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. In September 2021, the tool began to assess SNF overutilization by tracking
avoidable SNF admissions and resources that could have prevented an admission.
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© 2022 Published by Elsevier Inc.