US Generalist Physicians and Groups That Focused Practice in a Single Care Setting: 2014-2017.

BACKGROUND: Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown. OBJECTIVES: Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting. RESEARCH DESIGN: This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014-2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites. RESULTS: From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, p for trend <0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians. CONCLUSIONS: Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.

Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities.

BACKGROUND: The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES: Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN: Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS: Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS: While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

BACKGROUND: Hospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown. OBJECTIVE: To compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization. DESIGN: This was a retrospective cohort study. PARTICIPANTS: Participants are Medicare fee-for-service beneficiaries over 66 years of age who were hospitalized and discharged to a SNF in 2012-2014 (N = 2,839,779). MAIN MEASURES: We estimated the effect of being treated by a hospitalist on 30-day rehospitalization and mortality, 60-day episode Medicare payments (Parts A and B), and successful discharge to community. Patients discharged to the community within 100 days of SNF admission who remained alive and not readmitted to a hospital or SNF for at least 30 days were considered successfully discharged. All outcomes were adjusted for demographics and clinical characteristics. To account for heterogeneity across facilities, we included hospital fixed effects. KEY RESULTS: The 30-day rehospitalization rate was 17.59% for hospitalists' vs. 17.31% for non-hospitalists' patients (adjusted difference, 0.28%; 95% CI, 0.13 to 0.44). Sixty-day payments were $26,301 for hospitalists' vs. $25,996 for non-hospitalists' patients (adjusted difference, $305; 95% CI, $243 to $367). There was a non-significant trend toward lower successful discharge to the community rate (adjusted difference, - 0.26%; 95% CI, - 0.48 to - 0.04) and lower mortality for patients of hospitalists (adjusted difference, - 0.12%; 95% CI, - 0.22 to - 0.02). CONCLUSIONS: Among hospitalized Medicare beneficiaries who were discharged to SNFs, readmissions and Medicare costs were slightly higher for stays under the care of hospitalists compared with those of non-hospitalist generalist physicians, but there was a non-significant trend toward lower mortality.

Expectations and experiences with physician care among patients receiving post-acute care in US skilled nursing facilities.

BACKGROUND: In the US, post-acute care in skilled nursing facilities (SNFs) is common and outcomes vary greatly across facilities. Little is known about the expectations of patients and their caregivers about physician care during the hospital to SNF transition. Our objectives were to (1) describe the experiences and expectations of patients and their caregivers with SNF physicians in SNFs, and (2) identify patterns that differed between patients with vs. without cognitive impairment. METHODS: This qualitative study used grounded theory approach to analyze data collected from semi-structured interviews at five SNFs in January-August 2018. Patients admitted for short-term SNF care 5-10 days prior were eligible to participate. Thematic analysis was performed to detect recurrent themes with a focus on modifiable aspects of physician care. Analysis was stratified by patient cognitive impairment (measured by the Montreal Cognitive Assessment at the time of the interview). RESULTS: Fifty patients and six caregivers were interviewed. Major themes were: (1) patients had poor awareness of the physician in charge of their care; (2) they were dissatisfied with the frequency of interaction with the physician; and (3) participants valued the perception of receiving individualized care from the physician. Less cognitively impaired patients were more concerned about limited interactions with the physicians and were more likely to report attempts to seek out the physician. CONCLUSION: Patient and caregiver expectations of SNF physicians were not well aligned with their experiences. SNFs aiming to improve satisfaction with care may focus efforts in this area, such as facilitating frequent communication between physicians, patients and caregivers.

Seeking a stable foundation to build on: 1st-Year residents' views of high-value care teaching.

Background: United States (US) residency programs have been recently mandated to teach the concept of high-value care (HVC) defined as care that balances the benefits of interventions with their harms and costs. We know that reflective practice is a key to successful learning of HVC; however, little is known about resident perceptions of HVC learning. To better inform HVC teaching in graduate medical education, we asked 1st-year residents to reflect on their HVC learning. Methods: We conducted three focus groups (n = 36) and online forum discussion (n = 13) of 1st-year internal medicine residents. A constructivist grounded theory approach was used to assess transcripts for recurrent themes to identify the perspectives of residents shared about HVC learning. Results: Residents perceived their learning of HVC as limited by cultural and systemic barriers that included limited time, fear of missing a diagnosis, perceived expectations of attending physicians, and poor cost transparency. While the residents reported considerable exposure to the construct of HVC, they desired a more consistent framework that could be applied in different situations. In particular, residents reported frustration with variable incentives, objectives, and definitions pertaining to HVC. Suggestions for improvement in HVC teaching outlined three main needs for: (1) a generalizable framework to systematically approach each case that could be later adapted to independent practice; (2) objective real-time data on costs, benefits, and harms of medical interventions; and (3) standardized approach to assess resident competency in HVC. Discussion: As frontline clinicians and the intended target audience for HVC education, 1st-year residents are in a unique position to provide feedback to improve HVC teaching in residency. Our findings highlight the learners' desire for a more systematic approach to HVC teaching that includes the development of a stable generalizable framework for decision-making, objective data, and standardized assessment. These findings contrast current educational interventions in HVC that aim at reducing the overuse of specific practices.

Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial.

BACKGROUND: Social comparison feedback is an increasingly popular strategy that uses performance report cards to modify physician behavior. Our objective was to test the effect of such feedback on the ordering of routine laboratory tests for hospitalized patients, a practice considered overused. METHODS: This was a single-blinded randomized controlled trial. Between January and June 2016, physicians on six general medicine teams at the Hospital of the University of Pennsylvania were cluster randomized with equal allocation to two arms: (1) those e-mailed a summary of their routine laboratory test ordering vs. the service average for the prior week, linked to a continuously updated personalized dashboard containing patient-level details, and snapshot of the dashboard and (2) those who did not receive the intervention. The primary outcome was the count of routine laboratory test orders placed by a physician per patient-day. We modeled the count of orders by each physician per patient-day after the intervention as a function of trial arm and the physician's order count before the intervention. The count outcome was modeled using negative binomial models with adjustment for clustering within teams. RESULTS: One hundred and fourteen interns and residents participated. We did not observe a statistically significant difference in adjusted reduction in routine laboratory ordering between the intervention and control physicians (physicians in the intervention group ordered 0.14 fewer tests per patient-day than physicians in the control group, 95% CI - 0.56 to 0.27, p = 0.50). Physicians whose absolute ordering rate deviated from the peer rate by more than 1.0 laboratory test per patient-day reduced their laboratory ordering by 0.80 orders per patient-day (95% CI - 1.58 to - 0.02, p = 0.04). CONCLUSIONS: Personalized social comparison feedback on routine laboratory ordering did not change targeted behavior among physicians, although there was a significant decrease in orders among participants who deviated more from the peer rate. TRIAL REGISTRATION: Clinicaltrials.gov registration: #NCT02330289.

Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003-2013 Residency Graduates.

Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade. APPROACH: This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003-2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed. FINDINGS: A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.

Association Between 5-Star Nursing Home Report Card Ratings and Potentially Preventable Hospitalizations.

Nursing homes' publicly reported star ratings increased substantially since Centers for Medicare & Medicaid Services's Nursing Home Compare adopted a 5-star rating system. Our objective was to test whether the improvements in nursing home 5-star ratings were correlated with reductions in rates of hospitalization. We hypothesized that increased attention to 5-star star ratings motivated nursing homes to make changes that improved their star ratings but did not affect their hospitalization rate, resulting in a weakened association between ratings and hospitalizations. We used 2007-2010 Medicare hospital claims and nursing home clinical assessment data to compare the correlation between nursing home 5-star ratings and hospitalization rates before versus after 5-star ratings were publicly released. The correlation between the rate of hospitalization and a nursing home's 5-star rating weakened slightly after the ratings became publicly available. This decrease in correlation was concentrated among patients receiving post-acute care, who experienced relatively more hospitalizations from best-rated nursing homes. The improvements in nursing home star ratings after the release of Medicare's 5-star rating system were not accompanied by improvements in a broader measure of outcomes for post-acute care patients. Although this dissociation may be due to better matching of sicker patients to higher-quality nursing homes or superficial improvements by nursing homes to increase their ratings without substantial investments in quality improvement, the 5-star ratings nonetheless became less meaningful as an indicator of nursing home quality for post-acute care patients.

Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study.

BACKGROUND: Despite increased emphasis on cost-consciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area. OBJECTIVE: To study whether the prescribing practices of attendings influence residents' prescribing of brand-name statin medications in the ambulatory clinic setting. DESIGN AND PARTICIPANTS: A retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011. MAIN MEASURES: We estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending's rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. KEY RESULTS: The sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about one-fourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings' brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident's prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3-28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6-58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28-3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31-3.55, p = 0.003 for PGY-3, vs. PGY-1). CONCLUSIONS: Supervising attendings' prescribing of brand-name medications may have a significant influence on PGY-1 residents' prescribing of brand-name medications, but not on prescribing by more senior residents.

Development of a high-value care subscore on the internal medicine in-training examination.

BACKGROUND: Although high-value care (HVC) that balances benefits of tests or treatments against potential harms and costs has been a recently emphasized competency for internal medicine (IM) residents, few tools to assess residents' knowledge of HVC are available. OBJECTIVE: To describe the development and initial results of an HVC subscore of the Internal Medicine In-Training Examination (IM-ITE). DESIGN: The HVC concepts were introduced to IM-ITE authors during question development. Three physicians independently reviewed each examination question for selection in the HVC subscore according to 6 HVC principles. The final subscore was determined by consensus. Data from the IM-ITE administered in October 2012 were analyzed at the program level. SETTING: U.S. IM residency programs. PARTICIPANTS: 362 U.S. IM residency programs with IM-ITE data for at least 10 residents. MEASUREMENTS: Program-level performance on the HVC subscore was compared with performance on the overall IM-ITE, the Dartmouth Atlas hospital care intensity (HCI) index of the program's primary training hospital, and residents' attitudes about HVC assessed with a voluntary survey. RESULTS: The HVC subscore comprised 38 questions, including 21 (55%) on managing conservatively when appropriate and 14 (37%) on identifying low-value care. Of the 362 U.S. IM programs in the sample, 41% were in a different quartile when ranked based on the HVC subscore compared with overall IM-ITE performance. Rankings by HVC subscore and HCI index were modestly inversely associated, with 30% of programs ranked in the same quartile based on both measures. LIMITATION: Knowledge of HVC assessed from examination vignettes may not reflect practice of HVC. CONCLUSION: Although the HVC subscore has face validity and can contribute to evaluation of residents' HVC knowledge, additional tools are needed to accurately measure residents' proficiency in HVC. PRIMARY FUNDING SOURCE: None.

Emergency department visits by older adults receiving postacute care in skilled nursing facilities.

Skilled nursing facilities (SNF) represent a common postdischarge destination for hospitalized older adults. The goals of SNF care include the completion of extended skilled nursing care and physical rehabilitation to enable patients to safely return home. However, nearly one in four older adults discharged to SNF are rehospitalized and one in five seek care in the emergency department (ED) but are discharged back to SNF. Our aim was to measure the national prevalence and costs to Medicare of ED visits by SNF patients. Of the 1,551,703 Medicare beneficiaries discharged to SNF in 2019, 16.3% had an ED visit within 14 days (n = 253,104). Of those ED visits, 25.5% resulted in a same-day discharge back to SNF (n = 64,472), costing Medicare $24.6 million. Novel care models that can leverage SNF staff and resources while providing rapid diagnostic services are urgently needed.

State scope of practice restrictions and nurse practitioner practice in nursing homes: 2012-2019.

Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012-2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.

Nursing Home Compare star ratings before versus after a change in nursing home ownership.

BACKGROUND: Efforts to increase transparency and accountability of nursing homes, and thus improve quality, now include information about changes in nursing home ownership. However, little is known about how change in ownership affects nursing home quality. METHODS: We conducted a retrospective cohort study of 15,471 U.S. nursing homes between January 2016 and December 2022, identifying all changes in ownership during that period. We used logistic regression to measure the association between nursing home characteristics and the odds of a change in ownership. A difference-in-differences model with multiple time periods was used to examine the impact of a change in ownership on the Medicare Nursing Home Compare 5-star ratings. RESULTS: One in five (23%) facilities changed ownership between 2016 and 2022. Nursing homes that were urban, for-profit, part of a chain, located in the South, had >50 beds, lower occupancy, higher percentage of stays covered by Medicaid, higher percentage of residents with non-white race, or a 1-star (poor) rating were more likely to undergo a change in ownership. There was a small statistically significant decrease in 5-star ratings after a change in ownership (-0.09 points on a 5-point scale; 95% CI -0.13 to -0.04; p < 0.001), driven primarily by a decrease in staffing ratings (-0.19 points; 95% CI -0.24 to -0.14; p < 0.001), and health inspections ratings (-0.07 points; 95% CI -0.11 to -0.03; p = 0.001). This was mitigated by an increase in quality measure ratings (0.15 points; 95% CI 0.10-0.20; p < 0.001). CONCLUSION: Nursing Home Compare ratings decreased slightly after a change in facility ownership, driven by lower staffing and health inspection ratings and mitigated somewhat by higher quality measure ratings. These conflicting trends underscore the need for transparency around changes in facility ownership and a better understanding of consequences of changes in ownership that are salient to patients and families.

Geriatric conditions and healthcare utilization among older adults living in subsidized housing.

BACKGROUND: Nearly 2.9 million older Americans with lower incomes live in subsidized housing. While regional and single-site studies show that this group has higher rates of healthcare utilization compared to older adults in the general community, little is known about healthcare utilization nationally nor associated risk factors. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries aged ≥65 enrolled in the National Health and Aging Trends Study in 2011, linked to Medicare claims data, including individuals living in subsidized housing and the general community. Participants were followed annually through 2020. Outcomes were hospitalization, short-term skilled nursing facility (SNF) utilization, long-term care utilization, and death. Fine-Gray competing risks regression analysis was used to assess the association of subsidized housing residence with hospitalization and nursing facility utilization, and Cox proportional hazards regression analysis was used to assess the association with death. RESULTS: Among 6294 participants (3600 women, 2694 men; mean age, 75.5 years [SD, 7.0]), 295 lived in subsidized housing at baseline and 5999 in the general community. Compared to older adults in the general community, those in subsidized housing had a higher adjusted subdistribution hazard ratio [sHR] of hospitalization (sHR 1.21; 95% CI, 1.03-1.43), short-term SNF utilization (sHR 1.49; 95% CI, 1.15-1.92), and long-term care utilization (sHR 2.72; 95% CI, 1.67-4.43), but similar hazard of death (HR, 0.86; 95% CI, 0.69-1.08). Individuals with functional impairment had a higher adjusted subdistribution hazard of hospitalization and short-term SNF utilization and individuals with dementia and functional impairment had a higher hazard of long-term care utilization. CONCLUSIONS: Older adults living in subsidized housing have higher hazards of hospitalization and nursing facility utilization compared to those in the general community. Housing-based interventions to optimize aging in place and mitigate risk of nursing facility utilization should consider risk factors including functional impairment and dementia.

Disparities in access to specialty care and emergency department use after hospital discharge to a skilled nursing facility.

BACKGROUND: Patterns in access to specialists among patients in skilled nursing facilities (SNFs) have not been previously described. OBJECTIVE: To measure access to outpatient specialty follow-up and subsequent emergency department (ED) visits by patient characteristics, including race/ethnicity and those who received specialty care during the hospitalization that preceded the SNF stay. DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective cohort study used the minimum data set and 100% Medicare fee-for-service claims for beneficiaries admitted to an SNF between 2012 and 2014. Hospital stays for surgical procedures were excluded. MAIN OUTCOME AND MEASURES: The associations between ED visits, follow-up, and race/ethnicity were measured using logistic and linear regression, adjusting for patient demographic and clinical characteristics. RESULTS: The sample included 1,117,632 hospitalizations by Medicare beneficiaries ≥65 with a consult by a medical subspecialist followed by discharge to SNF. Of the sample, 85.4% were non-Hispanic White (NHW) and 14.6% were Black, indigenous, and people of color (BIPOC), according to Medicare beneficiary records. During the SNF stay, BIPOC patients had lower odds of specialty follow-up compared to NHW patients (odds ratio [OR]: 0.96, 95% confidence intervals [CI]: 0.94-0.99, p = .004). BIPOC patients had higher rates of ED visits compared to NHW patients (with follow-up: 24.1% vs. 23.4%, and without follow-up: 27.4% vs. 25.9%, p < .001). Lack of follow-up was associated with a 0.8 percentage point difference in ED visits between BIPOC and NHW patients (95% CI: 0.3-1.3, p = .003). CONCLUSIONS: There is a racial/ethnic disparity in subspecialty follow-up after hospital discharge to SNF that is associated with a higher rate of subsequent ED visits by BIPOC patients.

Use of Clinicians Who Focus on Nursing Home Care Among US Nursing Homes and Unplanned Rehospitalization.

Importance: The number of physicians and advanced practitioners who focus their practice in nursing homes (NHs), often referred to as "SNFists" (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the nursing home or skilled nursing facility [SNF] setting) has increased dramatically. Little is known about the association of the NH medical care delivery models that use SNFists with the quality of postacute care. Objective: To quantify the association between NH use of SNFists and facility-level, unplanned 30-day rehospitalization rates for patients receiving postacute care. Design, Setting, and Participants: This cohort study used Medicare fee-for-service claims for all hospitalized beneficiaries discharged to 4482 NHs from January 1, 2012, through December 31, 2019. The study sample comprised NHs that did not have patients under the care of SNFists as of 2012. The treatment group included NHs that adopted at least 1 SNFist by the end of the study period. The control group included NHs that did not have patients under the care of a SNFist during the study period. SNFists were defined as generalist physicians and advanced practitioners with 80% or more of their Medicare Part B services delivered in NHs. Statistical analysis was conducted from January 2022 to April 2023. Exposure: Nursing home adoption of 1 or more SNFists. Main Outcomes and Measures: The main outcome was the NH 30-day unplanned rehospitalization rate. A facility-level analysis was conducted using an event study approach to estimate the association of an NH adopting 1 or more SNFists with its unplanned 30-day rehospitalization rate, adjusting for patient case mix, facility, and market characteristics. Changes in patient case mix were examined in secondary analyses. Results: In this study of 4482 NHs, adoption of SNFists increased from 13.5% of facilities (550 of 4063) in 2013 to 52.9% (1935 of 3656) in 2018. Adjusted rehospitalization rates were not statistically different after SNFist adoption compared with before, with an estimated mean treatment effect of 0.05 percentage points (95% CI, -0.43 to 0.53 percentage points; P = .84). The share of Medicare-covered patients increased by 0.60 percentage points (95% CI, 0.21-0.99 percentage points; P = .003) in the year of SNFist adoption and by 0.54 percentage points (95% CI, 0.12-0.95 percentage points; P = .01) 1 year after adoption compared with NHs that did not adopt SNFists. The number of postacute admissions increased by 13.6 (95% CI, 9.7-17.5; P < .001) after SNFist adoption, but there was no statistically significant change in the acuity index. Conclusions and Relevance: This cohort study suggests that NH adoption of SNFists was associated with an increase in the number of admissions for postacute care but was not associated with a change in rehospitalization rates. This may represent a strategy by NHs to maintain rehospitalization rates while increasing the volume of patients receiving postacute care, which typically results in higher profit margins.

Potentially avoidable emergency department use by patients discharged to skilled nursing facilities.

One-third of patients discharged from hospitals to skilled nursing facilities (SNF) are sent back to the Emergency Department (ED) within 30 days. Little is known about those patients who are discharged from the ED directly back to SNF. We considered these ED visits as potentially avoidable since they did not result in observation or hospitalization stay. Using a retrospective chart review of 1010 patients with ED visits within 14-days of discharge to SNF from University of Pennsylvania health system (UPHS) in 2020-2021, we identified 202 patients with potentially avoidable ED visits among medical and surgical patients. The most common reasons for these ED visits were mechanical falls (17.3%), postoperative problems (16.8%), and cardiac or pulmonary complaints (11.4%). Future interventions to decrease avoidable ED visits from SNFs should aim to provide access for SNF patients to receive timely outpatient lab and imaging services and postoperative follow-ups.