Effect of hospital-SNF referral linkages on rehospitalization

ACO-Affiliated Hospitals Reduced Rehospitalizations From Skilled Nursing Facilities Faster Than Other Hospitals

Medicare's more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals.

Spending On Care After Surgery Driven By Choice Of Care Settings Instead Of Intensity Of Services

The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spending for fee-for-service Medicare beneficiaries after three common surgical procedures in the period 2009-12, we found that it varied widely between hospitals in the lowest versus highest spending quintiles for postacute care, with differences of 129 percent for total hip replacement, 103 percent for coronary artery bypass grafting (CABG), and 82 percent for colectomy. Wide variation persisted after we adjusted for the intensity of postacute care. However, the variation diminished considerably after we adjusted instead for postacute care setting (home health care, outpatient rehabilitation, skilled nursing facility, or inpatient rehabilitation facility): It decreased to 16 percent for hip replacement, 4 percent for CABG, and 21 percent for colectomy. Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value postacute care setting.

The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities

BACKGROUND

Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients.

OBJECTIVE

Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs.

DESIGN

An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015.

SETTING

A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs.

PATIENTS

All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation.

INTERVENTION

The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff.

MEASUREMENT

Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP.

RESULTS

The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting.

CONCLUSIONS

A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.

Partnerships in Transitions: Acute Care to Skilled Nursing Facility

PURPOSE/OBJECTIVES

Older adults, in particular those discharged to skilled nursing facilities (SNFs), are at high risk for readmission. As part of a multifaceted approach to reduce readmissions, a community hospital initiated a 3-prong approach (Collaboration, Communication, and Competency) and partnered with regional SNFs.

PRIMARY PRACTICE SETTINGS

El Camino Hospital, an independent, locally owned, not-for-profit district, acute care hospital in Northern California, and 11 participating SNFs in the same region.

FINDINGS/CONCLUSIONS

Collaboration: The combined leadership team developed a case report form and instituted regular reviews of 7-day readmissions. Communication: Standardized form for transferring patients to SNFs, form for transfer from SNF to emergency department, and consent form to enable SNFs to administer antipsychotic medications were developed. Regular phone and video conferencing between clinicians at the hospital and receiving SNF were instituted. Competency: Educational series to recognize and intervene to prevent readmission, and mutual exchange of best practices among hospital and SNF staff, were instituted. Continued work among ECH and the participating SNFs has improved the flow of information in both directions; favorable results from the broader study to reduce readmissions hospital-wide provide support for these efforts.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Initiating collaboration with the SNFs is imperative in the changing health care landscape. Because of the complexity of the problem, acute care facilities and SNFs need to create a partnership to ensure smooth patient transition. Communication between care settings is essential in achieving optimum patient outcomes.

Is Profit Status of Inpatient Rehabilitation Facilities Independently Associated With 30-Day Unplanned Hospital Readmission for Medicare Beneficiaries?

OBJECTIVE

To investigate the effects of facility-level factors on 30-day unplanned risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities (IRFs).

DESIGN

Study using 100% Medicare claims data, covering 269,306 discharges from 1094 IRFs between October 2010 and September 2011.

SETTING

IRFs with at least 30 discharges.

PARTICIPANTS

A total number of 1094 IRFs (N=269,306) serving Medicare fee-for-service beneficiaries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Risk-standardized readmission rate (RSRR) for 30-day hospital readmission.

RESULTS

Profit status was the only provider-level IRF characteristic significantly associated with unplanned readmissions. For-profit IRFs had a significantly higher RSRR (13.26±0.51) than did nonprofit IRFs (13.15±0.47) (P<.001). After controlling for all other facility characteristics (except for accreditation status because of its collinearity with facility type), for-profit IRFs had a 0.1% point higher RSRR than did nonprofit IRFs, and census region was the only significant region-level characteristic, with the South showing the highest RSRR of all regions (type III test, P=.005 for both).

CONCLUSIONS

Our findings support the inclusion of profit status on the IRF Compare website (a platform including IRF comparators to indicate quality of services). For-profit IRFs had a higher RSRR than did nonprofit IRFs for Medicare beneficiaries. The South had a higher RSRR than did other regions. The RSRR difference between for-profit and nonprofit IRFs could be due to the combined effects of organizational and regional factors.

Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees

Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities.

Perspectives of Post-Acute Transition of Care for Cardiac Surgery Patients

Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality.

Effects of Acute-Postacute Continuity on Community Discharge and 30-Day Rehospitalization Following Inpatient Rehabilitation

OBJECTIVE

To examine the effects of facility-level acute-postacute continuity on probability of community discharge and 30-day rehospitalization following inpatient rehabilitation.

DATA SOURCES

We used national Medicare enrollment, claims, and assessment data to study 541,097 patients discharged from 1,156 inpatient rehabilitation facilities (IRFs) in 2010-2011.

STUDY DESIGN

We calculated facility-level continuity as the percentages of an IRF's patients admitted from each contributing acute care hospital. Patients were categorized into three groups: low continuity (<26 percent from same hospital that discharged the patient), medium continuity (26-75 percent from same hospital), or high continuity (>75 percent from same hospital). The multivariable models included an interaction term to examine the potential moderating effects of facility type (freestanding facility vs. hospital-based rehabilitation unit) on the relationships between facility-level continuity and our two outcomes: community discharge and 30-day rehospitalization.

PRINCIPAL FINDINGS

Medicare beneficiaries in hospital-based rehabilitation units were more likely to be referred from a high-contributing hospital compared to those in freestanding facilities. However, the association between higher acute-postacute continuity and desirable outcomes is significantly better in freestanding rehabilitation facilities than in hospital-based units.

CONCLUSIONS

Improving continuity is a key premise of health care reform. We found that both observed referral patterns and continuity-related benefits differed markedly by facility type. These findings provide a starting point for health systems establishing or strengthening acute-postacute relationships to improve patient outcomes in this new era of shared accountability and public quality reporting programs.

Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery

BACKGROUND

Readmission within 30 d of an acute hospital stay is frequent, costly, and increasingly subject to penalties. Early readmission is most common after vascular surgery; these patients are often discharged to skilled nursing facilities (SNFs), making postacute care an essential partner in reducing readmissions. We characterize 30-day readmissions among vascular surgery patients discharged to SNF to provide evidence for this understudied segment of readmission after specialty surgery.

METHODS

We utilize the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries to study 30-day readmission or death after discharge to SNF following abdominal aortic aneurysm repair or lower extremity revascularization from 2005-2009. Descriptive statistics and logistic regression with Least Adaptive Shrinkage and Selection Operator were used for analysis.

RESULTS

Two thousand one hundred ninety-seven patients underwent an abdominal aortic aneurysm procedure or lower extremity revascularization at 686 hospitals and discharged to 1714 SNFs. Eight hundred (36%) were readmitted or had died at 30 d. In adjusted analysis, predictors of readmission or death at 30 d included SNF for-profit status (OR [odds ratio] = 1.2; P = 0.032), number of hospitalizations in the previous year (OR = 1.06; P = 0.011), number of comorbidities (OR = 1.06; P = 0.004), emergent procedure (OR = 1.69; P < 0.001), renal complication (OR = 1.38; P = 0.003), respiratory complication (OR = 1.45; P < 0.001), thromboembolic complication (OR = 1.57; P = 0.019), and wound complication (OR = 0.70; P = 0.017).

CONCLUSIONS

Patients discharged to SNF following vascular surgery have exceptionally high rates of readmission or death at 30 d. Many factors predicting readmission or death potentially modify decision-making around discharge, making early detection, discharge planning, and matching patient needs to SNF capabilities essential to improving outcomes.

Reducing Hospital Readmissions Through Preferred Networks Of Skilled Nursing Facilities

Establishing preferred provider networks of skilled nursing facilities (SNFs) is one approach hospital administrators are using to reduce excess thirty-day readmissions and avoid Medicare penalties or to reduce beneficiaries' costs as part of value-based payment models. However, hospitals are also required to provide patients at discharge with a list of Medicare-eligible providers and cannot explicitly restrict patient choice. This requirement complicates the development of a SNF network. Furthermore, there is little evidence about the effectiveness of network development in reducing readmission rates. We used a concurrent mixed-methods approach, combining Medicare claims data for the period 2009-13 with qualitative data gathered from interviews during site visits to hospitals in eight US markets in March-October 2015, to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal SNF networks. Four hospitals had developed formal SNF networks as part of their care management efforts. These hospitals saw a relative reduction from 2009 to 2013 in readmission rates for patients discharged to SNFs that was 4.5 percentage points greater than the reduction for hospitals without formal networks. Interviews revealed that those with networks expanded existing relationships with SNFs, effectively managed patient data, and exercised a looser interpretation of patient choice.

Perspectives of Clinicians at Skilled Nursing Facilities on 30-Day Hospital Readmissions: A Qualitative Study

BACKGROUND

Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. Skilled nursing facilities (SNFs) play an important role in the readmission process, but few studies have examined the factors that contribute to readmissions from SNFs, leaving hospitalists and other hospital-based clinicians with limited evidence on how to reduce SNF readmissions.

OBJECTIVE

To understand the perspectives of clinicians working at SNFs regarding factors contributing to readmissions.

DESIGN AND PARTICIPANTS

We prospectively identified consecutive readmissions from SNFs to a single tertiary-care hospital. Index admissions and readmissions were to the hospital's inpatient general medicine service. SNF clinicians who cared for the readmitted patients were identified and interviewed about root causes of the readmissions using a structured interview tool. Transcripts of the interviews were inductively analyzed using grounded theory methodology.

RESULTS

RESULTS: We interviewed 28 clinicians at 15 SNFs. The interviews covered 24 patient readmissions. SNF clinicians described a range of procedural, technological, and cultural contributors to unplanned readmissions. Commonly cited causes of readmission included a lack of coordination between emergency departments and SNFs, poorly defined goals of care at the time of hospital discharge, acute illness at the time of hospital discharge, limited information sharing between a SNF and hospital, and SNF process and cultural factors.

CONCLUSIONS

SNF clinicians identified a broad range of factors that contribute to readmissions. Addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.

Selecting a Skilled Nursing Facility for Postacute Care: Individual and Family Perspectives

OBJECTIVES

To describe individuals' experiences during the hospital discharge planning and skilled nursing facility (SNF) selection process.

DESIGN

Semistructured interviews focusing on discharge planning and nursing facility selection, including how facilities were chosen, who was involved, and what factors were important in decision-making.

SETTING

14 SNFs in five cities across the United States.

PARTICIPANTS

Newly admitted, previously community-dwelling SNF residents (N = 98) and their family members.

MEASUREMENT

Semistructured interviews were qualitatively coded to identify underlying themes.

RESULTS

Most respondents reported receiving only a list of SNF names and addresses from discharge planners and that hospital staff were minimally involved. Proximity to home and prior experience with the facility most often influenced choice of SNF. Most respondents reported being satisfied with their placement, although many stated that they would have been willing to travel further to another SNF were it recommended. Many reported feeling rushed and unprepared, stating that they did not know where or how to get help.

CONCLUSION

SNF placement is a stressful transition, occurring when people are physically vulnerable and with limited guidance from discharge planners. Therefore, most people select a facility based on its location, perhaps because they are provided with no other information. Given Centers for Medicare and Medicaid Services' proposed changes to the discharge planning process, this research highlights the value of providing people and family caregivers with quality data and assistance in interpreting it.

Comparison of methods to identify long term care nursing home residence with administrative data

BACKGROUND

To compare different methods for identifying a long term care (LTC) nursing home stay, distinct from stays in skilled nursing facilities (SNFs), to the method currently used by the Center for Medicare and Medicaid Services (CMS). We used national and Texas Medicare claims, Minimum Data Set (MDS), and Texas Medicaid data from 2011-2013.

METHODS

We used Medicare Part A and B and MDS data either alone or in combination to identify LTC nursing home stays by three methods. One method used Medicare Part A and B data; one method used Medicare Part A and MDS data; and the current CMS method used MDS data alone. We validated each method against Texas 2011 Medicare-Medicaid linked data for those with dual eligibility.

RESULTS

Using Medicaid data as a gold standard, all three methods had sensitivities > 92% to identify LTC nursing home stays of more than 100 days in duration. The positive predictive value (PPV) of the method that used both MDS and Medicare Part A data was 84.65% compared to 78.71% for the CMS method and 66.45% for the method using Part A and B Medicare. When the patient population was limited to those who also had a SNF stay, the PPV for identifying LTC nursing home was highest for the method using Medicare plus MDS data (88.1%).

CONCLUSIONS

Using both Medicare and MDS data to identify LTC stays will lead to more accurate attribution of CMS nursing home quality indicators.

Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: A targeted needs assessment using the Intervention Mapping framework

INTRODUCTION

Patients transitioning from the hospital to a skilled nursing home (SNF) are susceptible to medication-related errors resulting from fragmented communication between facilities. Through continuous process improvement efforts at the hospital, a targeted needs assessment was performed to understand the extent of medication-related issues when patients transition from the hospital into a SNF, and the gaps between the hospital's discharge process, and the needs of the SNF and long-term care (LTC) pharmacy. We report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to SNF and LTC pharmacy staff.

METHODS

Applying the Intervention Mapping (IM) framework, a targeted needs assessment was performed using quantitative and qualitative methods. Using the hospital discharge medication list as reference, medication discrepancies in the SNF and LTC pharmacy lists were identified. SNF and LTC pharmacy staffs were also interviewed regarding the continuity of medication information post-discharge from the hospital.

RESULTS

At least one medication discrepancy was discovered in 77.6% (n = 45/58) of SNF and 76.0% (n = 19/25) of LTC pharmacy medication lists. A total of 191 medication discrepancies were identified across all SNF and LTC pharmacy records. Of the 69 SNF staff interviewed, 20.3% (n = 14) reported patient care delays due to omitted documents during the hospital-to-SNF transition. During interviews, communication between the SNF/LTC pharmacy and the discharging hospital was described by facility staff as unidirectional with little opportunity for feedback on patient care concerns.

CONCLUSIONS

The targeted needs assessment guided by the IM framework has lent to several planned process improvements initiatives to help reduce medication discrepancies during the hospital-to-SNF transition as well as improve communication between healthcare entities. Opening lines of communication along with aligning healthcare entity goals may help prevent medication-related errors.

Changes in Postacute Care in the Medicare Shared Savings Program

Importance

Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care.

Objective

To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred.

Design, Setting, and Participants

With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014.

Exposures

Patient attribution to an ACO in the MSSP.

Main Outcomes and Measures

Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics.

Results

For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P = .19; and $4 per beneficiary [95% CI, -$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality.

Conclusions and Relevance

Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.

Hospital Postacute Care Referral Networks: Is Referral Concentration Associated with Medicare-Style Bundled Payments?

OBJECTIVE

To evaluate whether Medicare-style bundled payments are lower or higher for beneficiaries discharged from hospitals with postacute care (PAC) referrals concentrated among fewer PAC providers.

DATA SOURCE

Medicare Part A and Part B claim (2008-2012) for all beneficiaries residing in any of 17 market areas: the Provider of Service file, the Healthcare Cost Report Information System, and the Dartmouth Atlas.

STUDY DESIGN

An observational study in which hospitals were distinguished according to PAC referral concentration, which is the tendency to utilize fewer rather than more PAC providers. We tested the hypothesis that higher referral concentration would be associated with total Medicare bundled payments.

DATA COLLECTION/EXTRACTION METHODS

The data represent a convenience sample of market areas that were defined by the locations of grantees from the ONC Beacon Community Program.

PRINCIPAL FINDINGS

The four most-used PAC providers accounted for an average of 60 percent of patients discharged from hospitals in the sample. Regression analysis suggested that higher referral concentration was associated with lower Medicare costs per bundle.

CONCLUSIONS

Hospitals that tend to use fewer PAC providers may lead to lower costs for payers such as Medicare. The study results reinforce the importance of limited networks for PAC services under bundling arrangements for hospital and PAC payments.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?

OBJECTIVE

To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.

SETTINGS

Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.

STUDY DESIGN

We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.

PRINCIPAL FINDINGS

The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.

CONCLUSIONS

Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?

OBJECTIVE

To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.

SETTINGS

Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.

STUDY DESIGN

We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.

PRINCIPAL FINDINGS

The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.

CONCLUSIONS

Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

The Contribution of Skilled Nursing Facilities to Hospitals' Readmission Rate

OBJECTIVE

To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization.

DATA SOURCES/SETTINGS

Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization.

STUDY DESIGN

We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge.

PRINCIPAL FINDINGS

Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR.

CONCLUSIONS

The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.

Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery

BACKGROUND

In the health reform era, rehospitalization after discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction after surgery has not been explored.

METHODS

To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-2012) and evaluated patients who underwent 1 of 5 operative procedures (coronary artery bypass grafting [CABG], hip fracture repair, total hip arthroplasty, colectomy, or lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals' home and the SNF as the IV.

RESULTS

A strong negative correlation (P < .001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (regression coefficient, -0.04; 95% CI, -0.07 to -0.02). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to reduce significantly the likelihood of readmission for patients receiving lumbar spine surgery, CABG, and hip fracture repair.

CONCLUSION

The benefits of increased hospital-SNF linkage seem to include meaningful reductions in hospital readmission after surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to decrease readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.

A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes

OBJECTIVES

Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period.

DESIGN

Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact.

SETTING

A multispecialty group practice.

PARTICIPANTS

Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex.

MEASUREMENTS

For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days.

RESULTS

The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days.

CONCLUSION

Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates.

Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization

Postacute care (PAC) is an important source of cost growth and variation in the Medicare program and is critical to accountable care organization (ACO) and bundled payment efforts to improve quality and value in the Medicare program, but ACOs must often look outside their walls to identify high-value external PAC partners, including skilled nursing facilities (SNFs). As a solution to this problem, the integrated health system, Partners HealthCare System (PHS) and its Pioneer ACO launched the PHS SNF Collaborative Network in October 2013 to identify and partner with high-quality SNFs. This study details the method by which PHS selected SNFs using minimum criteria based on public scores and secondary criteria based on self-reported measures, describes the characteristics of selected and nonselected SNFs, and reports SNF satisfaction with the collaborative. The selected SNFs (n = 47) had significantly higher CMS Five-Star scores than the nonselected SNFs (n = 93) (4.6 vs 3.2, P < .001) and were more likely than nonselected SNFs that met the minimum criteria (n = 35) to have more than 5 days of clinical coverage (17.0% vs 2.9%, P = .02) and to have a physician see admitted individuals within 24 (38.3% vs 17.1%, P = .02) and 48 hours (93.6% vs 80.0%, P = .03). A survey sent to collaborative SNFs found high satisfaction with the process (average satisfaction, 4.6/5, with 1 = very dissatisfied and 5 = very satisfied, n = 19). Although the challenges of improving care in SNFs remain daunting, this approach can serve as a first step toward greater clinical collaboration between acute and postacute settings that will lead to better outcomes for frail older adults.

Hospital readmission of skilled nursing facility residents: a systematic review

Hospital readmission of patients discharged to skilled nursing facilities (SNFs) is common and costly with increasing public attention over the past decade, particularly in light of the new health care environment surrounding the advent of the Affordable Care Act. The purpose of the current systematic review is to critically examine prevalence, predictors, and costs of hospital readmission of SNF residents found in the medical literature. Individual resident, facility, and intervention factors predicting hospital readmission of SNF residents were studied. Despite the heterogeneity of the reviewed articles' data sources and study designs, the existing literature asserts that hospital readmission of SNF residents is associated with individual resident and facility characteristics. Implementation of promising intervention programs can promote quality of care and reduce hospital readmission of SNF residents.

Racial segregation and quality of care disparity in US nursing homes

In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality.

Post-acute integration strategies in an era of accountability

The Institute of Medicine, in its 2001 Crossing the Quality Chasm report, recommended greater integration and coordination as a component of a transformed health care system, yet relationships between acute and post-acute providers have remained weak. With payment reforms that hold hospitals and health systems accountable for the total costs of care and readmissions, the dynamic between acute and post-acute providers is changing. In this article, we outline the internal and market factors that will drive health systems' decisions about whether and how they integrate with post-acute providers. Enhanced integration between acute and post-acute providers should reduce variation in post-acute spending.

Sensitivity and specificity of the Minimum Data Set 3.0 discharge data relative to Medicare claims

OBJECTIVE

The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents.

DESIGN

We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes.

SETTINGS

All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011.

RESULTS

Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS discharge records. More than 99% of the variation in nursing home-level 30-day rehospitalization rate calculated using claims data can be explained by the same rates calculated using MDS. Nursing home structural characteristics explain only 5% of the variation in nursing home-level sensitivity and 3% of the variation in nursing home-level specificity.

CONCLUSION

The new MDS 3.0 discharge record matches Medicare enrollment and hospitalization claims events with a high degree of accuracy, meaning that hospitalization rates calculated based on MDS offer a good proxy for the "gold standard" Medicare data.

Incidence and risk factors for unplanned transfers to acute general hospitals from an intermediate care and rehabilitation geriatric facility

OBJECTIVE

Unplanned acute hospital transfers (AT) from post-acute or long-term care facilities represent critical transitions, which expose patients to negative health outcomes and increase the burden of the emergency departments that receive these patients. We aim at determining incidence and risk factors for AT during the first 30 days of admission at an intermediate care and rehabilitation geriatric facility (ICGF).

DESIGN AND SETTING

Prospective cohort study conducted in an ICGF of Barcelona, Spain. Sociodemographics, main diagnostics, and variables of the comprehensive geriatric assessment were recorded at admission. At the moment of AT, suspected diagnostic motivating the transfer was recorded. Multivariable Cox proportional hazard models were used to evaluate the association between admission characteristics and AT.

RESULTS

We included 1505 patients (mean age + standard deviation = 81.31 ± 7.06, 65.7% women). AT were 217 (14.4%, 5.64/1000 days of stay) resulting in only 81 final hospitalizations (37% of AT), whereas 136 patients returned to ICGF after visiting the emergency department. Principal triggers of AT were cardiovascular, falls/orthopedic, and gastrointestinal problems. Being admitted to ICGF after a general surgery [hazard ratio (HR) 1.88; 95% confidence interval (CI) 1.21-2.94; P < .001], taking 8 or more drugs at admission (HR 1.98; 95% CI 1.37-2.86; P < .001) and living with a partner (HR 1.35; 95% CI 1.01-1.81; P = .05) were independently associated with a higher risk of AT.

CONCLUSIONS

In our sample, clinical and social characteristics at admission to an ICGF are associated with a higher risk of AT. A relevant proportion of AT is not admitted to the acute hospital, suggesting perhaps some avoidable AT. Identification of risk factors might be relevant to design strategies to reduce AT.

Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer?

OBJECTIVE

To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies.

DATA SOURCES/COLLECTION

We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.

STUDY DESIGN

We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.

PRINCIPAL FINDINGS

Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.

CONCLUSIONS

Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.

Dual Eligibility, Selection of Skilled Nursing Facility, and Length of Medicare Paid Postacute Stay

Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients' SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.