Dual Eligibility, Selection of Skilled Nursing Facility, and Length of Medicare Paid Postacute Stay

Factors Influencing Hospitalization of Nursing Home Residents in Korea Using Regularized Negative Binomial Regression

The appropriateness of hospitalization for nursing home (NH) residents is still up for debate, with determining factors including timeliness, available treatment, healthcare staff, medication options in hospitals, and safety issues. Although the factors leading to hospitalization have been studied expansively, research on staffing is limited. Thus, this study aimed to investigate organizational predictors, nurse staffing, and government incentives and find important factors to hospitalization due to infection or disease among NH residents in Korea. A cross-sectional design was used, and data were collected via survey from a total of 51 NHs from August 27, 2021 to March 25, 2022. A total of 32 explanatory variables were included. The response variable was the count of hospitalized residents due to infection or disease. We analyzed data using least absolute shrinkage and negative binomial regression. We found that registered nurses' increased hours per resident day were related to decreased hospitalizations due to infection or disease. Appropriate retention and recruitment of nurse staffing with professional leadership should be performed to increase the quality of care for NH residents.

The health effects of nursing home specialization in post-acute care

Nursing homes serve both long-term care and post-acute care (PAC) patients, two groups with distinct financing mechanisms and requirements for care. We examine empirically the effect of nursing home specialization in PAC using 2011-2018 data for Medicare patients admitted to nursing homes following a hospital stay. To address patient selection into specialized nursing homes, we use an instrumental variables approach that exploits variation over time in the distance from the patient's residential ZIP code to the closest nursing home with different levels of PAC specialization. We find that patients admitted to nursing homes more specialized in PAC have lower hospital readmissions and mortality, longer nursing home stays, and higher Medicare spending for the episode of care, suggesting that specialization improves patient outcomes but at higher costs.

Risk of Discharge to Lower-Quality Nursing Homes Among Hospitalized Older Adults With Alzheimer Disease and Related Dementias

IMPORTANCE

Individuals with Alzheimer disease and related dementias (ADRD) frequently require skilled nursing facility (SNF) care following hospitalization. Despite lower SNF incentives to care for the ADRD population, knowledge on how the quality of SNF care differs for those with vs without ADRD is limited.

OBJECTIVE

To examine whether persons with ADRD are systematically admitted to lower-quality SNFs.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of Medicare beneficiaries hospitalized between January 1, 2017, and December 31, 2019, was conducted. Data analysis was performed from January 15 to May 30, 2022. Participants were discharged to a Medicare-certified SNF from a general acute hospital. Patients younger than 65 years, enrolled in Medicare Advantage, and with prior SNF or long-term nursing home use within 1 year of hospitalization were excluded.

EXPOSURES

The quality level of all SNFs available at the patient's discharge, measured using publicly reported 5-star staffing ratings. The 5-star ratings were grouped into 3 levels (1-2 stars [reference category, low-quality], 3 stars [average-quality], and 4-5 stars [high-quality]).

MAIN OUTCOMES AND MEASURES

The outcome was the SNF a patient entered among the possible SNF destinations available at discharge. Differences in the association between SNF quality and SNF entry for patients with and without ADRD were assessed using a conditional logit model, which simultaneously controls for differences in discharging hospital, residential neighborhood, and the other characteristics (eg, postacute care specialization) of all SNFs available at discharge.

RESULTS

The sample included 2 619 464 patients (mean [SD] age, 81.3 [8.6] years; 61% women; 87% were White; 8% were Black; 22% with ADRD). The probability of discharge to higher quality SNFs was lower for patients with ADRD. If the star rating of an SNF was high instead of low, the log-odds of being discharged to it increased by 0.31 for patients with ADRD and by 0.47 for those without ADRD (difference, -0.16; P < .001). The weaker association between quality and entry for patients with ADRD indicates that they are less likely to be discharged to high-quality SNFs.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with ADRD are more likely to be discharged to lower-quality SNFs. Targeted reforms, such as ADRD-specific compensation adjustments, may be needed to improve access to better SNFs for patients with ADRD.

Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status

OBJECTIVE

To evaluate how post-acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare-Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market-level factors associated with PAC; (3) the association between PAC and outcomes.

DATA SOURCES/STUDY SETTING

We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI).

STUDY DESIGN

This observational study consisted of 619,262 community-residing Medicare fee-for-service (FFS) beneficiaries with ADRD who had a hospital stay in 2017.

DATA COLLECTION/EXTRACTION METHODS

PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30-day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit.

PRINCIPAL FINDINGS

Dual-related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%-points for non-duals and duals, respectively. The difference between non-dual/dual White patients was 21.6% points, and among Black patients 18.0%-points. The adjusted risk of 30-day readmission was 5.6 percentage point higher among non-duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30-day mortality were larger for duals and non-duals who transitioned to SNF, compared to those discharged home.

CONCLUSIONS

PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi-level variables that need to be incorporated in discharge decision making.

Risk Factors of Skilled Nursing Facility Admissions and the Interrelation With Hospitalization and Amount of Informal Caregiving Received

BACKGROUND

The correlations between skilled nursing facility (SNF) admissions, number of hospitalizations, and informal caregiving hours received after adjusting for physical and cognitive function and sociodemographic covariates are not well understood.

OBJECTIVE

The objective of this study was to better understand risk factors for SNF admissions and the interrelation with hospitalizations and amount of informal caregiving received, this study applied a novel joint modeling analysis to simultaneously explore the correlation and shared information between the 3 outcomes.

RESEARCH DESIGN

This was an observational follow-up study.

SUBJECTS

Data from 4836 older Americans included in the 2011-2015 rounds of the National Health and Aging Trends Study were linked with Centers for Medicare & Medicaid Services.

MEASURES

We jointly modeled SNF admission, hospital admissions, and informal caregiving hours received while accounting for possible risk factors. We addressed missing values by multiple imputation with chained equations.

RESULTS

SNF admission evidenced a strong positive correlation with hospital admission, and SNF admission evidenced a weak positive correlation with the informal caregiving hours received after adjustment for important risk factors. Non-Hispanic White race/ethnicity, living alone, not being Medicaid eligible, Alzheimer disease and related dementias diagnosis, activities of daily living disabilities, and frailty were associated with increased risk of SNF admissions and any/number of hospital admission. Lower educational level was also associated with the latter. Medicaid eligibility was the only factor not associated with any nor numbers of informal caregiving hours received.

CONCLUSIONS

Sociodemographic and health factors were important for predicting SNF admissions. After adjustment for important risk factors, SNF evidenced a strong positive correlation with the number of hospitalizations and a weak positive correlation with the hours of informal caregiving received.

Three-Year Impact Of Stratification In The Medicare Hospital Readmissions Reduction Program

The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with high readmission rates. In fiscal year 2019 the program was changed to account for the association between social risk and high readmission rates. The new approach stratifies hospitals into five groups by hospitals' proportion of patients dually enrolled in Medicare and Medicaid, and it evaluates performance within each stratum instead of within the national cohort. Its impact on hospitals caring for vulnerable populations has not been studied. We calculated the change in average annual penalty percentage, before and after stratification, for safety-net hospitals, rural hospitals, and hospitals caring for a high share of Black and Hispanic or Latino patients. We found that stratification by proportion of dual enrollees was associated with a decrease in penalties by -0.09 percentage points at hospitals with the highest proportion of dual enrollees, -0.08 percentage points at rural hospitals, and -0.06 percentage points at hospitals with a large share of Black and Hispanic or Latino patients. Fully adjusted analyses suggest that these patterns were driven by penalty reductions at rural hospitals and hospitals disproportionately serving Black and Hispanic or Latino patients. Given the allocation of fewer penalties to these hospitals, we conclude that the stratification mandate was a modest step toward equity within the HRRP.

Medicare Beneficiary Factors Associated with Skilled Nursing Facility Lengths of Stay

The objectives of this study are (1) to identify beneficiary-level characteristics associated with skilled nursing facility (SNF) length of stay (LOS), and (2) to determine if significant differences in LOS exist for vulnerable populations at the individual level or among nursing homes that serve a disproportionate share of vulnerable populations. This study employed 2014-2015 Medicare Long-Term Care Minimum Data Set (MDS v3.0) assessment, fee-for-service claims and enrollment, and 2014 Nursing Home Compare data to examine SNF LOS in Medicare beneficiaries. We used a hierarchical linear model to identify which beneficiary-level characteristics are associated with SNF LOS, while controlling for facility-level characteristics. After controlling for beneficiary-and facility-level characteristics, we found dual eligibility, racial or ethnic minority, depression, and Alzheimer's disease to be associated with longer Medicare covered SNF stays. We found that facilities that served higher proportions of dually eligible individuals tended to have higher average LOS compared to other facilities.

Health Disparities Attributed to Medicare-Medicaid Dual-Eligible Status in Patients with Peripheral Arterial Disease

OBJECTIVE

Peripheral arterial disease (PAD) is a prevalent and debilitating disease that can be effectively treated by surgical revascularization. However, Medicare-Medicaid dual-eligible patients experience worse long-term outcomes, notably higher rates of amputation and mortality, relative to other insurance groups. This study aims to investigate how insurance status may perpetuate health disparities in PAD outcomes.

METHODS

The National Inpatient Sample was queried from 2000 to 2011 for patients ≥18 years with PAD who underwent surgical revascularization with hospitalization. Patients were stratified by insurance, and dual-eligibles were compared to Medicare-only, Medicaid-only, private insurance, and self-pay patients. Multivariable regression analysis was performed to assess the effect of dual-eligible status on postoperative outcomes such as inpatient mortality, complications, and favorable discharge (home or home with services).

RESULTS

A total of 771,790 hospitalizations were included in the analysis and stratified according to insurance type. Dual-eligible patients had the highest rates of major (32%) and extreme (11%) severity of illness and the highest rates of major (19%) and extreme (6%) risk of mortality among all insurance groups (p<0.001). Dual-eligibility status was independently associated with reduced odds of favorable discharge relative to all patients (p<0.001) and increased length of stay relative to Medicare-only (p=0.002) and private-payor groups (p<0.001). While dual-eligible patients had increased mortality odds relative to Medicaid-only and self-pay groups, they did not have significantly different odds of perioperative complications relative to all other insurance groups.

CONCLUSIONS

Medicare-Medicaid dual-eligible patients with PAD had more severe clinical presentations, a greater risk of extended hospitalizations, and a lower likelihood of being discharged home, relative to patients without dual-eligibility. Further studies are needed to examine the link between discharge disposition and disparities in health outcomes, as well as investigate interventions that effectively address the increased severity of PAD in dual-eligible patients.

Psychological interventions with older adults during inpatient postacute rehabilitation: A systematic review

Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Identifying the Main Predictors of Length of Care in Social Care in Portugal

In this paper, we aim to identify the main predictors at admission and estimate patients’ length of care (LOC), within the framework of the Portuguese National Network for Long-Term Integrated Care, considering two care settings: (1) home and community-based services (HCBS) and (2) nursing home (NH) units comprising Short, Medium, or Long Stay Care. This study relied on a database of 20,984 Portuguese individuals who were admitted to the official long-term care (LTC) system and discharged during 2015. A generalised linear model (GLM) with gamma distribution was adjusted to HCBS and NH populations. Two sets of explanatory variables were used to model the random variable, LOC, namely, patient characteristics (age, gender, family/neighbour support, dependency levels at admission for locomotion, cognitive status, and activities of daily living [ADL]) and external factors (referral entity, number of beds/treatment places per 1,000 inhabitants ≥65 years of age), maturity and occupancy rate of the institution, and care setting. The features found to most influence the reduction of LOC are: male gender, having family/neighbour support, being referred by hospitals to NH (or by primary care to HCBS), and being admitted to units with a lower occupancy rate and with fewer months in operation. Regarding the dependency levels, as the number of ADL considered “dependent” increases, LOC also increases. As for the cognitive status, despite the opposite trend, it was only statistically significant for NH. Furthermore, two additional models were applied by including “death,” although this feature is not observable upon admission. By creating a model that allows for an estimate of the expected LOC for a new individual entering the Portuguese LTC system, policy-makers are able to estimate future costs and optimise resources.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury in Skilled Nursing Facilities

OBJECTIVE

To identify patient, injury, and functional status characteristics associated with successful discharge to the community following a skilled nursing facility (SNF) stay among older adults hospitalized following traumatic brain injury (TBI).

SETTING

Skilled nursing facilities.

PARTICIPANTS

Medicare fee-for-service beneficiaries admitted to an SNF after hospitalization for TBI.

DESIGN

Retrospective cohort study using Medicare administrative data merged with the National Trauma Data Bank using a multilayered Bayesian record linkage approach.

MAIN OUTCOME MEASURE

Successful community discharge: discharged alive within 100 days of SNF admission and remaining in the community for 30 days or more without dying or admission to a healthcare facility.

RESULTS

Medicaid enrollment, incontinence, decreased independence with activities of daily living, and cognitive impairment were associated with lower odds of successful discharge, whereas race "other" was associated with higher odds of successful discharge. Injury factors including worse injury severity (Glasgow Coma Scale and Abbreviated Injury Scale scores) and fall-related injury mechanism were not associated with successful discharge.

CONCLUSION

Among older adults with TBI who discharge to an SNF, sociodemographic and functional status characteristics are associated with successful discharge and may be useful to clinicians for discharge planning. Acute injury severity indices may have limited utility in predicting discharge disposition once a patient is admitted to an SNF for post-acute care.

Nurse Staffing and Coronavirus Infections in California Nursing Homes

In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.

Health Insurance and Disparities in Mortality among Older Survivors of Critical Illness: A Population Study

OBJECTIVES

The 1.5 million Medicare beneficiaries who survive intensive care each year have a high post-hospitalization mortality rate. We aimed to determine whether mortality after critical illness is higher for Medicare beneficiaries with Medicaid compared with those with commercial insurance.

DESIGN

A retrospective cohort study from 2010 through 2014 with 1 year of follow-up using the New York Statewide Planning and Research Cooperative System database.

SETTING

A New York State population-based study of older (age ≥65 y) survivors of intensive care.

PARTICIPANTS

Adult Medicare beneficiaries age 65 years or older who were hospitalized with intensive care at a New York State hospital and survived to discharge.

INTERVENTION

None.

MEASUREMENT

Mortality in the first year after hospital discharge.

RESULTS

The study included 340 969 Medicare beneficiary survivors of intensive care with a mean (standard deviation) age of 77 (8) years; 20% died within 1 year. There were 152 869 (45%) with commercial insurance, 78 577 (23%) with Medicaid, and 109 523 (32%) with Medicare alone. Compared with those with commercial insurance, those with Medicare alone had a similar 1-year mortality rate (adjusted hazard ratio [aHR] = 1.01; 95% confidence interval [CI] = .99-1.04), and those with Medicaid had a 9% higher 1-year mortality rate (aHR = 1.09; 95% CI = 1.05-1.12). Among those discharged home, the 1-year mortality rate did not vary by insurance coverage, but among those discharged to skilled-care facilities (SCFs), the 1-year mortality rate was 16% higher for Medicaid recipients (aHR = 1.16; 95% CI = 1.12-1.21; P for interaction <.001).

CONCLUSIONS

Older adults with Medicaid insurance have a higher 1-year post-hospitalization mortality compared with those with commercial insurance, especially among those discharged to SCFs. Future studies should investigate care disparities at SCFs that may mediate these higher mortality rates. J Am Geriatr Soc 67:2497-2504, 2019.

Urinary tract infection-related hospitalization among older adults receiving home health care

BACKGROUND

Urinary tract infection (UTI)- related hospitalizations are a poor patient outcome in the rapidly growing home health care (HHC) arena that serves a predominantly elderly population. We examined the association between activities of daily living (ADL) and risk of UTI-related hospitalization among this population.

METHODS

Using a retrospective cohort design, we conducted a secondary data analysis of a 5% random sample of a national HHC dataset, the Outcome and Assessment Information Set for the year 2013. Andersen's Behavioral Model of Health Service Utilization was used as a guiding framework for statistical modeling. We used logistic regression to examine the association between UTI-related hospitalization and predisposing, enabling, or need factors.

RESULTS

Among beneficiaries (n = 24,887) hospitalized in 2013, 1,133 had UTI-related hospitalizations. HHC patients with a UTI-related hospitalization were more likely to have severe ADL dependency, impaired decision making, and lower Charlson Comorbidity Index, than those with a non UTI-related hospitalization (P < .001). Risk factors for UTI-related hospitalization included female sex, (adjusted odds ratio [AOR], 1.44; 95% confidence interval [CI], 1.25-1.66), Medicaid recipient (AOR, 1.99; 95% CI, 1.09-3.64), severe ADL dependency (AOR, 1.50; 95% CI, 1.16-1.94), the presence of a caregiver to assist with supervision and safety (AOR, 1.26; 95% CI, 1.06-1.49), treatment for UTI in the previous 14 days (AOR, 2.85; 95% CI, 2.46-3.29), presence of a urinary catheter (AOR, 3.77; 95% CI, 2.98-4.77), and prior history of indwelling or suprapubic catheter (AOR, 1.44; 95% CI, 1.06-1.94).

CONCLUSIONS

ADL dependency levels are a potentially modifiable risk factor for UTI-related hospitalization on admission to HHC. ADL dependency levels can inform clinical interventions to ameliorate ADL dependency in HHC settings and identify groups of patients at high risk for UTI-related hospitalization.

Do report cards predict future quality? The case of skilled nursing facilities

Report cards on provider performance are intended to improve consumer decision-making and address information gaps in the market for quality. However, inadequate risk adjustment of report-card measures often biases comparisons across providers. We test whether going to a skilled nursing facility (SNF) with a higher star rating leads to better quality outcomes for a patient. We exploit variation over time in the distance from a patient's residential ZIP code to SNFs with different ratings to estimate the causal effect of admission to a higher-rated SNF on health care outcomes, including mortality. We found that patients who go to higher-rated SNFs achieved better outcomes, supporting the validity of the SNF report card ratings.

Medicaid and Nursing Home Choice: Why Do Duals End Up in Low-Quality Facilities?

We provide empirical evidence on the relative importance of specific observable factors that can explain why individuals enrolled in both Medicare and Medicaid (duals) are concentrated in lower quality nursing homes, relative to those not on Medicaid. Descriptive results show that duals are 9.7 percentage points more likely than nonduals to be admitted to a low-quality (1-2 stars) nursing home. Using the Blinder-Oaxaca decomposition approach in a multivariate framework, we find that 35.4% of the difference in admission to low-quality nursing homes can be explained by differences in the distribution of observable characteristics. Differences in education and distance to high-quality nursing homes are important drivers, as are health status and race. Our findings highlight the need for creative policy solutions targeting the modifiable factors to reduce the disparity.

Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program

OBJECTIVE

Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties.

STUDY DESIGN

Retrospective cohort study.

DATA SOURCES/STUDY SETTING

Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015.

PRINCIPAL FINDINGS

Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals.

CONCLUSIONS

Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.

Do Skilled Nursing Facilities Selected to Participate in Preferred Provider Networks Have Higher Quality and Lower Costs?

OBJECTIVE

To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix.

DATA SOURCES

Medicare provider and claims data, 2012 and 2013.

STUDY DESIGN

We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks.

DATA EXTRACTION METHODS

We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay.

PRINCIPAL FINDINGS

Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs.

CONCLUSIONS

Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.

The effect of political control on financial performance, structure, and outcomes of US nursing homes

Objective

To evaluate the effect of partisan political control on financial performance, structure, and outcomes of for‐profit and not‐for‐profit US nursing homes.

Data Sources/Study Setting

Nineteen‐year panel (1996‐2014) of state election outcomes, financial performance data from nursing home cost reports, operational and aggregate resident characteristics from OSCAR of 13 737 nursing homes.

Study Design

A linear panel model was estimated to identify the effect of Democratic and Republican political control on next year's outcomes. Nursing home outcomes were defined as yearly facility revenues, expenses, and profits; the number of Medicaid, Medicare, and private‐pay residents; staffing levels; and selected resident outcomes.

Principal Findings

Democratic political control leads to an increase in financial flows to for‐profit nursing homes, boosting profits without producing observable improvements in resident outcomes. Republican political control leads to lower revenues and profits of for‐profit nursing homes. A shift from Medicaid to more profitable private‐pay residents following Republican political control is observed for all nursing homes. Financial performance of not‐for‐profit nursing homes is not significantly affected by changes in political control.

Conclusion

Political control of the two legislative chambers—but not of the governorship—shapes the structure of the nursing home industry as seen in provider behavior.

Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries

Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.

Disparities in the Prevalence of Unmet Needs and Their Consequences Among Black and White Older Adults

OBJECTIVE

We document differential prevalence of need for assistance with personal, instrumental, and mobility tasks and adverse consequences of unmet needs, nursing home relocation, and mortality among Black and White older adults.

METHOD

Data are from the National Health and Aging Trends Study. Using logistic and multinomial logistic regression, we determine whether race is predictive of reporting need or adverse consequence and test the role of race as a moderator of the relationship between baseline need and three 1-year outcomes.

RESULTS

Black older adults are more likely to experience a consequence of unmet need (35.33% vs. 29.97%, p = .028) in unadjusted models. In adjusted models, we find no moderating effect of race on baseline need on nursing home placement (0.00, 95% confidence interval [CI] = [-2.43, 2.42], p = .991), mortality (0.73, 95% = [-1.58, 0.11], p = .089), or a Round 2 consequence of unmet (-0.51, 95% CI = [-1.15, 0.14], p = .121).

DISCUSSION

This work highlights the complex relationship between race, need, unmet need, mortality, and nursing home entry.

An Unintended Consequence of Culture Change in VA Community Living Centers

OBJECTIVE

Although a growing body of evidence suggests that culture change and its corollary, person-centered care improves resident outcomes in the nursing home setting, little is known about the effect of culture change in a postacute setting in which patients receive skilled nursing and rehabilitation services for a relatively short period of time before returning home.

DESIGN

Data for this study were collected as part of a larger project to understand the impact of Veterans Health Administration (VHA) policies to shift the mission of VHA Community Living Centers (CLCs) from long-stay custodial care to short-stay skilled nursing and rehabilitative care.

RESULTS

Although qualitative data collected during interviews from site visits to eight geographically diverse CLCs suggest an increase in the quality of life and care for veterans, interview data also indicate an unintended consequence. Specifically, staff described how aspects of the homelike environment, relationship-based care delivery, and attention to veterans' preferences that characterize culture change can prolong a veteran's length of stay beyond treatment completion. In addition to providing skilled nursing and rehabilitation, VHA CLCs also serve a latent function of providing a comfortable home and a peer community for veterans to connect and socialize with one another. A congregate living environment for persons with the shared symbolic status of being a veteran is unique to VHA CLCs. Strong bonding among peers and staff as well as staff respect for veterans' service to the country may increase their sense of obligation to keep veterans past their expected discharge date.

CONCLUSION

Our findings suggest that the complexities of culture change and veteran- centered care in a short-term care setting may be underrecognized. We discuss how findings may also be relevant for the non-VHA sector.

Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?

OBJECTIVE

To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.

SETTINGS

Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.

STUDY DESIGN

We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.

PRINCIPAL FINDINGS

The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.

CONCLUSIONS

Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?

OBJECTIVE

To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.

SETTINGS

Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.

STUDY DESIGN

We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.

PRINCIPAL FINDINGS

The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.

CONCLUSIONS

Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

Favorable Risk Selection in Medicare Advantage: Trends in Mortality and Plan Exits Among Nursing Home Beneficiaries

The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates.

The Contribution of Skilled Nursing Facilities to Hospitals' Readmission Rate

OBJECTIVE

To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization.

DATA SOURCES/SETTINGS

Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization.

STUDY DESIGN

We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge.

PRINCIPAL FINDINGS

Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR.

CONCLUSIONS

The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.

Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery

BACKGROUND

In the health reform era, rehospitalization after discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction after surgery has not been explored.

METHODS

To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-2012) and evaluated patients who underwent 1 of 5 operative procedures (coronary artery bypass grafting [CABG], hip fracture repair, total hip arthroplasty, colectomy, or lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals' home and the SNF as the IV.

RESULTS

A strong negative correlation (P < .001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (regression coefficient, -0.04; 95% CI, -0.07 to -0.02). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to reduce significantly the likelihood of readmission for patients receiving lumbar spine surgery, CABG, and hip fracture repair.

CONCLUSION

The benefits of increased hospital-SNF linkage seem to include meaningful reductions in hospital readmission after surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to decrease readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.

Racial segregation and quality of care disparity in US nursing homes

In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality.

The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries

OBJECTIVE

Our objective is to estimate and compare the prevalence of selected adverse consequences associated with unmet need for assistance among a socioeconomically and medically vulnerable subgroup of the older adult population, those who are dually eligible for Medicare and Medicaid, with those eligible for Medicare only.

METHOD

Using data from the National Health and Aging Trends Study (NHATS), a representative survey of the older Medicare population, we calculated the prevalence of disability-related need for assistance with self-care, household tasks, and mobility activities and the prevalence of adverse consequences of unmet need by dually eligible and Medicare only status.

RESULTS

Over 2 million community-dwelling older persons experienced an adverse consequence due to unmet need for assistance with self-care (e.g., soiled their clothes), over 2 million experienced adverse consequences due to unmet need for assistance with household tasks (e.g., went without groceries), and over 3 million persons experienced at least one adverse consequence of unmet need for assistance with mobility-related activities (e.g., had to stay in bed) in the month prior to the NHATS interview. Dually eligible persons experienced higher rates of 6 of the 11 adverse consequences studied and were more likely to have at least one adverse consequence in all 3 domains than others.

DISCUSSION

Several care models are emerging with the goal of integrating medical care, behavioral health, and long-term services for the dual eligible population. Indicators of adverse consequences of unmet need could be used to monitor the quality and adequacy of such care systems.