SDoH at the Intersection of Skilled Nursing Facilities

by Tiffany Ferguson, LMSW, CMAC, ACM
Published on Aug 17, 2022

This article appeared on on August 17, 2022.

EDITOR’S NOTE: This story comes at the request of Mary Beth Pace, vice president of care at Trinity Health. Her question last week arose out of the hospital three-day waiver for skilled nursing facilities (SNFs) during the public health emergency (PHE) waiver.

The PHE removed the required three-day inpatient stay for any hospitals struggling with a surge in patients as a result COVID. 

Just a reminder the PHE stated that “Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a three-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19” (, COVID-19 Emergency Declaration Waivers).

Now, what I saw early in the pandemic were SNFs that although, the PHE was in place, were unwilling to accept patients until the three-day stay was met for fear they would not be reimbursed by the Centers for Medicare & Medicaid Services (CMS). However, Mary Beth highlighted a new trend that required me to do some digging. I reached out to my trusty colleagues who are apart of health system ACOs across the country and we found a new discovery. Many of the SNFs were moving their long-term patients back into “skilled care” for additional reimbursement under the waiver without a hospitalization, let alone a three-day inpatient stay.    

Since many health systems are apart of an arrangement for their Medicare populations typically MSSP, they are indirectly responsible for the cost of care which also lends them to valuable data on their post-acute utilization. One health system, reported, a 20 percent increase in SNF utilization for patient stays with no preceding inpatient stay. The stays were also unrelated to COVID or a COVID related diagnosis for skilled care. Another colleague at a major health system in Texas also experienced this utilization issue and found that many SNFs had seen a drop in their skilled census and thus were using the waiver to “skill their existing long-term patients.” 

So, I would like to ask our listeners today if you are seeing similar trends. Are your local SNFs or is your health system seeing either SNFs not taking patients despite the waiver for the three-day stay or are they overusing this waiver by filling their beds with their existing patients to bill for a SNF stay?   

  • Under utilizing the three-day SNF waiver
  • Over utilizing the three-day SNF waiver
  • Appropriate use of the three-day SNF waiver
  • Unsure
  • Does not apply


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Programming Note: Listen to Tiffany Ferguson live reporting on the SDoH every Monday on Monitor Mondays at 10 Eastern.