Administrator Perspectives on the Impact of COVID-19 on the Administration of the Patient Driven Payment Model in U.S. Skilled Nursing Facilities.

The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model.

Implementing the Patient Driven Payment Model-Perspectives from Skilled Nursing Facility Administrators.

Objective: To explore skilled nursing facility (SNF) administrator retrospective perspectives on their preparation for and initial implementation of the Patient Driven Payment Model (PDPM), the new Medicare payment system for SNFs enacted on October 1, 2019. Methods: 156 interviews at 40 SNFs in eight U.S. markets were conducted and qualitatively analyzed. Results: Administrators retrospectively expressed feeling well-prepared for the PDPM implementation. Advance preparation focused on training staff regarding patient assessment and documentation. Administrators also recognized increased incentives for admitting patients with more complex needs and prepared accordingly. Therapy staffing reductions were concentrated in contract employees, while SNF-employed therapists were less affected. Conclusion: Policy makers and industry experts should consider the long-term impact of changing financial incentives through payment reform, and ensure that reimbursement best reflects the cost of providing services while prioritizing high-quality care. PDPM's effect on care quality and access to care should continue to be monitored.

Home-delivered meals for people with dementia: Which model delays nursing home placement? - Protocol for a feasibility pilot.

BACKGROUND: Home-delivered meals promote food security, socialization, and independence among homebound older adults. However, it is unclear which of the two predominant modes of meal delivery, daily-delivered vs. drop-shipped, frozen meals, promotes community living for homebound older adults with dementia. Our objective is to present the protocol for a pilot multisite, two-arm, pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among people with dementia. We include justifications for individual randomization with different consent processes and waivers for specific elements of the trial. METHODS: 236 individuals with dementia on waiting lists at three Meals on Wheels programs' in Florida and Texas will be randomized to receive either: 1) meals delivered multiple times per week by a Meals on Wheels volunteer or paid driver who may socialize with and provide an informal wellness check or 2) frozen meals that are mailed to participants' homes every two weeks. We will evaluate and refine processes for recruitment and randomization; assess adherence to the intervention; identify common themes in participant experience; and test processes for linking participant data with Medicare records and nursing home assessment data. We will conduct exploratory analyses examining time to nursing home placement, the primary outcome for the larger trial. CONCLUSION: This pilot will inform the follow-on large-scale, definitive pragmatic trial. In addition, the justifications for individual randomization with differing consent procedures for elements of a pragmatic trial provide a model for future trialists looking to develop ethical and feasible pragmatic studies enrolling people with dementia.

Quality Management Strategies in Medicaid Managed Care: Perspectives From Medicaid, Plans, and Providers.

Medicaid managed care allows Medicaid beneficiaries to receive services through contractual relationships between managed care organizations and state Medicaid offices. Medicaid offices monitor quality of care, and many states encourage or require plans to adopt quality management practices. This research examines quality management in Medicaid managed care from the perspectives of Medicaid officials, managed care plan representatives, and providers through 25 qualitative interviews in one Northeastern state. Plan representatives described quality management efforts as robust and discussed strategies targeting providers and beneficiaries. Medicaid officials indicated motivations for plans to be responsible for quality management. Providers were unaware of plan efforts or reported them to be counterproductive since performance data were thought to be inaccurate or limited, and modest incentive programs presented excessive administrative burden. Providers' general skepticism about managed care plans' quality improvement efforts may hinder their effectiveness, cause frustration, and lead to administrative burden that may harm care quality.

Care Transition Decisions After a Fall-related Emergency Department Visit: A Qualitative Study of Patients' and Caregivers' Experiences.

OBJECTIVE: Falls are a leading cause of injury-related emergency department (ED) visits and may serve as a sentinel event for older adults, leading to physical and psychological injury. Our primary objective was to characterize patient- and caregiver-specific perspectives about care transitions after a fall. METHODS: Using a semistructured interview guide, we conducted in-depth, qualitative interviews using grounded theory methodology. We included patients enrolled in the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare) trial aged 65 years and older who had an ED visit for a fall and their caregivers. Patients with cognitive impairment (CI) were interviewed in patient-caregiver dyads. Domains assessed included the postfall recovery period, the skilled nursing facility (SNF) placement decision-making process, and the ease of obtaining outpatient follow-up. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed for a priori and emergent themes. RESULTS: A total of 22 interviews were completed with 10 patients, eight caregivers, and four patient-caregiver dyads within the 6-month period after initial ED visits. Patients were on average 83 years old, nine of 14 were female, and two of 14 had CI. Six of 12 caregivers were interviewed in reference to a patient with CI. We identified four overarching themes: 1) the fall as a trigger for psychological and physiological change, 2) SNF placement decision-making process, 3) direct effect of fall on caregivers, and 4) barriers to receipt of recommended follow-up. CONCLUSIONS: Older adults presenting to the ED after a fall report physical limitations and a prominent fear of falling after their injury. Caregivers play a vital role in securing the home environment; the SNF placement decision-making process; and navigating the transition of care between the ED, SNF, and outpatient visits after a fall. Clinicians should anticipate and address feelings of isolation, changes in mobility, and fear of falling in older adults seeking ED care after a fall.

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.

Leveraging Home-Delivered Meal Programs to Address Unmet Needs for At-Risk Older Adults: Preliminary Data.

BACKGROUND: Home-delivered meal programs serve a predominantly homebound older adult population, characterized by multiple chronic conditions, functional limitations, and a variety of complex care needs, both medical and social. DESIGN: A pilot study was designed to test the feasibility of leveraging routine meal-delivery service in two home-delivered meal programs to proactively identify changes in older adult meal recipients' (clients') health, safety, and well-being and address unmet needs. INTERVENTION: Meal delivery personnel (drivers) were trained to use a mobile application to submit electronic alerts when they had a concern or observed a change in a client's condition. Alerts were received by care coordinators, who followed up with clients to offer support and help connect them to health and community services. RESULTS: Over a 12-month period, drivers submitted a total of 429 alerts for 189 clients across two pilot sites. The most frequent alerts were submitted for changes in health (56%), followed by self-care or personal safety (12%) and mobility (11%). On follow-up, a total of 132 referrals were issued, with most referrals for self-care (33%), health (17%), and care management services (17%). Focus groups conducted with drivers indicated that most found the mobile application easy to use and valued change of condition monitoring as an important contribution. CONCLUSION: Findings suggest that this is a feasible approach to address unmet needs for vulnerable older adults and may serve as an early-warning system to prevent further decline and improve quality of life. Efforts are underway to test the protocol across additional home-delivered meal programs. J Am Geriatr Soc 67:1946-1952, 2019.

Choosing the Best and Scrambling for the Rest: Hospital-Nursing Home Relationships and Admissions to Post-Acute Care.

OBJECTIVE: We explored post-Affordable Care Act hospital and skilled nursing facility (SNF) perspectives in discharge and admission practices. METHOD: Interviews were conducted with 138 administrative personnel in 16 hospitals and 25 SNFs in eight U.S. markets and qualitatively analyzed. RESULTS: Hospitals may use prior referral rates and patients' geographic proximity to SNFs to guide discharges. SNFs with higher hospital referral rates often use licensed nurses to screen patients to admit more preferred patients. While SNFs with lower hospital referral rates use marketing strategies to increase admissions, these patients are often less preferred due to lower reimbursement or complex care needs. CONCLUSION: An unintended consequence of increased hospital-SNF integration may be greater disparity. SNFs with high hospital referral rates may admit well-reimbursed or less medically complex patients than SNFs with lower referral rates. Without policy remediation, SNFs with lower referral rates may thus care for more medically complex long-term care patients.

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.

Qualitative perspectives of primary care providers who treat Medicaid managed care patients.

BACKGROUND: Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis. METHODS: We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes. RESULTS: Providers expressed challenges effectively meeting their patients' needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice. CONCLUSIONS: Underinvestment in primary care in Medicaid may detract from providers' professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

The Prevalence of Culture Change Practice in US Nursing Homes: Findings From a 2016/2017 Nationwide Survey.

BACKGROUND AND OBJECTIVES: Given the dynamic nursing home (NH) industry and evolving regulatory environment, depiction of contemporary NH culture-change (person/resident-centered) care practice is of interest. Thus, we aimed to portray the 2016/2017 prevalence of NH culture change-related processes and structures and to identify factors associated with greater practice prevalence. RESEARCH DESIGN AND METHODS: We administered a nationwide survey to 2142 NH Administrators at NHs previously responding to a 2009/2010 survey. Seventy-four percent of administrators (1583) responded (with no detectable nonresponse bias) enabling us to generalize (weighted) findings to US NHs. From responses, we created index scores for practice domains of resident-centered care, staff empowerment, physical environment, leadership, and family and community engagement. Facility-level covariate data came from the survey and the Certification and Survey Provider Enhanced Reporting system. Ordered logistic regression identified the factors associated with higher index scores. RESULTS: Eighty-eight percent of administrators reported some facility-level involvement in NH culture change, with higher reported involvement consistently associated with higher domain index scores. NHs performed the best (82.6/100 weighted points) on the standardized resident-centered care practices index, and had the lowest scores (54.8) on the family and community engagement index. Multivariable results indicate higher index scores in NHs with higher leadership scores and in states having Medicaid pay-for-performance with culture change-related quality measures. CONCLUSIONS: The relatively higher resident-centered care scores (compared with other domain scores) suggest an emphasis on person-centered care in many US NHs. Findings also support pay-for-performance as a potential mechanism to incentivize preferred NH practice.

The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment.

OBJECTIVE: To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. DATA SOURCES: 2011-2016 Medicaid claims from a Northeastern state. STUDY DESIGN: Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. DATA COLLECTION: We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. PRINCIPAL FINDINGS: Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. CONCLUSIONS: Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.

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.

Comparison of Electronic Health Record-Based and Claims-Based Diabetes Care Quality Measures: Causes of Discrepancies.

OBJECTIVE: To investigate magnitude and sources of discrepancy in quality metrics using claims versus electronic health record (EHR) data. STUDY DESIGN: Assessment of proportions of HbA1c and LDL testing for people ascertained as diabetic from the respective sources. Qualitative interviews and review of EHRs of discrepant cases. DATA COLLECTION/EXTRACTION: Claims submitted to Rhode Island Medicaid by three practice sites in 2013; program-coded EHR extraction; manual review of selected EHRs. PRINCIPAL FINDINGS: Of 21,030 adult Medicaid beneficiaries attributed to a primary care patient at a site by claims or EHR data, concordance on assignment ranged from 0.30 to 0.41. Of patients with concordant assignment, the ratio of patients ascertained as diabetic by EHR versus claims ranged from 1.06 to 1.14. For patients with concordant assignment and diagnosis, the ratio based on EHR versus claims ranged from 1.08 to 18.34 for HbA1c testing, and from 1.29 to 14.18 for lipid testing. Manual record review of 264 patients discrepant on diagnosis or testing identified problems such as misuse of ICD-9 codes, failure to submit claims, and others. CONCLUSIONS: Claims data underestimate performance on these metrics compared to EHR documentation, by varying amounts. Use of claims data for these metrics is problematic.

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.

Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change.

Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and "culture change" NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH's payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.