Prospective payment for nursing homes increased therapy provision without improving community discharge rates

OBJECTIVES

To determine the impact of the prospective payment system (PPS) for skilled nursing facilities (SNFs) on therapy use and community discharge rates.

DESIGN

Quasi-experimental study examining the predemonstration (1994) to demonstration (1997) change in amount of therapy provided, and in community discharge rates at PPS participating and nonparticipating facilities.

SETTING

Eighteen PPS participating and 17 nonparticipating SNFs in five states.

PARTICIPANTS

Two thousand sixty-seven admissions to 18 PPS participating and 17 nonparticipating SNFs in five states.

MEASUREMENTS

We compared changes in number of physical and occupational therapy visits per stay for patients receiving therapy and likelihood of being located in the community 60 days after admission between 1994 and 1997. Analyses were stratified by functional category and risk adjusted using multivariate methods.

RESULTS

Demographics and percentage of patients in each stratum were similar in participating and nonparticipating sites and between 1994 and 1997. Amount of therapy received by the highest-functioning patients increased in participating sites (19.3 to 26.5 visits per stay, P = .005), but not in nonparticipating sites (23.3 to 18.2, P = .98). After adjusting for covariates, likelihood of community discharge for the highest-functioning patients did not change between participating and nonparticipating sites.

CONCLUSIONS

The highest-functioning patients treated under the SNF PPS demonstration experienced great increases in therapy, without any improvement in rate of community discharge.

Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits

CONTEXT

Emergency department utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination. A primary care group visit (i.e., several patients meeting together with the provider at the same time) may reduce fragmentation of care and subsequent emergency department utilization.

OBJECTIVE

To determine whether primary care group visits reduce emergency department utilization in chronically ill older adults.

DESIGN

Randomized trial conducted over a 2-year period.

SETTING

Group-model HMO in Denver, Colorado.

PATIENTS

295 older adults (> or = 60 years of age) with frequent utilization of outpatient services and one or more chronic illnesses.

INTERVENTION

Monthly group visits (generally 8 to 12 patients) with a primary care physician, nurse, and pharmacist held in 19 physician practices. Visits emphasized self-management of chronic illness, peer support, and regular contact with the primary care team.

MEASURES

Emergency department visits, hospitalizations, and primary care visits.

RESULTS

On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. 1.08 visits; P = 0.005) and were less likely to have any emergency department visits (34.9% vs. 52.4%; P = 0.003) than controls. These differences remained statistically significant after controlling for demographic factors, comorbid conditions, functional status, and prior utilization. Adjusted mean difference in visits was -0.42 visits (95% CI, -0.13 to -0.72), and adjusted RR for any emergency department visit was 0.64 (CI, 0.44 to 0.86).

CONCLUSION

Monthly group visits reduce emergency department utilization for chronically ill older adults.

Application of functional independence measure-function related groups and resource utilization groups-version III systems across post acute settings

OBJECTIVES

The present study evaluated alternative patient classification systems for skilled nursing facility and rehabilitation facility patients.

METHODS

Medicare patients were selected from a random sample of 27 rehabilitation facilities and 65 skilled nursing facilities participating in a national longitudinal study of subacute care. Detailed casemix and resource use data was obtained on 513 patients with hip fracture and 483 stroke patients. The Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system for rehabilitation facilities was replicated on length of stay and tested on resource use for rehabilitation facility patients as well as for skilled nursing facility patients. Modifications to the FIM-FRGs also were tested. The Resource Utilization Groups-Version III classification was tested on rehabilitation facility patients.

RESULTS

The FIM-FRGs explained the same amount of variance in length of stay as in the original FIM-FRGs development sample (R2 hip fracture = 0.14, R2 stroke = 0.28), and similar variance in resource use. A modified version of the FIM-FRGs explained more variance in length of stay (R2 hip fracture = 0.19, R2 stroke = 0.39) and resource use (R2 hip fracture = 0.20, R2 stroke = 0.41). Neither model adequately predicted length of stay or resource use in skilled nursing facility patients. The Resource Utilization Groups-Version III rehabilitation groups accounted for little variance in rehabilitation facility patients' per-diem resource use (R2 = 0.11).

CONCLUSIONS

The FIM-FRGs are valid for resource use as well as length of stay for rehabilitation facility patients, but are not valid for skilled nursing facility patients. Similarly, the Resource Utilization Groups-Version III system does not apply to rehabilitation facility patients. Related work, however, suggests that development of a single episode-based patient classification system for skilled nursing facility and rehabilitation facility patients is possible and should be pursued.

Development and validation of a clinical prediction rule for prolonged nursing home residence after hip fracture

OBJECTIVES

To develop and validate a clinical prediction rule for nursing home residence 6 months after a hip fracture.

DESIGN

Two prospective cohort studies, a development study (DS) and a validation study (VS).

SETTING

The DS included hip fracture patients admitted to 92 rehabilitation units or skilled nursing facilities; the VS included hip fracture patients from 11 integrated healthcare systems.

PARTICIPANTS

A total of 344 community-dwelling hip fracture patients aged 65 and older participated in the DS; 239 similar patients were enrolled in the VS.

INTERVENTION

None.

MEASUREMENTS

The acute hospital record, nursing evaluations, and patient questionnaires provided information about demographics, physical and neuropsychological function, and comorbidity. Residence 6 months after fracture was determined by phone interview. Multivariate analysis identified predictors for a risk score to assess the likelihood of nursing home residence.

RESULTS

18.7% of patients in the DS resided in nursing homes 6 months after hip fracture. The four independent risk factors for institutionalization were (1) being unmarried (OR = 6.7 [95% CI 2.4 to 19]), (2) incontinence (OR = 2.3 [CI 1.2 to 4.7]), (3) dependence in ambulation (OR = 5.0 [CI 2.1 to 12.3]), and (4) cognitive impairment (OR = 6.6 [CI 3.3 to 13.2]). Of patients with all four risk factors, 73.2% were institutionalized at 6 months, compared with 0% of patients with no risk factors. In the VS, 6.1% of patients resided in nursing homes after 6 months, with a range from 50.0% of patients with four risk factors to 0% of those with no risk factors. Areas under receiver-operating characteristic curves for the prediction rule were 0.84 +/- .03 in the DS, and 0.81 +/- .06 in the VS.

CONCLUSION

A clinical prediction rule using four easily measurable characteristics can identify individuals at high or low risk of nursing home residence 6 months after hip fracture.

Rehabilitation costs: implications for prospective payment

OBJECTIVE

To obtain information relevant to development of prospective payment for Medicare rehabilitation facilities (RFs) and skilled nursing facilities (SNFs): compares service utilization, length of stay (LOS), case mix, and resource consumption for Medicare patients receiving postacute institutional rehabilitation care.

DATA SOURCES/STUDY SETTING

Longitudinal patient-level and related facility-level data on Medicare hip fracture (n = 513) and stroke (n = 483) patients admitted in 1991-1994 to a sample of 27 RFs and 65 SNFs in urban areas in 17 states.

STUDY DESIGN

For each condition, two-group RF-SNF comparisons were made. Regression analysis was used to adjust RF-SNF differences in resource consumption per stay for patient condition (case mix) and other factors, since random assignment was not possible.

DATA COLLECTION/EXTRACTION METHODS

Providers at each facility were trained to collect patient case-mix and service utilization information. Secondary data also were obtained.

PRINCIPAL FINDINGS

RF patients had shorter LOS, fewer total nursing hours (but more skilled nursing hours), and more ancillary hours than SNF patients. After adjustment, ancillary resource consumption per stay remained substantially higher for RF than SNF patients, particularly for stroke. The adjusted nursing resource consumption differences were smaller than the ancillary differences and not statistically significant for hip fracture. Supplemental outcome findings suggested minimal differences for hip fracture patients but better outcomes for RF than SNF stroke patients.

CONCLUSIONS

Much can be gained from an integrated approach to developing prospective payment for RFs and SNFs. In that context, consideration of condition-specific per-stay payment methods applicable to both settings appears warranted.

Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings

OBJECTIVE

To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes.

DESIGN

Inception cohort stratified by provider type and followed prospectively for 6 months.

SETTING

A total of 92 hospital-based units and freestanding facilities from 17 states.

PATIENTS

A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994.

MAIN OUTCOME MEASURES

At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments.

RESULTS

On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients.

CONCLUSIONS

Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.