The primary purpose of hospitals will always be to provide acute, short-term care. But if you think about it, hospital facilities can serve patients in many more ways than that narrow perception.
That’s part of the idea behind a “swing bed,” a coding term created in the 1980s by Congress in an attempt to address both the shortage in long-term care beds in rural areas and a declining patient census at hospitals in those same rural communities.
“Swing beds give the hospital the ability to ‘swing’ a patient back and forth between two levels of care in the same place,” explains Adam Parsons BSN, RN, Director of Post Acute Care at McLeod Health. “It’s for a patient who no longer needs to be cared for in an acute care setting, but still does need things like physical therapy and continued nursing care.”
Prior to 1980, Medicare required that skilled nursing (SNFs) and intermediate care facilities exist in stand-alone fashion from acute care hospitals; this made it difficult for discharged patients to receive care close to home and was a de facto additional hardship on rural hospitals who had the beds and staff available to care for these patients and needed the influx.
Swing beds were the solution, allowing hospitals to provide different levels of care and, more importantly, code the patient in two different ways for Medicare reimbursement.
Despite the widespread use of swing beds, rural hospitals still struggled, particularly after the economic downturn in 2008 and the Medicare cuts in the Affordable Care Act. And, as it turns out, swing beds themselves were not doing as much financially as originally intended.
“Swing beds were being misused to a certain extent, at McLeod and a lot of other places,” explains Parsons. “It was a place to offload patients from a tertiary care center when they didn't have any other place to go. So a lot of these patients were unfunded or underfunded, that we couldn't place otherwise in order to free up a bed needed on the acute side. Which meant we knew were going to lose money on that case. The organization wasn't prospering at all from that process--it was all a loss.”
That situation, however, is starting to change in the McLeod Health system, which implemented a revamped swing bed model over the last few years that made the program cost-effective, better serves the patient and renewed its ability to make a difference to the rural facilities in the system.
The process of rethinking the program was extensive and strategic, with an interdisciplinary workgroup of CNOs, administrators, staff nurses, physical therapists and respiratory therapists coming together to re-envision their approach to swing beds.
“We opened up swing beds to our patients on Medicare, Medicaid and even private insurance, instead of just utilizing the SNFs in our community,” says Parsons. “We revamped our model and standardized the patients that could go there across the system.”
Another key innovation was allowing swing beds to exist side-by-side with acute beds in the same unit, rather than attempting to create an SNF-like separate unit just for swing beds. This made it more effective to staff swing beds but requires buy-in and commitment from clinical staff to truly take advantage of these efficiencies.
“We had to do a year's worth of education, and it's still ongoing, on the culture of what a swing bed is for us, because we had only done it this one way,” admits Parsons.
But the advantages for the hospital and the patient, both in terms of the care they receive and their proximity to their community, were clear.
“We make sure [swing bed patients] are cared for appropriately and do well,” Parson points out. “Our nurses are required to do head-to-head assessments once a day, at nursing homes it's less frequently. We take vital signs every day, nursing homes do it once a week. Doctors are required to meet with the patient once a week, in a nursing home it's a lot less frequent. So we have much more clinical oversight.”
The new program also utilizes a complex care case manager facilitates the entire swing bed process.
“There's a lot of case-by-case work on that,” he continues. “We make it as easy on families as possible.”
The new model also required more attention to taking care of patients and preparing them for a transition to home or another tertiary care center. By doing due diligence, McLeod was able to cut the average length of stay by almost 75 percent over the length of the new program.
“From last year  to this year , we made a $1.5 million improvement on the contribution to the bottom line from the swing bed program,” Parsons says proudly. “And that's from an average daily census between all four campuses of about 30 patients.”
What’s more, there’s also been measurable improvement in terms of readmissions—the swing bed program saw a significant decline in their patients return within 30 days last year far below the average readmissions rate of 20% for SNFs statewide last year.
“We have much more clinical oversight, and we suffer a little bit on the financial end because we have a lot more salary cost overhead than other folks do,” says Parsons of those readmission numbers. “But at the same time, the patients get better care. They don't need to come back to the hospital.”