Inclusion of Nursing Homes and Long-term Residents in Medicare ACOs

Transfer Trauma Among Nursing Home Residents: Development of a Composite Measure

BACKGROUND AND OBJECTIVES

Nursing home (NH)-to-NH transfers place NH residents at risk for developing transfer trauma. We aimed to develop a composite measure of transfer trauma and apply it among those transferring before and during the pandemic.

RESEARCH DESIGN AND METHODS

Cross-sectional cohort analysis of long-stay NH residents with a NH-to-NH transfer. Minimum Data Set data (2018-2020) were used to create the cohorts. A composite measure of transfer trauma was developed (2018 cohort) and applied to the 2019 and 2020 cohorts. We analyzed resident characteristics and conducted logistic regression analyses to compare rates of transfer trauma between periods.

RESULTS

In 2018, 794 residents were transferred; 242 (30.5%) met the criteria for transfer trauma. In the 2019 and 2020, 750 residents (2019) and 795 (2020) were transferred. In 2019 cohort, 30.7% met the criteria for transfer trauma, and 21.9% in 2020 cohort. During the pandemic, a higher proportion of transferred residents left the facility before the first quarterly assessment. Among residents who stayed in NH for their quarterly assessment, after adjusting for demographic characteristics, residents in the 2020 cohort were less likely to experience transfer trauma than those in the 2019 cohort (adjusted odds ratio [AOR] = 0.64, 95% confidence interval [CI]: 0.51, 0.81). However, residents in 2020 cohort were two times more likely to die (AOR = 1.94, 95% CI: 1.15, 3.26) and 3 times more likely to discharge within 90 days after transfer (AOR = 2.86, 95% CI: 2.30, 3.56) compared with those in 2019 cohort.

DISCUSSION AND IMPLICATIONS

These findings highlight how common transfer trauma is after NH-to-NH transfer and the need for further research to mitigate negative outcomes associated with the transfer in this vulnerable population.

The Association Between Facility Affiliations and Revenue Generation in Skilled Nursing Facilities - An Exploratory Study

Background

Although hospitals have been the traditional setting for interventional and rehabilitative care, skilled nursing facilities (SNFs) can offer a high-quality and less costly alternative than hospitals. Unfortunately, the financial health of SNFs is often a matter of concern. To partially address these issues, SNF leaders have increased engagement in a number of affiliations to assist in improving quality and reducing operational costs, including Accountable Care Organizations (ACOs), Health Information Exchanges (HIEs), and participation in Bundled Payment for Care Improvement (BPCI) programs. What is not well understood is what impact these affiliations have on the financial viability of the host organizations. Given these factors, this study aims to identify what association, if any, exists between SNF affiliations and revenue generation.

Methods

Data from calendar year 2022 for n=13,447 SNFs in the US were assessed using multivariate regression analysis. We evaluated two separate dependent measures of revenue generation capacity: net patient revenue per bed and net patient revenue per discharge and considered three unique facility affiliations including (1) ACOs, (2) HIEs, and (3) BPCI participants.

Results

Six multivariable linear regressions revealed that ACO affiliation is negatively associated with revenue generation on both dependent measures, while HIE affiliation and BPCI participation reflected mixed results.

Conclusion

A better understanding of the financial impact of SNFs' affiliations may prove insightful. By carefully considering the value of each affiliation, and how each is applicable to any given market, policymakers, funding agencies, and facility leaders may be able to better position SNFs for more sustainable financial performance in a challenging economic environment.

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia

BACKGROUND

Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown.

OBJECTIVE

The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status.

RESEARCH DESIGN

Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns.

SUBJECTS

A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey.

MEASURES

We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status.

RESULTS

Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05).

CONCLUSION

Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.

Nursing Home to Nursing Home Transfers during the Early COVID-19 Pandemic

OBJECTIVES

To examine the nursing home to nursing home transfer rates before and during the early COVID-19 pandemic and to identify risk factors associated with those transfers in a state with a policy to create COVID-19-care nursing homes.

DESIGN

Cross-sectional cohorts of nursing home residents in prepandemic (2019) and COVID-19 (2020) periods.

SETTING AND PARTICIPANTS

Michigan long-term nursing home residents were identified from the Minimum Data Set.

METHODS

Each year, we identified transfer events as a resident's first nursing home to nursing home transfer between March and December. We included residents' characteristics, health status, and nursing home characteristics to identify risk factors for transfer. Logistic regression models were conducted to determine risk factors for each period and changes in transfer rates between the 2 periods.

RESULTS

Compared to the prepandemic period, the COVID-19 period had a higher transfer rate per 100 (7.7 vs 5.3, P < .05). Age ≥80 years, female sex, and Medicaid enrollment were associated with a lower likelihood of transfer for both periods. During the COVID-19 period, residents who were Black, with severe cognitive impairment, or had COVID-19 infection were associated with a higher risk of transfer [adjusted odds ratio (AOR) (95% CI): 1.46 (1.01-2.11), 1.88 (1.11-3.16), and 4.70 (3.30-6.68), respectively]. After adjusting for resident characteristics, health status, and nursing home characteristics, residents had 46% higher odds [AOR (95% CI): 1.46 (1.14-1.88)] of being transferred to another nursing home during the COVID-19 period compared to the prepandemic period.

CONCLUSIONS AND IMPLICATIONS

In the early COVID-19 pandemic, Michigan designated 38 nursing homes to care for residents with COVID-19. We found a higher transfer rate during the pandemic than during the prepandemic period, especially among Black residents, residents with COVID-19 infection, or residents with severe cognitive impairment. Further investigation is warranted to understand the transfer practice better and if any policies would mitigate the transfer risk for these subgroups.

COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now

Policy Points To address systemic problems amplified by COVID-19, we need to restructure US long-term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near-term and long-term policy solutions. Seven near-term policy recommendations include requiring the uniform public reporting of COVID-19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations. Long-term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age-friendly public health system.

CONTEXT

The heavy toll of COVID-19 brings the failings of the long-term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID-19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long-term disinvestment and neglect of state- and local-level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.

METHODS

We analyze several impacts of the COVID-19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states' fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.

FINDINGS

We propose seven near-term actions that US policymakers could take: implementing a uniform public reporting of COVID-19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age-friendly public health system.

CONCLUSIONS

COVID-19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations

OBJECTIVES

Nursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use.

DESIGN

Observational propensity-matched study.

SETTING AND PARTICIPANTS

Medicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration.

METHODS

ACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending.

RESULTS

Nearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents' attribution status switched (14.6%), either into or out of an ACO.

CONCLUSIONS AND IMPLICATIONS

ACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.