Paying for Nursing Home Quality: An Elusive But Important Goal

Impact of dementia special care units for short-stay nursing home patients

BACKGROUND

Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients.

METHODS

We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool.

RESULTS

The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode.

CONCLUSIONS

Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.

Increasing illness severity of skilled nursing facility patients over time: Implications for readmission penalties

BACKGROUND

Current financial penalties for rehospitalization of skilled nursing facilities (SNFs) patients are based in part on the studies by Ouslander et al., 2011, and Mor et al., 2010, demonstrating that many SNF hospitalizations were avoidable. With increasing age, complex illness severity, and use of SNFs for subacute rehabilitation, readmission metrics and financial penalties based on previous data may be due for reevaluation.

METHODS

Retrospective electronic medical record (EMR) review of 21,591 admissions and discharges between 2010 and 2019 inclusive. Data extracted included demographics, LACE, Charlson comorbidity index (CCI), and simplified HOSPITAL score parameters. The scores were calculated for the study years from the extracted data. Patients readmitted to the hospital within 30 days were identified.

RESULTS

Mean yearly score of all three indices rose steadily: LACE score 10.76-12.04 (0.43 estimated annual increase, 95% CI [0.39, 0.46]), CCI 4.26-5.05 (0.31 estimated annual increase, 95% CI [0.27, 0.34]), and simplified HOSPITAL score 3.46-4.03 (0.21 estimated annual increase, 95% CI [0.18, 0.24]). The estimated probability of readmission across observed CCI scores ranged from 15.4% to 15.9%, 95% CI bounds (10.8%, 22.7%). The estimated probability of readmission across observed LACE scores ranged from 4.7% to 36.3%, 95% CI bounds (3.4%, 54.7%). The estimated probability of readmission across observed HOSPITAL scores ranged from 5.8% to 54.1%, 95% CI bounds (6.2%, 66.0%).

CONCLUSIONS AND IMPLICATIONS

The study confirms anecdotal experience that the illness acuity of patients admitted to SNFs increased progressively over time and was associated with an increased risk of 30-day readmissions to the hospital. Our study suggests that the use of clinically validated readmission risk assessment tools instead of the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP) current risk adjustors may be a more accurate reflection of the current illness severity of a facility's patient population at the time of payment adjustment.

The balance of prescriptive and dynamic regulatory policies in nursing homes: Lessons learned from the COVID-19 pandemic

See related Brief report by Festa et al. in this issue.