Fostering organizational resilience: The relevance of organization theory in a postpandemic world.

ASSOCIATE EDITORS NOTE: This article is an adapted version of Dr. Jacqueline Zinn's Keith G. Provan Distinguished Scholar Award plenary to the Health Care Management Division of the Academy of Management in 2020. We are excited to share it with you because it is noteworthy among scholarly career award plenaries. Specifically, the article does two big things exceptionally well: (a) provides a compelling and informative retrospective on a truly exceptional scholarly career renowned for work that consistently and deeply engages with practice, practitioners, and emerging, urgent problems in a conceptually and empirically rigorous manner and (b) inventively connects her research to the health care, managerial, and organizational challenges posed by the pandemic (and pandemics from prior eras) to provide a forward looking research agenda on organizational resilience and well-being that offers ready-made conceptual development and empirical work for the next generation.

Home Health Care Quality, Its Costs and Implications for Home Health Value-Based Purchasing.

The Home Health Value-based Purchasing (HHVBP) demonstration, incorporating a payment formula designed to incentivize both high-quality care and quality improvement, is expected to become a national program after 2022, when the demonstration ends. This study investigated the relationship between costs and several quality dimensions, to inform HHVBP policy. Using Medicare cost reports, OASIS and Home Health Compare data for 7,673 home health agencies nationally, we estimated cost functions with instrumental variables for quality. The estimated net marginal costs varied by composite quality measure, baseline quality, and agency size. For four of the five composite quality measures, the net marginal cost was negative for low-quality agencies, suggesting that quality improvement was cost saving for this agency type. As the magnitude of the net marginal cost is commensurate with the payment incentive planned for HHVBP, it should be considered when designing the incentives for HHVBP, to maximize their effectiveness.

Identifying Associations between Quality Initiatives and Quality Measures among Home Health Agencies: Findings from a National Study.

Home health performance gained visibility with the publication of Home Health Compare and the Home Health Value-Based Payment demonstration. Both provide incentives for home health agencies (HHA) to invest in quality improvements. The objective of this study is to identify the association between quality initiatives adopted by HHAs and improved performance. A 2018 national survey of 7459 HHAs, yielding a sample of 1192 eligible HHAs, provided information about 23 quality initiatives, which was linked to 5 composite Super Quality Measures (SQMs): ADL/pain, self-treatment, timely care, hospitalizations, and patient experience. Exclusions for missing data and outliers yielded a final analytical sample of 903 HHAs. Regression models estimated associations between quality initiatives and SQMs. The relationships between sixteen of the SQM/quality initiative pairs were positively associated with improvement and 7 were negatively associated. Web-based technologies for staff and care-givers improved performance but deteriorated patient experience. Web support-groups for staff and review of HHC rankings reduced hospitalization rates. While this study offers insights for quality improvement, a limitation may be a lack of sensitivity to the nuances of quality improvement implementation. Therefore, this study should be viewed as hypothesis-generating concerning initiatives likely to have the greatest potential meriting further investigation.

Certificate of need and the cost of competition in home healthcare markets.

We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.

Moving organizational theory in health care forward: A discussion with suggestions for critical advancements.

In May 2019, scholars in management and organization of health care organizations and systems met. The opening plenary was a moderated discussion with five distinguished scholars who have exemplified pushing the frontier of organizational theory and practice throughout their careers: Ann Barry Flood of Dartmouth College, John Kimberly of the University of Pennsylvania, Anthony (Tony) Kovner of New York University, Stephen (Steve) Shortell of University of California at Berkeley, and Jacqueline (Jackie) Zinn of Temple University. The discussion was moderated by Ingrid Nembhard of the University of Pennsylvania. The goal of the plenary was to provide an opportunity to hear from senior members of the health care management community how they think about organizational behavior and theory, changes that they have observed, research gaps that they see, and lessons for research and practice that they have learned. This article is the transcript of that plenary discussion. It is shared to capture the intellectual history of the field and help surface the critical advancements still needed in organizational theory and practice in health care. The closing remarks of the panelists summarize recommendations for both practice and scholarship in health care organization management.

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.

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.

The Impact of Certificate-of-Need Laws on Nursing Home and Home Health Care Expenditures.

Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes.

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.

Effect of hospital-SNF referral linkages on rehospitalization.

OBJECTIVE: To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage. DATA SOURCES/COLLECTION: We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006. STUDY DESIGN: We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument. PRINCIPAL FINDINGS: Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge. CONCLUSIONS: Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs.

The impact of hospital-based skilled nursing facility closures on rehospitalizations.

OBJECTIVE: To examine the effect of reductions in hospital-based (HB) skilled nursing facility (SNF) bed supply on the rate of rehospitalization of patients discharged to any SNF from zip codes that lost HB beds. DATA SOURCE: We used Medicare enrollment records, Medicare hospital and SNF claims, and nursing home Minimum Dataset assessments and characteristics (OSCAR) to examine nearly 10 million Medicare fee-for-service hospital discharges to SNFs between 1999 and 2006. STUDY DESIGN: We calculated the number of HB and freestanding (FS) SNF beds within a 22 km radius from the centroid of all zip codes in which Medicare beneficiaries reside in all years. We examined the relationship between HB and FS bed supply and the rehospitalization rates of the patients residing in corresponding zip codes in different years using zip code fixed effects and instrumental variable methods including extensive sensitivity analyses. PRINCIPAL FINDINGS: Our estimated coefficients suggest that closure of 882 HB homes during our study period resulted in 12,000-18,000 extra rehospitalizations within 30 days of discharge. The effect was largely concentrated among the most acutely ill, high-need patients. CONCLUSIONS: SNF patient-based prospective payment resulted in closure of higher cost HB facilities that had served most postacute patients. As other, less experienced SNFs replaced HB facilities, they were less able to manage high acuity patients without rehospitalizing them.

The effect of state policies on nursing home resident outcomes.

OBJECTIVES: To test the effect of changes in Medicaid reimbursement on clinical outcomes of long-stay nursing home (NH) residents. DESIGN: Longitudinal, retrospective study of NHs, merging aggregated resident-level quality measures with facility characteristics and state policy survey data. SETTING: All free-standing NHs in urban counties with at least 20 long-stay residents per quarter (length of stay > 90 days) in the continental United States between 1999 and 2005. PARTICIPANTS: Long-stay NH residents INTERVENTIONS: Annual state Medicaid average per diem reimbursement and the presence of case-mix reimbursement in each year. MEASUREMENTS: Quarterly facility-aggregated, risk-adjusted quality-of-care measures surpassing a threshold for functional (activity of daily living) decline, physical restraint use, pressure ulcer incidence or worsening, and persistent pain. RESULTS: All outcomes showed an improvement trend over the study period, particularly physical restraint use. Facility fixed-effect regressions revealed that a $10 increase in Medicaid payment increased the likelihood of a NH meeting quality thresholds by 9% for functional decline, 5% for pain control, and 2% for pressure ulcers but not reduced use of physical restraints. Facilities in states that increased Medicaid payment most showed the greatest improvement in outcomes. The introduction of case-mix reimbursement was unrelated to quality improvement. CONCLUSION: Improvements in the clinical quality of NH care have been achieved, particularly where Medicaid payment has increased, generally from a lower baseline. Although this is a positive finding, challenges to implementing efficient reimbursement policies remain.