Post-acute care reform: Implications and opportunities for hospitalists

Factors influencing clinicians' referral or admission decisions for post-acute stroke or traumatic brain injury rehabilitation: A scoping review

Demand for post-acute stroke and traumatic brain injury (TBI) rehabilitation outweighs resource availability. Every day, clinicians face the challenging task of deciding which patient will benefit or not from rehabilitation. The objectives of this scoping review were to map and compare factors reported by clinicians as influencing referral or admission decisions to post-acute rehabilitation for stroke and TBI patients, to identify most frequently reported factors and those perceived as most influential. We searched four major databases for articles published between 1946 and January 2021. Articles were included if they reported clinicians' perceptions, investigated referral or admission decisions to post-acute rehabilitation, and focused on patients with stroke or TBI. Twenty articles met inclusion criteria. The International Classification of Functioning, Disability and Health framework was used to guide data extraction and summarizing. Patient-related factors most frequently reported by clinicians were age, mental status prior to stroke or TBI, and family support. The two latter were ranked among the most influential by clinicians working with stroke patients, whereas age was ranked of low importance. Organizational factors were reported to influence decisions (particularly the availability of post-acute care services) as well as clinicians' characteristics (eg, knowledge). Moreover, clinicians' prediction of patient outcome ranked among the most important driver of referral or admission decisions by clinicians working with stroke patients. Findings highlight the complex nature of decision-making regarding patient selection for rehabilitation and provide insight on important factors that frontline clinicians need to consider when having to make rapid decisions in high-pressured acute care environments.

VA nursing home compare metrics as an indicator of skilled nursing facility quality for veterans

BACKGROUND

The Veterans Administration (VA) provides several post-acute care (PAC) options for Veterans, including VA-owned nursing homes (called Community Living Centers, CLCs). In 2016, the VA released CLC Compare star ratings to support decision-making. However, the relationship between CLC Compare star ratings and Veterans CLC post-acute outcomes is unknown.

METHODS

Retrospective observational study using national VA and Medicare data for Veterans discharged to a CLC for PAC. We used a multivariate regression model with hospital random effects to examine the association between CLC Compare overall star ratings and PAC outcomes while controlling for patient, facility, and hospital factors. Our sample included Veteran enrollees age 65+ who were community-dwelling, experienced a hospitalization, and were discharged to a CLC in 2016-2017. PAC outcomes included 30-day unplanned hospital readmission, 30-day mortality, 100-day successful community discharge, and a secondary composite outcome of unplanned readmission or death within 30-days of the hospital discharge.

RESULTS

Of the 25,107 CLC admissions, 4088 (16.3%) experienced an unplanned readmission, 4069 (16.2%) died within 30-days of hospital discharge, and 12,093 (48.2%) had a successful 100-day community discharge. Admission to a lower-quality (1-star) facility was associated with lower odds of successful community discharge (OR 0.78; 95% CI 0.66, 0.91) and higher odds of a combined endpoint of 30-day mortality and readmission (OR 1.27; 95% CI 1.09, 1.49), compared to 5-star facilities. However, outcomes were not consistently different between 5-star and 2, 3, or 4-star facilities. Star ratings were not associated with individual readmission or mortality outcomes when considered separately.

CONCLUSION

These findings suggest comparisons of 1-star and 5-star CLCs may provide meaningful information for Veterans making decisions about post-acute care. Identifying ways to alter the star ratings so they are differentially associated with outcomes meaningful to Veterans at each level is essential. We found that 1-star facilities had higher rates of 30-day unplanned hospital readmission/death, and lower rates of 100-day successful community discharges compared to 5-star facilities. Yet, like past work on CMS Nursing Home Compare ratings, these relationships were found to be inconsistent or not meaningful across all star levels. CLC Compare may provide useful information for discharge and organizational planning, with some limitations.

National survey of health services provided by pediatric post-acute care facilities in the US

PURPOSE

The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff.

METHODS

An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery.

RESULTS

Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%).

CONCLUSION

PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

Discharge locations after hospitalizations involving opioid use disorder among medicare beneficiaries

BACKGROUND

Hospitalizations involving opioid use disorder (OUD) have been increasing among Medicare beneficiaries of all ages. With rising OUD-related acute care use comes the need to understand where post-acute care is provided and the capacities for OUD treatment in those settings. Our objective was to describe hospitalized Medicare beneficiaries with OUD, their post-acute care locations, and all-cause mortality and readmissions stratified by post-acute care location.

METHODS

We conducted a retrospective cohort study of acute hospitalizations using 2016-2018 Medicare Provider Analysis and Review (MedPAR) files linked to Medicare enrollment data and the Residential History File (RHF) for 100% of Medicare fee-for-service beneficiaries. The RHF which provides a person-level chronological history of health service utilization and locations of care was used to identify hospital discharge locations. We used ICD-10 codes for opioid dependence or "abuse" to identify OUD diagnoses from the MedPAR file. We conducted logistic regression to identify factors associated with discharge to an institutional setting versus home adjusting for demographics, comorbidities, and hospital stay characteristics.

RESULTS

Our analysis included 459,763 hospitalized patients with OUD. Of these, patients aged < 65 years and those dually enrolled in Medicaid comprised the majority (59.1%). OUD and opioid overdose were primary diagnoses in 14.3% and 6.2% of analyzed hospitalizations, respectively. We found that 70.3% of hospitalized patients with OUD were discharged home, 15.8% to a skilled nursing facility (SNF), 9.6% to a non-SNF institutional facility, 2.5% home with home health services, and 1.8% died in-hospital. Within 30 days of hospital discharge, rates of readmissions and mortality were 29.7% and 3.9%; respectively, with wide variation across post-acute locations. Factors associated with greater odds of discharge to institutional settings were older age, female sex, non-Hispanic White race and ethnicity, dual enrollment, longer hospital stay, more comorbidities, intensive care use, surgery, and primary diagnoses including opioid or other drug overdoses, fractures, and septicemia.

CONCLUSIONS

More than one-quarter (25.8%) of hospitalized Medicare beneficiaries with OUD received post-acute care in a setting other than home. High rates and wide variation in all-cause readmissions and mortality within 30 days post-discharge emphasize the need for improved post-acute care for people with OUD.

Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing

BACKGROUND

Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care.

PURPOSE

The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms.

METHODS

We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs-including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach.

RESULTS

We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients.

CONCLUSIONS

We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing.

PRACTICE IMPLICATIONS

SNFs can most effectively respond to these pressures by increasing their agency within hospital-SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.

Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives

BACKGROUND

Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions.

OBJECTIVE

We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions.

DESIGN

Semi-structured interviews with interdisciplinary hospital and SNF providers.

PARTICIPANTS

Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6).

APPROACH

Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs.

KEY RESULTS

Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge.

CONCLUSIONS

As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

Improved outcomes with delayed admission to post-acute care: results of a natural experiment

PURPOSE

To determine the effectiveness of a post-acute care scheme by exploiting a natural experiment.

METHODS

We used a reduction in funding for an Irish PAC scheme based in private nursing homes as a natural experiment to explore the effectiveness of this scheme in a single large general hospital.

RESULTS

Compared with an equivalent 3-month period in 2017 (pre-change, N = 169), those admitted to PAC in 2019 (post-change, N = 179), spent a median 6 days longer in acute care, although total duration spent in healthcare settings was the same. Compared with 2017, readmissions to hospital within 90 days of discharge (43/179 (24.0% v 58/169 (34.3%), p = 0.03) and discharge to long-term care from the PAC facility (3 (1.7%) v 14 (8.3%), p = 0.004) were significantly lower in 2019.

CONCLUSION

Our results suggest that the longer stay in acute care and shorter stay in PAC was beneficial for patients and led to improved outcomes.

Wounds Related to Malignancy in Postacute and Long-term Care: A Case Series

OBJECTIVE

To study the epidemiology and characteristics of wounds related to malignancy in a large, academically affiliated postacute/long-term care (PALTC) facility.

DESIGN

Retrospective case series of 1 year of wound care consultations. Inclusion criteria included a cancer diagnosis with wounds related to malignancy or complications from cancer-related debility and/or treatment.

SETTING

Academically affiliated 514-bed PALTC facility.

PARTICIPANTS

Of 190 consults, 27 residents (14.2%) met the inclusion criteria. Of these, 20 (74.1%) were female, and 7 (25.9%) were male. The average age of residents with a cancer diagnosis and wounds was 69.5 years (range, 48.1-86.7 years), and 25 (92.6%) were on the postacute service.

RESULTS

The most common reasons for consultation included pressure injuries (44.4%), surgical wounds (21.4%), and malignant wounds (14.8%). Seventy-six percent of pressure injuries were present on admission. Breast (29.6%), gastrointestinal (25.9%), and gynecologic (11.1%) malignancies were most common. Of the studied residents, 14 (51.9%) had metastases, and 13 (92.9%) had pressure injuries.

CONCLUSIONS

These findings begin to fill a gap in understanding the spectrum of wounds in PALTC residents with cancer and reinforce the importance of the wound care skill set, including pressure injury prevention. Quality cancer care for older adults must anticipate severe skin complications not only from the tumor and its treatment, but also from the sequelae of immobility, immune compromise, malnutrition, and skin failure. The close association of metastatic disease with pressure injury raises issues of unavoidability and casts new doubt upon the use of pressure injuries for quality measurement.

Physical Function in the Hospital Is Associated With Patient-Centered Outcomes in an Inpatient Rehabilitation Facility

OBJECTIVE

Poor knowledge of the relationships between physical function (PF) in the hospital and patient outcomes in an inpatient rehabilitation facility (IRF) limits the identification of patients most appropriate for discharge to an IRF. This study aimed to test for independent associations between PF measured via the AM-PAC "6-clicks" basic mobility short form in the hospital and outcomes in an IRF.

METHODS

This was a retrospective cohort study. Primary data were collected from an acute hospital and IRF at 1 academic medical center. Associations were tested between PF at hospital admission or discharge and PF improvement in the IRF, discharge from the IRF to the community, and 30-day hospital events by estimating adjusted relative risk (aRR) using modified Poisson regression and the relative difference in IRF length of stay (LOS) using Gamma regression.

RESULTS

A total of 1323 patients were included. Patients with moderately low, (aRR = 1.50; 95% CI = 1.15-1.93), moderately high (aRR = 1.52; 95% CI = 1.16-2.01), or high (aRR = 1.37; 95% CI = 1.02-1.85) PF at hospital discharge were more likely than those with very low PF to improve their PF while in the IRF. These same patients were more likely to discharge from IRF to the community and had significantly shorter IRF LOS. Hospital-measured PF did not differentiate risk for 30-day hospital events.

CONCLUSION

Patients with moderate-but not very low or very high-PF measured near the time of acute hospital discharge were likely to achieve meaningful PF improvement in an IRF. They also had a shorter IRF LOS so may be ideal candidates for discharge to IRF. Prospective studies with larger samples are necessary to test this assertion.

IMPACT

Providers in the hospital should identify patients with moderate PF near the time of hospital discharge as those who may benefit most from post-acute rehabilitation in an IRF.

Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities

BACKGROUND

The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known.

OBJECTIVES

Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals.

RESEARCH DESIGN

Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans.

SUBJECTS

Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient.

MEASURES

Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge.

RESULTS

Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission.

CONCLUSIONS

While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.

Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility

BACKGROUND

Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions.

OBJECTIVE

To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases.

DESIGN

Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians.

SETTING

Three hospitals and three SNFs in a single metropolitan area.

PATIENTS

Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings.

MEASUREMENTS

We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases.

RESULTS

Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs.

CONCLUSIONS

Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.

Cardiac Rehabilitation as Part of Management in Postacute Care: Opportunities for Improving Care

Cardiac rehabilitation is an evidence-based intervention, yet only 20% of eligible patients attend. Participation is even lower for patients discharged to postacute care. The lack of data surrounding the use, benefit, safety, and feasibility of cardiac rehabilitation for elderly cardiac patients has contributed to inaccurate perceptions and related patterns of underuse. However, recently published studies are creating new opportunities for the integration of cardiac rehabilitation into postacute care services. This article reviews the current state of reimbursement and use of cardiac rehabilitation, gaps in services, and opportunities to improve the use of cardiac rehabilitation, and provides recommendations for future research.

Transitional Care Outcomes in Veterans Receiving Post-Acute Care in a Skilled Nursing Facility

BACKGROUND

As the veteran population ages, more veterans are receiving post-acute care in skilled nursing facilities (SNFs). However, the outcomes of these transitions across Veterans Affairs (VA) and non-VA settings are unclear.

OBJECTIVE

To measure adverse outcomes in veterans transitioning from hospital to SNF in VA and non-VA hospitals and SNFs.

DESIGN

Retrospective observational study using the 2012 to 2014 Residential History File, which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for veterans.

SETTING

VA and non-VA hospitals and SNFs in four categories: non-VA SNFs, VA-contracted SNFs, VA Community Living Centers (CLCs), and State Veterans Homes.

PARTICIPANTS

Veterans, aged 65 years or older, who were acutely hospitalized and discharged to an SNF; one transition was randomly selected per patient.

MEASUREMENTS

Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge.

RESULTS

More than four in five veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7% in the 388 339 veterans included. Adverse outcomes were lowest in VA hospital-CLC transitions (7.5%; 95% confidence interval [CI] = 7.1%-7.8%) and highest in non-VA hospital to VA-contracted nursing home transitions (17.5%; 95% CI = 16.0%-18.9%) in unadjusted analysis. In multivariate analyses adjusted for patient and hospital characteristics, VA hospitals had lower adverse outcome rates than non-VA hospitals (odds ratio [OR] = 0.80; 95% CI = 0.74-0.86). In comparison to VA hospital-VA CLC transitions, non-VA hospital to VA-contracted nursing homes (OR = 2.51; 95% CI = 2.09-3.02) and non-VA hospital to CLC (OR = 2.25; 95% CI = 1.81-2.79) had the highest overall adverse outcome rates.

CONCLUSION

Most veteran hospital-SNF transitions occur outside the VA, although adverse transitional care outcomes are lowest inside the VA. These findings raise important questions about the VA's role as a provider and payer of post-acute care in SNFs. J Am Geriatr Soc 67:1820-1826, 2019.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care

BACKGROUND

Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization.

OBJECTIVE

We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF.

DESIGN

Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making.

PARTICIPANTS

Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities.

MAIN MEASURES

We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame.

KEY RESULTS

The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome.

CONCLUSIONS

Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

Predicting Potential Adverse Events During a Skilled Nursing Facility Stay: A Skilled Nursing Facility Prognosis Score

OBJECTIVES

To derive a risk prediction score for potential adverse outcomes in older adults transitioning to a skilled nursing facility (SNF) from the hospital.

DESIGN

Retrospective analysis.

SETTING

Medicare Current Beneficiary Survey (2003-11).

PARTICIPANTS

Previously community-dwelling Medicare beneficiaries who were hospitalized and discharged to SNF for postacute care (N=2,043).

MEASUREMENTS

Risk factors included demographic characteristics, comorbidities, health status, hospital length of stay, prior SNF stays, SNF size and ownership, treatments received, physical function, and active signs or symptoms at time of SNF admission. The primary outcome was a composite of undesirable outcomes from the patient perspective, including hospital readmission during the SNF stay, long SNF stay (≥100 days), and death during the SNF stay.

RESULTS

Of the 2,043 previously community-dwelling beneficiaries hospitalized and discharged to a SNF for post-acute care, 589 (28.8%) experienced one of the three outcomes, with readmission (19.4%) most common, followed by mortality (10.5%) and long SNF stay (3.5%). A risk score including 5 factors (Barthel Index, Charlson-Deyo comorbidity score, hospital length of stay, heart failure diagnosis, presence of an indwelling catheter) demonstrated very good discrimination (C-statistic=0.75), accuracy (Brier score=0.17), and calibration for observed and expected events.

CONCLUSION

Older adults frequently experience potentially adverse outcomes in transitions to a SNF from the hospital; this novel score could be used to better match resources with patient risk.