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Lin SC, Zheng J, Epstein A, Orav EJ, Barnett M, Grabowski DC, Joynt Maddox KE. The extended impact of the COVID-19 pandemic on long-term care residents in Medicare with frailty or dual Medicaid enrollment. J Am Geriatr Soc 2024. [PMID: 39143027 DOI: 10.1111/jgs.19131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/10/2024] [Accepted: 07/13/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Although many healthcare settings have since returned to pre-pandemic levels of operation, long-term care (LTC) facilities have experienced extended and significant changes to operations, including unprecedented levels of short staffing and facility closures, that may have a detrimental effect on resident outcomes. This study assessed the pandemic's extended effect on outcomes for LTC residents, comparing outcomes 1 and 2 years after the start of the pandemic to pre-pandemic times, with special focus on residents with frailty and dually enrolled in Medicare and Medicaid. METHODS Using Medicare claims data from January 1, 2018, through December 31, 2022, we ran over-dispersed Poisson models to compare the monthly adjusted rates of emergency department use, hospitalization, and mortality among LTC residents, comparing residents with and without frailty and dually enrolled and non-dually enrolled residents. RESULTS Two years after the start of the pandemic, adjusted emergency department (ED) and hospitalization rates were lower and adjusted mortality rates were higher compared with pre-pandemic years for all examined subgroups. For example, compared with 2018-2019, 2022 ED visit rates for dually enrolled residents were 0.89 times lower, hospitalization rates were 0.87 times lower, and mortality rates were 1.17 higher; 2022 ED visit rates for frail residents were 0.85 times lower, hospitalization rates were 0.83 times lower, and mortality rates were 1.21 higher. CONCLUSIONS In 2022, emergency department and hospital utilization rates among long-term residents were lower than pre-pandemic levels and mortality rates were higher than pre-pandemic levels. These findings suggest that the pandemic has had an extended impact on outcomes for LTC residents.
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Affiliation(s)
- Sunny C Lin
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Center for Advancing Health Services, Policy & Economics Research, Institute of Public Health at Washington University, St. Louis, Missouri, USA
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Arnold Epstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen E Joynt Maddox
- Center for Advancing Health Services, Policy & Economics Research, Institute of Public Health at Washington University, St. Louis, Missouri, USA
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Beauvais B, Mileski M, Ramamonjiarivelo Z, Lee KA, Kruse CS, Betancourt J, Pradhan R, Shanmugam R. The Association Between Facility Affiliations and Revenue Generation in Skilled Nursing Facilities - An Exploratory Study. J Multidiscip Healthc 2023; 16:3099-3114. [PMID: 37901598 PMCID: PMC10612498 DOI: 10.2147/jmdh.s433771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
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.
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Affiliation(s)
- Bradley Beauvais
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Michael Mileski
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Zo Ramamonjiarivelo
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Kimberly Ann Lee
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Clemens Scott Kruse
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Jose Betancourt
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Rohit Pradhan
- School of Health Administration, Texas State University, San Marcos, TX, USA
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Chen AC, Epstein AM, Joynt Maddox KE, Grabowski DC, Orav EJ, Barnett ML. Care delivery approaches and perceived barriers to improving quality of care: A national survey of skilled nursing facilities. J Am Geriatr Soc 2023; 71:2141-2150. [PMID: 36918371 PMCID: PMC10363227 DOI: 10.1111/jgs.18331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/08/2023] [Accepted: 02/12/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Nursing home quality of care is a persistent challenge, with recent reports calling for increased reforms to improve quality and safety. Less is known about the clinical approaches currently used and the barriers perceived by skilled nursing facilities (SNFs) to provide care for their short-stay residents. METHODS We conducted a nationally representative survey of SNFs from October 2020 to May 2021 to understand their care delivery approaches and perceived barriers. Our primary outcomes were the reported number of 23 separate care delivery approaches and the reported number of 12 separate barriers to reduce spending or improve care for SNF short-stay residents. We also performed stratified analyses by facility participation in bundled payments and other SNF characteristics. RESULTS We received 377 responses from 693 SNFs contacted (response rate = 54%). SNFs reported an average of 16.8 care delivery approaches and an average of 5.0 barriers. While there were some differences observed in SNF characteristics, such as by bundled payments participation or ownership type, there were common care delivery approaches and barriers shared by most facilities. Care management practices, including reviewing the patient census and medication reconciliation on discharge, were the most common delivery approaches reported. SNFs were less likely to ensure the completion of a follow-up appointment with a primary care provider or track repeat emergency room visits. Issues concerning staffing, such as staff turnover and/or burnout, and lack of resources to provide patients social support, mental health, and substance use services, were the most cited barriers to care delivery. CONCLUSIONS Nationally, SNFs implemented a wide array of care delivery approaches, but challenges with staffing and limited resources to address patients' social and mental health needs were dominant. Individual SNFs may have limited ability to address these key barriers, so the involvement of many stakeholders across the entire healthcare system may be necessary.
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Affiliation(s)
- Amanda C Chen
- Harvard Graduate School of Arts and Sciences, Boston, Massachusetts, USA
| | - Arnold M Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Karen E Joynt Maddox
- Center for Economics and Policy, Institute of Public Health at Washington University, St. Louis, Missouri, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Ying M, Thirukumaran CP, Temkin-Greener H, Joynt Maddox KE, Holloway RG, Li Y. Association of Skilled Nursing Facility Participation in Voluntary Bundled Payments With Postacute Care Outcomes for Joint Replacement. Med Care 2023; 61:109-116. [PMID: 36630561 DOI: 10.1097/mlr.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. OBJECTIVE To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). DESIGN, SETTING, AND PARTICIPANTS Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. RESULTS Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. CONCLUSIONS Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.
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Affiliation(s)
- Meiling Ying
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Caroline P Thirukumaran
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Helena Temkin-Greener
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Medicare’s Bundled Payments For Care Improvement Advanced Model: Impact On High-Risk Beneficiaries. Health Aff (Millwood) 2022; 41:1661-1669. [DOI: 10.1377/hlthaff.2022.00138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - E. John Orav
- E. John Orav, Harvard University and Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Arnold M. Epstein
- Arnold M. Epstein, Harvard University and Brigham and Women’s Hospital
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Thirukumaran CP. Lessons from Medicare's Bundled Payments for Care Improvement initiative for postacute care. J Am Geriatr Soc 2021; 69:3410-3412. [PMID: 34510413 DOI: 10.1111/jgs.17439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Caroline P Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York, USA.,Department of Public Health Sciences, University of Rochester, Rochester, New York, USA.,Center for Musculoskeletal Research, University of Rochester, Rochester, New York, USA
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