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 RAFT Model Cuts Emergency Department Transfers in SNF Population

Three rural skilled nursing facilities (SNFs) using the Reducing Avoidable Facility Transfers (RAFT) model saw emergency department (ED) trips from their facilities to hospitals decline “substantially,” and they also recorded a reduction in some acute health care utilization, according to research in the August JAMDA, the journal of AMDA–The Society for Post-Acute and Long-Term Care Medicine.

These new data lend credence to the positives that can result from deploying the RAFT model,  research authors said. The RAFT model seeks to bring closer monitoring of a resident’s care plan and more expert clinical evaluations in order to prevent unnecessary hospitalizations for those in long term and post-acute care.  

The researchers noted that the model consists of several components, including having a small team of providers who manage care and after-hours calls; a systematic understanding of advance care plans, including acute-care preferences; increased engagement of the provider during an acute-care event; and biweekly meetings to discuss or review each case.

“While results varied across categories, all three SNFs in the study demonstrated substantial reductions in ED transfers and hospitalizations (between Jan. 1, 2016, to June 30, 2017),” the study said.

For the three SNFs in the study, mean average of monthly ED transfers decreased by 35.8 percent. Mean monthly hospitalizations decreased by 30.5 percent. Although the authors did not have access to health insurance claims data, they were able to document reductions in monthly post-acute and long term care charges.

“Like other models, RAFT provides evidence that much of the acute care provided to SNF residents can be provided more safely, more effectively, and more inexpensively than is currently the norm,” the authors said.

Researchers emphasized that the RAFT intervention resulted in a statistically significant reduction in ED and hospital use among long term care residents of SNFs. And, this was achieved without a related impact on key quality measures.

However, they said the study showed limited benefit with post-acute care patients. “Although there was some utilization reduction among this population, the reduction was not statistically significant across facilities,” the authors said.

Much of the benefit of RAFT hinged on systematic goals of care discussions. “Scheduling a meeting shortly after SNF admission when risk of rehospitalization is highest often proved unfeasible in the midst of the other more pressing details. Further modifications to better identify high-risk patients and facilitate early conversations could prove very helpful,” the authors said.

The research team stressed that several components of the study model were noteworthy. First, they said they limited the on-call pool to a small team of clinicians familiar with the care of frail individuals and SNFs. “For most clinicians, a phone call about an acutely ill patient represents a high-risk situation for which ED transfer can seem the only alternative,” the authors said.

The “SNFist,” as the expert in long term care was called in the report, was armed with a deep understanding of the patients, schedule, culture, and resources in residential care, and better able to implement a practicable alternative than the clinician who has little SNF experience, the authors said.

Another factor in the study model was the addition of “do not hospitalize—treat in place” as a formal option for residents. “Many patients and their families expressed an explicit interest in limiting aggressive interventions; at the end of the study, only 14 percent of directives elected unlimited life-prolonging interventions,” the authors said.

But, although most were not in favor of unlimited care, many were not ready for a purely comfort-focused approach either. “They wanted some interventions taken to prolong life, particularly if those interventions offered limited risk of distress. The option of ‘limited interventions—treat in place’ provided an attractive middle road that matched the values of 32 percent of our long term patients,” authors said.

They further noted that while their study was small, the magnitude of its results is at least equal to those of larger studies.

Researchers were based at the Dartmouth Hitchcock Medical Center (General Internal Medicine), Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy & Clinical Practice, The Collaboratory for Implementation Science at Dartmouth, Dartmouth Centers for Health & Aging, Population Health for D-H Health, and The Mongan Institute—Massachusetts General Hospital in Boston.

Access the study at

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