannot start a med they don't have an order for.

    Hip fx VTE rate without prophylaxis ~30%. Missing the SNF script = 35-day gap.

    ACCP CHEST 2024 + AAOS Hip Fracture CPG·Evidence: VTE prophylaxis order in transfer packet
  9. #9T-1d·PharmacymedicationBlocked
    Med reconciliation — confirm SNF can source every active med; if not, switch to formulary equivalent BEFORE transfer.

    SNF formularies are tight. Discovering a missing med on arrival creates a 24h dosing gap.

    Project RED Component 5 + ASCP SNF formulary best practice·Evidence: Reconciled med list with SNF formulary cross-check
  10. #15T-3d·PharmacymedicationHITLBlocked
    Pre-SNF polypharmacy review — flag drugs on Beers Criteria for SNF deprescribing; reduce med count where possible.

    Patients with ≥10 active meds on SNF admit have ~2× the readmit rate. Deprescribing at the transfer point is the cleanest moment.

    AGS Beers Criteria 2023·Evidence: Deprescribing note + revised med list

Day of discharge

2 of 3 done
  1. #10Day of DC·Case ManagerresourcesHITLDone
    Transport — confirm NEMT wheelchair-van or BLS ambulance booking; verify SNF accepting clinician on shift.

    Transport mismatched to mobility level = re-transfer cost. SNF arrival to a missing intake nurse = 4-hour hallway wait.

    42 CFR §440.170 (Medicaid NEMT) + plan-specific NEMT benefits·Evidence: NEMT confirmation + SNF arrival nurse confirmed
  2. #11Day of DC·RNmedicalDone
    SBAR warm handoff phone call to SNF charge RN; transmit full transfer packet via secure channel.

    Verbal handoff catches issues a packet misses (e.g., 'she actually walks better in the afternoon').

    TJC NPSG.02.05.01 (handoff communication)·Evidence: Handoff call documented; SNF RN named
  3. #12Day of DC·Case Managercost coverageBlocked
    Write UB-04 Patient Discharge Status Code 03 (SNF) to encounter.

    Encounter billing closes once UB-04 is set; DRG transfer rules differ for SNF vs. home.

    NUBC UB-04 + 42 CFR §412.4 (post-acute care transfer policy)·Evidence: UB-04 03 on encounter

Post-discharge

1 of 3 done
  1. #13T+7d·Case ManagerfunctionalIn progress
    7-day SNF check-in — confirm MDS 3.0 admission assessment complete; functional gain trending; no transfer-back risk emerging.

    MDS 3.0 by day 5 is a CMS condition. Early functional plateau signals SNF won't restore baseline.

    42 CFR §483.20 (MDS 3.0)·Evidence: SNF MDS 3.0 status + functional trend note
  2. #14T+14d·Case ManagerresourcesHITLDone
    Begin return-to-home planning — outpatient PT referral, home safety eval, family caregiver readiness, DME if needed.

    SNF-to-home transition has its own readmit spike if outpatient PT and DME aren't lined up before discharge from SNF.

    AHA Return-to-Home Best Practice + Project RED·Evidence: Return-to-home plan in EHR
  3. #16T+21d·Social Workerpatient agreementHITLBlocked
    21-d SNF goals-of-care conversation — if functional plateau persists, surface long-term placement (ICF) options early to family rather than at week 6 crisis.

    Plateau at 21 days predicts long-term placement need. Early conversation = better family decision-making, less SNF-to-acute bounce-back.

    Naylor TCM + Coleman CTI sustained engagement·Evidence: Goals-of-care conversation note
Demo data · no PHI · mocked Epic + payer endpoints