Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias.

OBJECTIVE: The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners. DATA SOURCES: The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019. STUDY DESIGN: We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. DATA COLLECTION: Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. PRINCIPAL FINDINGS: Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD. CONCLUSIONS: Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).

Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island.

As health systems attempt to contain utilization and costs, care management programs are proliferating. However, there are mixed findings on their impact. In 2018, Rhode Island initiated a care management program for dually eligible Medicare and Medicaid beneficiaries at high risk of hospitalization or institutionalization. The objective of this study is to evaluate the association between health care utilization and costs and care management for dual-eligible participants (n = 169). The authors employed an interrupted time series analysis of administrative claims data using the Rhode Island All Payer Claims Database, which includes data from all major payers in the state, for 11 quarters (January 1, 2017 until September 1, 2019). On average, participants were younger (46.2% were 19-64 years of age vs. 41.9% of non-participants), female (71% vs. 62.6% of non-participants), and had a higher comorbidity burden (more commonly had anemia, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, ischemic heart disease, and stroke). Participation was associated with significantly fewer hospital admissions (118 fewer admissions per 1000 admissions per quarter; 95% confidence interval [CI] -11 to -22), and a reduction in Medicaid ($1841 less spent per quarter, 95% CI -2407 to -1275) and total ($2570 less spent per quarter; 95% CI -$4645 to -$495) costs. Participation was not significantly associated with a change in Emergency Department (ED) visits, preventable ED visits, Skilled Nursing Facility stays, or Medicare costs. These results suggest that targeted care management programs may provide dual-eligible beneficiaries with needed services while diverting inefficient health care utilization.

Higher hospital referral concentration associated with lower-risk patients in skilled nursing facilities.

OBJECTIVE: To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. DATA SOURCES/COLLECTION: We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. STUDY DESIGN: We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. DATA COLLECTION/EXTRACTION METHODS: We used previously collected MedPAR and OSCAR/CASPER survey data. PRINCIPAL FINDINGS: We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. CONCLUSIONS: We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs.

Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City.

BACKGROUND: Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home. PURPOSE: Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems. METHODS: Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems. RESULTS: Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017. CONCLUSION: As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.

Strategy and risk sharing in hospital-postacute care integration.

ISSUE/TREND: Postacute care has been identified as a primary area for cost containment. The continued shift of payment structures from volume to value has often put hospitals at the forefront of addressing postacute care cost containment. However, hospitals continue to struggle with models to manage patients in postacute care institutions, such as skilled nursing facilities or in home health agencies. Recent research has identified postacute care network development as one mechanism to improve outcomes for patients sent to postacute care providers. Many hospitals, though, have not utilized this strategy for fear of not adhering to Centers for Medicare & Medicaid Services requirements that patients are given choice when discharged to postacute care. MANAGERIAL APPROACH: A hospital's approach to postacute care integration will be dictated by environmental uncertainty and the level of embeddedness hospitals have with potential postacute care partners. Hospitals, though, must also consider how and when to extend shared savings to postacute care partners, which will be based on the complexity of the risk-sharing calculation, the ability to maintain network flexibility, and the potential benefits of preserving competition and innovation among the network members. For hospital leaders, postacute care network development should include a robust and transparent data management process, start with an embedded network that maintains network design flexibility, and include a care management approach that includes patient-level coordination. CONCLUSION: The design of care management models could benefit from elevating the role of postacute care providers in the current array of risk-based payment models, and these providers should consider developing deeper relationships with select postacute care providers to achieve cost containment.

Association of daily copayments with use of hospital care among medicare advantage enrollees.

BACKGROUND: While the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay. METHODS: We used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans - similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007-2010 period. RESULTS: The imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI - 1.8 to - 0.9), 6.9 inpatient days/100 enrollees (95% CI - 10.1 to - 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI - 1.0 to - 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI - 8.4 to 1.4), 31.1 days/100 (95% CI - 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI - 3.8 to - 0.6) in intervention plans relative to control plans. CONCLUSIONS: Instituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.

Medicare Advantage control of postacute costs: perspectives from stakeholders.

OBJECTIVES: Medicare Advantage (MA) plans have strong incentives to control costs, including postacute spending; however, to our knowledge, no research has examined the methods that MA plans use to control or reduce postacute costs. This study aimed to understand such MA plan efforts and the possible unintended consequences. STUDY DESIGN: A multiple case study method was used. METHODS: We conducted 154 interviews with administrative and clinical staff working in 10 MA plans, 16 hospitals, and 25 skilled nursing facilities (SNFs) in 8 geographically diverse markets across the United States. RESULTS: Participants discussed how MA plans attempted to reduce postacute care spending by controlling the SNF to which patients are discharged and SNF length of stay (LOS). Plans typically influenced SNF selection by providing patients with a list of facilities in which their care would be covered. To influence LOS, MA plans most commonly authorized patient stays in SNFs for a certain number of days and required that SNFs adhere to this limitation, but they did not provide guidance or assistance in ensuring that the LOS goals were met. Hospital and SNF responses to the largely authorization-based system were frequently negative, and participants expressed concerns about potential unintended consequences. CONCLUSIONS: In their interactions with hospitals and SNFs, MA plans attempted to influence the choice of SNF and LOS to control postacute spending. However, exerting too much influence over hospitals and SNFs, as these results seem to indicate, may have the negative consequences of delayed hospital discharge and SNFs' avoidance of burdensome plans.

Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay.

OBJECTIVE: To identify the challenges that reductions in length of stay (LOS) pose for skilled nursing facilities (SNFs) and their postacute care (PAC) patients. DATA SOURCES/SETTING: Seventy interviews with staff in 25 SNFs in eight U.S. cities, LOS data for patients in those SNFs. STUDY DESIGN: Data were qualitatively analyzed, and key themes were identified. Interview data from SNFs with and without reductions in median risk-adjusted LOS were compared and contrasted. DATA COLLECTION/EXTRACTION METHODS: We conducted 70 semistructured interviews. LOS data were derived from minimum dataset (MDS) admission records available for all patients in all U.S. SNFs from 2012 to 2014. PRINCIPAL FINDINGS: Challenges reported regardless of reductions in LOS included frequent and more complicated re-authorization processes, patients becoming responsible for costs, and discharging patients whom staff felt were unsafe at home. Challenges related to reduced LOS included SNFs being pressured to discharge patients within certain time limits. Some SNFs reported instituting programs and processes for following up with patients after discharge. These programs helped alleviate concerns about patients, but they resulted in nonreimbursable costs for facilities. CONCLUSIONS: The push for shorter LOS has resulted in unexpected challenges and costs for SNFs and possible unintended consequences for PAC patients.

Reducing Hospital Readmissions Through Preferred Networks Of Skilled Nursing Facilities.

Establishing preferred provider networks of skilled nursing facilities (SNFs) is one approach hospital administrators are using to reduce excess thirty-day readmissions and avoid Medicare penalties or to reduce beneficiaries' costs as part of value-based payment models. However, hospitals are also required to provide patients at discharge with a list of Medicare-eligible providers and cannot explicitly restrict patient choice. This requirement complicates the development of a SNF network. Furthermore, there is little evidence about the effectiveness of network development in reducing readmission rates. We used a concurrent mixed-methods approach, combining Medicare claims data for the period 2009-13 with qualitative data gathered from interviews during site visits to hospitals in eight US markets in March-October 2015, to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal SNF networks. Four hospitals had developed formal SNF networks as part of their care management efforts. These hospitals saw a relative reduction from 2009 to 2013 in readmission rates for patients discharged to SNFs that was 4.5 percentage points greater than the reduction for hospitals without formal networks. Interviews revealed that those with networks expanded existing relationships with SNFs, effectively managed patient data, and exercised a looser interpretation of patient choice.

Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals.

Hospitals are now being held at least partly accountable for Medicare patients' care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities' quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients' choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

ACO-Affiliated Hospitals Reduced Rehospitalizations From Skilled Nursing Facilities Faster Than Other Hospitals.

Medicare's more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals.

Post-acute integration strategies in an era of accountability.

The Institute of Medicine, in its 2001 Crossing the Quality Chasm report, recommended greater integration and coordination as a component of a transformed health care system, yet relationships between acute and post-acute providers have remained weak. With payment reforms that hold hospitals and health systems accountable for the total costs of care and readmissions, the dynamic between acute and post-acute providers is changing. In this article, we outline the internal and market factors that will drive health systems' decisions about whether and how they integrate with post-acute providers. Enhanced integration between acute and post-acute providers should reduce variation in post-acute spending.

Ultrasonic prediction of term birth weight in Hispanic women. Accuracy in an outpatient clinic.

OBJECTIVE: To investigate the accuracy of ultrasonic fetal biometric algorithms for estimating term fetal weight. STUDY DESIGN: Ultrasonographic fetal biometric assessments were made in 74 Hispanic women who delivered at 37-42 weeks of gestation. Measurements were taken of the fetal biparietal diameter, head circumference, abdominal circumference and femur length. Twenty-seven standard fetal biometric algorithms were assessed for their accuracy in predicting fetal weight. Results were compared to those obtained by merely guessing the mean term birth weight in each case. RESULTS: The correlation between ultrasonically predicted and actual birth weights ranged from 0.52 to 0.79. The different ultrasonic algorithms estimated fetal weight to within +/- 8.6-15.0% (+/- 295-520 g) of actual birth weight as compared with +/- 13.6% (+/- 449 g) for guessing the mean birth weight in each case (mean +/- SD). The mean absolute prediction errors for 17 of the ultrasonic equations (63%) were superior to those obtained by guessing the mean birth weight by 3.2-5.0% (96-154 g) (P < .05). Fourteen algorithms (52%) were more accurate for predicting fetal weight to within +/- 15%, and 20 algorithms (74%) were more accurate for predicting fetal weight to within +/- 10% of actual birth weight than simply guessing the mean birth weight (P < .05). Ten ultrasonic equations (37%) showed significant utility for predicting fetal weight > 4,000 g (likelihood ratio > 5.0). CONCLUSION: Term fetal weight predictions using the majority of sonographic fetal biometric equations are more accurate, by up to 154 g and 5%, than simply guessing the population-specific mean birth weight.