Network Success Story

3 Day Skilled Nursing Facility Rule Waiver Implementation and Success in 2018

In 2018, OneCare elected to offer the 3-Day Skilled Nursing Facility (SNF) Rule Waiver under its Medicare program. The SNF Waiver allows a Medicare beneficiary, who is attributed to OneCare, to be admitted to a participating SNF without the traditional fee-for-service Medicare qualifying 3-day hospital stay. Under the SNF Waiver, patients can be admitted to a SNF from short-inpatient, observation, emergency department (ED), provider office, or patient’s home after a medical exam confirming a skilled nursing need, avoiding unnecessary inpatient stays and allowing patients to access their skilled nursing benefits sooner.

Focus / Spotlight

Patient Benefits

  • Clinically appropriate access to SNF care for patients exhibiting a skilled nursing need including physical therapy, occupational therapy and speech therapy to return to prior level of functioning.

  • Reduces avoidable and costly ED and hospital stays with admissions from provider office or home.

  • Promotes patient-centered care and shared decisionmaking.

Action Taken

  • Outreach and education to Medicare program participating hospitals and eligible SNFs

  • Development and roll-out of Operations Manual to guide implementation and utilization

  • Training provided to providers and SNFs on SNF Waiver program, including building workflows for patient admissions to SNFs and using the OneCare Secure Portal

Spotlight on the Middlebury Health Service Area SNF Waiver Pilot

In spring 2018, Porter Medical Center and Helen Porter Rehabilitation and Nursing, part of the UVM Health Network, were chosen as a pilot site for implementation of the SNF Waiver. OneCare Clinical Consultants worked with staff at both facilities to implement the SNF Waiver and Helen Porter admitted its first patient under the SNF waiver in May 2018. The following implementation steps were taken to ensure a successful SNF Waiver program roll-out:

Identification of roles and responsibilities of both hospital/medical staff and SNF staff

Patient attribution identification process established at Porter Medical Center, with ACO attribution patient identifier button added to hospital EHR system

Discussions and education on the SNF Waiver incorporated into Transitions of Care Committee meeting between hospital and SNF

Creation of patient admission work flow from ED to SNF under the SNF Waiver. This is used as an example during ongoing OneCare SNF Waiver trainings


Outcomes: Since the initial roll-out of the program in the Middlebury HSA, 24 patients have been successfully discharged from Helen Porter under the SNF Waiver in 2018; 7 from Observation, 15 from Short-Inpatient (< 3 days) and 2 from the patients home.

Lessons Learned


ACO identification in EHR is sometimes not reliable, must know how to verify patient attribution on OneCare Secure Portal to ensure attribution


Important for SNF to provide bed availability status to the hospital care management department regularly so hospital staff know if beds available for use under the SNF Waiver


Important to designate between SNF admissions for Rehab and those for Long Term Care (LTC); the SNF Waiver is only for Rehab SNF admissions, not LTC