Community Discharge of Nursing Home Residents: The Role of Facility Characteristics

Institutional Special Needs Plans In Nursing Homes: Substantial Enrollment Growth But Low Availability, 2006-21

Institutional Special Needs Plans (I-SNPs) are a type of Medicare Advantage (MA) plan designed for long-term residents of nursing homes or those who live in the community but need a nursing home level of care. I-SNPs provide for on-site nurse practitioners in nursing homes to help improve primary care, care planning, and care coordination. Our study was the first to undertake a nationwide descriptive analysis of the I-SNP market. The share of long-stay nursing home residents enrolled in I-SNPs quadrupled from 2006 to 2021, from 2.2 percent to 8.8 percent. Despite this growth, nearly 70 percent of nursing homes did not have any residents enrolled in I-SNPs in 2021, and in more than 60 percent of US counties, there were no I-SNPs available. Nearly 94 percent of long-stay nursing home residents who were enrolled in I-SNPs in 2021 were eligible for both Medicare and Medicaid. More research is needed to understand why I-SNPs enter certain markets and why long-stay nursing home residents choose to enroll in them; to assess I-SNP enrollment barriers; and to compare hospital admission rates and quality outcomes among long-stay nursing home residents by I-SNP enrollment status. Increased understanding of I-SNPs could inform policies to address long-standing concerns about the quality of care in nursing homes.

Natural Language Processing Applied to Clinical Documentation in Post-acute Care Settings: A Scoping Review

OBJECTIVES

To determine the scope of the application of natural language processing to free-text clinical notes in post-acute care and provide a foundation for future natural language processing-based research in these settings.

DESIGN

Scoping review; reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

SETTING AND PARTICIPANTS

Post-acute care (ie, home health care, long-term care, skilled nursing facilities, and inpatient rehabilitation facilities).

METHODS

PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched in February 2023. Eligible studies had quantitative designs that used natural language processing applied to clinical documentation in post-acute care settings. The quality of each study was appraised.

RESULTS

Twenty-one studies were included. Almost all studies were conducted in home health care settings. Most studies extracted data from electronic health records to examine the risk for negative outcomes, including acute care utilization, medication errors, and suicide mortality. About half of the studies did not report age, sex, race, or ethnicity data or use standardized terminologies. Only 8 studies included variables from socio-behavioral domains. Most studies fulfilled all quality appraisal indicators.

CONCLUSIONS AND IMPLICATIONS

The application of natural language processing is nascent in post-acute care settings. Future research should apply natural language processing using standardized terminologies to leverage free-text clinical notes in post-acute care to promote timely, comprehensive, and equitable care. Natural language processing could be integrated with predictive models to help identify patients who are at risk of negative outcomes. Future research should incorporate socio-behavioral determinants and diverse samples to improve health equity in informatics tools.

Nursing Homes Underreport Antipsychotic Use but Overreport Diagnoses Qualifying for Appropriate Use

Antipsychotic drug use in U.S. nursing homes remains a priority concern, but less is understood about the characteristics associated with reporting. Using linked Medicare claims and Minimum Data Set (MDS) assessments for long-stay nursing home residents from January 2018 to December 2019, we assessed the consistency of antipsychotic drug reporting and diagnosis of conditions (schizophrenia, Tourette's syndrome, and Huntington's disease) which qualify as appropriate drug use across data sources by calculating reporting rates in facility-reported MDS and Medicare claims. The antipsychotic reporting outcome is conditional on claims reporting while the condition reporting outcomes are conditional on MDS reporting. We found underreporting (87% reporting rate) in facility-reported antipsychotic use relative to Medicare claims. In contrast, we found overreporting of the qualifying conditions with a number of facility-reported diagnoses unsupported by a corresponding claims diagnosis. Only 54.8% of schizophrenia, 46.5% of Tourette's syndrome, and 72.4% of Huntington's disease diagnoses reported in the MDS had a claims diagnosis. There was also variation in reporting odds for antipsychotic drug use by dual-eligibility status and race, with higher odds for dual-eligible and lower odds for Black residents These findings suggest CMS should continue investigating the source of reporting discrepancies in antipsychotic drug use and qualifying diagnoses.

Life-space mobility and post-hospitalization outcomes among older Mexican American Medicare beneficiaries

BACKGROUND

Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries.

METHODS

Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes.

RESULTS

Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores.

CONCLUSIONS

Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults.

Community Discharge Among Post-Acute Nursing Home Residents: An Association With Patient Safety Culture?

OBJECTIVES

We examined whether better patient safety culture (PSC) in skilled nursing facilities was associated with higher likelihood of successful community discharge for post-acute care residents.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Medicare beneficiaries who were newly admitted for post-acute care (N = 53,929) to skilled nursing facilities participating in PSC survey (N = 818).

METHODS

Facility-level PSC scores were obtained from a national, random survey conducted in 2017. Survey data was linked to Minimum Dataset 3.0, Medicare Provider Analysis and Review, Master Beneficiary Summary File, Nursing Home Compare File, Payroll-Based Journal, and Areal Health Resources File. Successful discharge to community was the outcome of interest. Facility-level PSC scores were the key covariate. We controlled for individual-level, facility-level, and area-level characteristics. Separate logistic regression models for each of the 12 PSC domains and for the overall score were fit.

RESULTS

Post-acute care residents who were successfully discharged to community were more likely to be female (63.7%), white (87.1%), Medicare-only (88.1%), cognitively intact (87.8%), and admitted following a surgery (40.9%) The multivariable analyses showed that teamwork (odds ratio 1.09, P = .02) and supervisor expectations and actions promoting resident safety (odds ratio 1.11, P = .01) were significantly associated with the increased likelihood of successful community discharge.

CONCLUSIONS AND IMPLICATIONS

This is the first study to analyze the relationship between patient safety culture and successful discharge among post-acute care residents. Our results suggest that nursing home leaders may want to focus their quality and safety improvement efforts on specific PSC domains (eg, teamwork) as means for improving community discharge for post-acute care residents.

Successful Discharge to Community Gap of FFS Medicare Beneficiaries With and Without ADRD Narrowed

BACKGROUND/OBJECTIVES

We sought to compare the post-acute and long-term care experience of Medicare beneficiaries with and without Alzheimer Disease and Related Dementias (ADRD), and whether differences changed from January 1, 2007 to September 30, 2015.

DESIGN

Retrospective cross-sectional trend study using Medicare claims linked to the Centers for Medicare & Medicaid Services' (CMS) Minimum Data Set.

SETTING

CMS-certified skilled nursing facilities (skilled nursing facility (SNF), n = 17,043).

PARTICIPANTS

Fee-for-service Medicare beneficiaries aged ≥66 years (n = 6,614,939) discharged from a hospital to a SNF who had not lived in a nursing home during the year before hospitalization.

MEASUREMENTS

ADRD was defined by the Chronic Condition Data Warehouse. Outcome measures included: (1) successful discharge defined as being in SNF less than 90 days, then discharged back to the community, alive without subsequent inpatient health care for 30 continuous days; (2) became long-stay resident in SNF; (3) death in SNF within 90 days; (4) hospital readmission within 30 days of entering SNF; and (5) transferred to another nursing home within 30 days of entering SNF.

RESULTS

Successful discharge of beneficiaries with ADRD increased from 43.4% in 2007 to 53.9% in 2015 (average annual percent change (AAPC) = 2.1 (95% CI = 2.0-2.2)); those without ADRD also increased (from 59.1% to 63.6%, AAPC = 0.9 (95% CI = 0.7-1.1)) but not as fast as those with ADRD (P < .01). The proportion of all beneficiaries who became long-stay or were readmitted to the hospital decreased (P < .05). The proportion with ADRD who became long-stay was nearly three times higher than those without throughout the study (15.0% vs 5.5% in 2007; 11.3% vs 4.3% in 2015).

CONCLUSION

Though disparity in ADRD in becoming long-stay residents remains, the increase in successful discharges among those with ADRD also stresses the increasing importance of community as a care setting for adults with ADRD.

Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death

The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.

Challenges to community transitions through Money Follows the Person

OBJECTIVE

To examine the effects of transition challenges on the success and timeliness of transitions from institutions to community living for long-stay participants in the Money Follows the Person (MFP) Rebalancing Demonstration and determine whether outcomes vary by age and disability.

DATA SOURCE

Secondary data on transition challenges for individuals enrolled in Connecticut's MFP program between December 2008 and December 2017.

STUDY DESIGN

Challenges were analyzed for older adults, people with mental health disability, and people with physical disability. Bivariate and multivariate analyses investigated which transition challenges and selected demographic variables predict transition versus closure and length of transition period for each group.

DATA EXTRACTION METHODS

The sample includes 3506 persons who attempted transition from institutions to community living and whose case concluded with transition or closure from 2015 to 2017.

PRINCIPAL FINDINGS

The association between most transition challenges and the ability of long-stay institutional residents to return to the community, and to do so in a timely manner, varies significantly among older adults and younger persons with physical or mental health disabilities. For all groups, however, consumer engagement challenges predicted closure without transition (OR: 1.3-3.9) and housing challenges predicted longer transition periods (84-132 days). Length of institutional stay was associated with both outcomes for older adults and persons with physical disability. Other challenges, such as issues with services and supports, differed among the three groups on both outcomes.

CONCLUSIONS

Knowledge of the effects of transition challenges on success and timeliness of transition for each group allows program managers and health and service providers to focus resources on addressing the most serious challenges. Particular emphasis should be placed on consumer engagement and housing challenges, and on targeting persons for transition early in their institutional stay. Federal and state transition programs can benefit by individualizing supports for residents to yield successful outcomes.

Reengineering Skilled Nursing Facility Discharge: Analysis of Reengineered Discharge Implementation

BACKGROUND

There is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population.

PURPOSE

This article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation.

METHODS

The methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities.

RESULTS

Standard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation.

CONCLUSION

This research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.

Nursing Home Compare Star Rankings and the Variation in Potentially Preventable Emergency Department Visits and Hospital Admissions

Measurement of the quality of US health care increasingly emphasizes clinical outcomes over clinical processes. Nursing Home Compare Star Ratings are provided by Medicare to help select better nursing home care. The authors determined the rates and types of 2 important clinical outcomes-potentially preventable hospital admissions and potentially preventable emergency department (ED) visits-for a subset of 439,011 long-term nursing homes residents residing in 12,883 nursing homes throughout the United States over a 2-year period (2010-2011) and compared them with the Star Rating system. This study found that (1) the likelihood of potentially preventable events increases with increasing burden of chronic illness, (2) the principle reasons for hospital admissions and ED visits (eg, septicemia, pneumonia, confusion, gastroenteritis) are not part of existing nursing home quality measures, (3) the rate of potentially preventable admissions and ED visits for nursing homes residents varies greatly both across and within states, with 5 states having in excess of 20% more than the national average for both, and (4) the Nursing Home Compare Stars measure has limited correlation with rates of these potentially preventable events. Nursing Home Compare Star rankings could benefit by incorporating outcomes measures such as preventable hospitalizations and ED visits, and by comparing nursing home performance on results drawn from across states rather than within them. Such reform could better help users find nursing homes of higher quality and stimulate homes to improve quality in ways that benefit residents.

Nutritional status is associated with the return home in a long-term care health facility

Background

The purpose of this study was to determine the association between nutritional status and the return home of older people living in a long‐term care health facility (LCHF).

Methods

A nested case control study was performed in 116 people ≥65 years of age in a single LCHF. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA‐SF) and activities of daily living by the Functional Independence Measure (FIM). The return home, duration of rehabilitation, and the family wanting the patient to return home were obtained from clinical records. Multivariate logistic regression analysis was used to assess whether malnutrition had independent effects on the return home.

Results

The participants included 36 males and 80 females with a mean age of 82 years. Thirty‐seven people returned home while 79 did not. The MNA‐SF showed that 80 subjects were malnourished. Sixty‐six of the participants received rehabilitation for longer than 1 hour per week, while 50 received rehabilitation for <1 hour. The proportion of subjects with malnutrition who returned home was significantly lower (P = .003) than in participants who did not return home. Multivariate logistic regression analysis showed that malnutrition (adjusted odds ratio [AOR], 0.23; 95% confidence interval [CI], 0.08‐0.65; P = .006), total FIM score (AOR, 1.03; 95% CI, 1.01‐1.06; P = .012), and the family wanting the patient to return home (AOR, 9.46; 95% CI, 3.19‐28.12; P < .001) were independently associated with the return home.

Conclusions

Nutritional status is associated with the return home in older people living in LCHF.

Trajectories Over the First Year of Long-Term Care Nursing Home Residence

OBJECTIVES

To describe the trajectories in the first year after individuals are admitted to long-term care nursing homes.

DESIGN

Retrospective cohort study.

SETTING

US long-term care facilities.

PARTICIPANTS

Medicare fee-for-service beneficiaries newly admitted to long-term care nursing homes from July 1, 2012, to December 31, 2013 (N=535,202).

MEASUREMENTS

Demographic characteristics were from Medicare data. Individual trajectories were conducted using the Minimum Data Set for determining long-term care stays and community discharge, and Medicare Provider and Analysis Reviews claims data for determining hospitalizations, skilled nursing facility stays, inpatient rehabilitation, long-term acute hospital and psychiatric hospital stays.

RESULTS

The median length of stay in a long-term care nursing home over the 1 year following admission was 127 [interquartile range (IQR): 24, 356] days. The median length of stay in any institution was 158 (IQR: 38, 365). Residents experienced a mean of 2.1  ± 2.8 (standard deviation) transitions over the first year. The community discharge rate was 36.5% over the 1-year follow-up, with 20.8% discharged within 30 days and 31.2% discharged within 100 days. The mortality rate over the first year of nursing home residence was 35.0%, with 16.3% deaths within 100 days. At 12 months post long-term care admission, 36.9% of the cohort were in long-term care, 23.4% were in community, 4.7% were in acute care hospitals or other institutions, and 35.0% had died.

CONCLUSION

After a high initial community discharge rate, the majority of patients newly admitted to long-term care experienced multiple transitions while remaining institutionalized until death or the end of 1-year follow-up.

Modeling Community Discharge of Medicaid Nursing Home Residents: Implications for Money Follows the Person

OBJECTIVE

To build and test a model that predicts community discharge probabilities for Medicaid-eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program.

DATA SOURCE

The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file.

DATA

Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013.

STUDY DESIGN

Mixed effects logistic regression model to predict community discharge.

PRINCIPAL FINDINGS

The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range.

CONCLUSIONS

Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid-eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states.

Factors affecting residents transition from long term care facilities to the community: a scoping review

BACKGROUND

Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community.

METHODS

This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person's own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review.

RESULTS

The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community.

CONCLUSIONS

Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.

Factors affecting residents transition from long term care facilities to the community: a scoping review

Background

Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community.

Methods

This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person’s own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review.

Results

The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community.

Conclusions

Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.

Postacute Care Setting, Facility Characteristics, and Poststroke Outcomes: A Systematic Review

OBJECTIVES

To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes.

DATA SOURCES

PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English.

STUDY SELECTION

Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ≥1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included.

DATA EXTRACTION

The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer.

DATA SYNTHESIS

Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation.

CONCLUSIONS

The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.