Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Background

Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

PURPOSE

We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration.

RESULTS

We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87–0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51–0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious.

CONCLUSIONS

Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.     

Readmission Patterns Over 90-Day Episodes of Care Among Medicare Fee-for-Service Beneficiaries Discharged to Post-acute Care

Objective

Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings.

Post-Acute Care and ACOs — Who Will Be Accountable?

Objective

To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs).

Data Sources

Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation.

Study Design

We calculated the fraction of community-dwelling beneficiaries whose assignment shifted, as a consequence of including post-acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post-acute care.

Principal Findings

Assignment shifts occurred for 27.6 percent of 25,992 community-dwelling beneficiaries with at least one post-acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community-dwelling beneficiaries cared for by large ACO-eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population.

Conclusions

Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post-acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions.     

A Randomized,Controlled Pragmatic Trial of Telephonic Medication Therapy Management to Reduce Hospitalization in Home Health Patients

Objective

To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients.

Setting

Forty randomly selected, geographically diverse home health care centers in the United States.

Design

Two-stage, randomized, controlled trial with 60-day follow-up. All Medicare- insured home health care patients were eligible to participate. Twenty-eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist-provided medication regimen review by telephone; and (3) follow-up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60-day all-cause hospitalization.

Data Collection

Data were collected from in-home nursing assessments using the OASIS-C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients’ baseline risk of hospitalization, number of medications taken daily, and other OASIS-C data elements.

Principal Findings

A total of 895 patients (intervention n = 415, control n = 480) were block-randomized to the intervention or usual care. There was no significant difference in the 60-day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89–1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35–10.57, p = .01) compared to the usual care group.

Conclusions

This MTM intervention may not be effective for all home health patients; however, for those patients with the lowest-risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.     

Nutritional follow-up after discharge prevents readmission to hospital - A randomized clinical trial

Objective

To compare the effects of two individualized nutritional follow-up intervention strategies (home visit or telephone consultation) with no follow-up, with regard to acute readmissions to hospital at two points in time, 30 and 90 days after discharge from hospital.

Design

Randomized clinical trial with two intervention groups and one control group, and monitoring on readmission at 30 and 90 days after discharge.

Setting

Intervention in the participants’ homes after discharge from hospital.

Participants

Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: Upon discharge, the patients were stratified according to nutritional status (MNA), and assigned to one of three groups: ‘home visit’, ‘telephone’, or ‘control’ group. Intervention: Individualized nutritional counselling of the patient and the patient’s daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patient’s homes, or over the telephone. All patients received a diet plan on discharge. The control group received standard care, but no follow-up after discharge.

Measurements

Information on readmissions to hospital and mortality at 30 and 90 days after discharge was obtained from electronic patient records. Intention-to-treat (ITT) and per-protocol (PP) analyses were carried out.

Results

Two-hundred and eight participants were randomized, 73 to home visits, 68 to the telephone consultation group, and 67 to the control group. The mean age of the participants was 86.1 years. Home visit participants had a lower risk of readmission to hospital compared to control participants at 30 days after discharge (HR=0.4; 95% CI: 0.2-0.9, p=0.03) and 90 days after discharge (HR=0.4; 95% CI: 0.2-0.8, p<0.01). No significant difference was detected between the telephone consultation group and the control group, at either 30 days (HR=0.6, 95% CI: 0.3-1.3, p=0.18) or 90 days after discharge (HR=0.7, 95% CI: 0.4-1.3, p=0.23). The PP analysis revealed that the risk of readmission was significantly lower in the home visit group compared to the control group and the telephone consultation group compared to the control group, and this was evident at 30 days as well as at 90 days after discharge.

Conclusion

An individualized nutritional follow-up performed as home visits seems to reduce readmission to hospital 30 and 90 days after discharge. Intervention by telephone consultations may also prevent readmission, but only among participants who receive the full intervention.

     

Medicaid, hospital financial stress, and the incidence of adverse medical events for children

Objective

To assess the association between Medicaid-induced financial stress of a hospital and the probability of an adverse medical event for a pediatric discharge.

Data Sources

Secondary data from the Nationwide Inpatient Sample, Agency for Healthcare Research and Quality''s Healthcare Cost and Utilization Project, and the American Hospital Association''s Annual Survey of Hospitals. Study examines 985,896 pediatric discharges (children age 0–17), from 1,050 community hospitals in 26 states (representing 63 percent of the U.S. Medicaid population) between 2005 and 2007.

Study Design

We estimate the probability of an adverse event, controlling for patient, hospital, and state characteristics, using an aggregated, composite measure to overcome rarity of individual events.

Principal Findings

Children in hospitals with relatively high proportions of pediatric discharges that are more reliant on Medicaid reimbursement are more likely than children in other hospitals (odds ratio = 1.62) to experience an adverse event. Medicaid pediatric inpatients are more likely than privately insured patients (odds ratio = 1.10) to experience an adverse event.

Conclusions

Hospital reliance on comparatively low Medicaid reimbursement may contribute to the problem of adverse medical events for hospitalized children. Policies to reduce adverse events should account for differences in underlying, contributing factors of these events.     

What Is the Value of Adding Medicare Data in Estimating VA Hospital Readmission Rates?

Objective

To determine the effects of including diagnostic and utilization data from a secondary payer on readmission rates and hospital profiles.

Data Sources/Study Setting

Veterans Health Administration (VA) and Medicare inpatient and outpatient administrative data for veterans discharged from 153 VA hospitals during FY 2008–2010 with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia.

Study Design

We estimated hospital-level risk-standardized readmission rates derived using VA data only. We then used data from both VA and Medicare to reestimate readmission rates and compared hospital profiles using two methods: Hospital Compare and the CMS implementation of the Hospital Readmissions Reduction Program (HRRP).

Data Collection/Extraction Methods

Retrospective data analysis using VA hospital discharge and outpatient data matched with Medicare fee-for-service claims by scrambled Social Security numbers.

Principal Findings

Less than 2 percent of hospitals in any cohort were classified discordantly by the Hospital Compare method when using VA-only compared with VA/Medicare data. In contrast, using the HRRP method, 13 percent of hospitals had differences in whether they were flagged as having excessive readmission rates in at least one cohort.

Conclusions

Inclusion of secondary payer data may cause changes in hospital profiles, depending on the methodology used. An assessment of readmission rates should include, to the extent possible, all available information about patients'' utilization of care.     

Effects of Postacute Settings on Readmission Rates and Reasons for Readmission Following Total Knee Arthroplasty

Objectives

Examine the effects of postacute discharge setting on unplanned hospital readmissions following total knee arthroplasty (TKA) in older adults.

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients

Objectives

To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care.

Data Sources/Study Setting

Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas.

Study Design

Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods.

Data Collection/Extraction Methods

The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006.

Principal Findings

Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries.

Conclusions

More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.     

Selecting the Best Prediction Model for Readmission

Objectives

This study aims to determine the risk factors predicting rehospitalization by comparing three models and selecting the most successful model.

Methods

In order to predict the risk of rehospitalization within 28 days after discharge, 11 951 inpatients were recruited into this study between January and December 2009. Predictive models were constructed with three methods, logistic regression analysis, a decision tree, and a neural network, and the models were compared and evaluated in light of their misclassification rate, root asymptotic standard error, lift chart, and receiver operating characteristic curve.

Results

The decision tree was selected as the final model. The risk of rehospitalization was higher when the length of stay (LOS) was less than 2 days, route of admission was through the out-patient department (OPD), medical department was in internal medicine, 10th revision of the International Classification of Diseases code was neoplasm, LOS was relatively shorter, and the frequency of OPD visit was greater.

Conclusions

When a patient is to be discharged within 2 days, the appropriateness of discharge should be considered, with special concern of undiscovered complications and co-morbidities. In particular, if the patient is admitted through the OPD, any suspected disease should be appropriately examined and prompt outcomes of tests should be secured. Moreover, for patients of internal medicine practitioners, co-morbidity and complications caused by chronic illness should be given greater attention.     

Template Matching for Auditing Hospital Cost and Quality

Objective

Develop an improved method for auditing hospital cost and quality.

Data Sources/Setting

Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, Texas, and New York between 2004 and 2006.

Study Design

A template of 300 representative patients was constructed and then used to match 300 patients at hospitals that had a minimum of 500 patients over a 3-year study period.

Data Collection/Extraction Methods

From each of 217 hospitals we chose 300 patients most resembling the template using multivariate matching.

Principal Findings

The matching algorithm found close matches on procedures and patient characteristics, far more balanced than measured covariates would be in a randomized clinical trial. These matched samples displayed little to no differences across hospitals in common patient characteristics yet found large and statistically significant hospital variation in mortality, complications, failure-to-rescue, readmissions, length of stay, ICU days, cost, and surgical procedure length. Similar patients at different hospitals had substantially different outcomes.

Conclusion

The template-matched sample can produce fair, directly standardized audits that evaluate hospitals on patients with similar characteristics, thereby making benchmarking more believable. Through examining matched samples of individual patients, administrators can better detect poor performance at their hospitals and better understand why these problems are occurring.     

Health Care Utilization and Receipt of Preventive Care for Patients Seen at Federally Funded Health Centers Compared to Other Sites of Primary Care

Objective

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.

Data Sources

A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004–2008).

Study Design

HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.

Principal Findings

Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.

Conclusions

Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.     

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program

Objective

To estimate the relationship between physicians'' acceptance of new Medicaid patients and access to health care.

Data Sources

The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.

Study Design

Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children''s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.

Principal Findings

Nearly 16 percent of children with a significant health condition or development delay had a doctor''s office or clinic indicate that the child''s health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar.

Conclusions

Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients.     

Higher Medicare SNF Care Utilization by Dual-Eligible Beneficiaries: Can Medicaid Long-Term Care Policies Be the Answer?

Objective

To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states'' Medicaid long-term care policies.

Data Sources/Collection

We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.

Study Design

We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.

Principal Findings

Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.

Conclusions

Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.     

Surgery Wait Times and Specialty Services for Insured and Uninsured Breast Cancer Patients: Does Hospital Safety Net Status Matter?

Objective

To determine whether safety net and non-safety net hospitals influence inpatient breast cancer care in insured and uninsured women and in white and African American women.

Data Sources

Six years of Virginia Cancer Registry and Virginia Health Information discharge data were linked and supplemented with American Hospital Association data.

Study Design

Hierarchical generalized linear models and linear probability regression models were used to estimate the relationship between hospital safety net status, the explanatory variables, and the days from diagnosis to mastectomy and the likelihood of breast reconstruction.

Principal Findings

The time between diagnosis and surgery was longer in safety net hospitals for all patients, regardless of insurance source. Medicaid insured and uninsured women were approximately 20 percent less likely to receive reconstruction than privately insured women. African American women were less likely to receive reconstruction than white women.

Conclusions

Following the implementation of health reform, disparities may potentially worsen if safety net hospitals’ burden of care increases without commensurate increases in reimbursement and staffing levels. This study also suggests that Medicaid expansions may not improve outcomes in inpatient breast cancer care within the safety net system.     

Do Changes in Hospital Outpatient Payments Affect the Setting of Care?

Objective

To examine whether decreases in Medicare outpatient payment rates under the Outpatient Prospective Payment System (OPPS) caused outpatient care to shift toward the inpatient setting.

Data Sources/Study Setting

Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008.

Study Design

This study focuses on inguinal hernia repair surgery, one of the most commonly performed surgical procedures in the United States. We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting. The key explanatory variable is the time-varying Medicare payment rate specific to the procedure and hospital. Control variables include time-varying hospital and county characteristics and hospital and year-fixed effects.

Principal Findings

Outpatient hernia surgeries fell in response to OPPS-induced rate cuts. The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate.

Conclusions

Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare''s efforts to contain hospital outpatient costs.     

Effectiveness of Evidence-based Pneumonia CPOE Order Sets Measured by Health Outcomes

Objective

Evidence-based sets of medical orders for the treatment of patients with common conditions have the potential to induce greater efficiency and convenience across the system, along with more consistent health outcomes. Despite ongoing utilization of order sets, quantitative evidence of their effectiveness is lacking. In this study, conducted at Advocate Health Care in Illinois, we quantitatively analyzed the benefits of community acquired pneumonia order sets as measured by mortality, readmission, and length of stay (LOS) outcomes.

Methods

In this study, we examined five years (2007–2011) of computerized physician order entry (CPOE) data from two city and two suburban community care hospitals. Mortality and readmissions benefits were analyzed by comparing “order set” and “no order set” groups of adult patients using logistic regression, Pearson’s chi-squared, and Fisher’s exact methods. LOS was calculated by applying one-way ANOVA and the Mann-Whitney U test, supplemented by analysis of comorbidity via the Charlson Comorbidity Index.

Results

The results indicate that patient treatment orders placed via electronic sets were effective in reducing mortality [OR=1.787; 95% CF 1.170-2.730; P=.061], readmissions [OR=1.362; 95% CF 1.015-1.827; P=.039], and LOS [F (1,5087)=6.885, P=.009, 4.79 days (no order set group) vs. 4.32 days (order set group)].

Conclusion

Evidence-based ordering practices have the potential to improve pneumonia outcomes through reduction of mortality, hospital readmissions, and cost of care. However, the practice must be part of a larger strategic effort to reduce variability in patient care processes. Further experimental and/or observational studies are required to reduce the barriers to retrospective patient care analyses.     

Can Additional Patient Experience Items Improve the Reliability of and Add New Domains to the CAHPS® Hospital Survey?

Context

The Centers for Medicare and Medicaid Services will introduce the reporting of patient surveys in 2008. The Consumer Assessment of Health Care Providers and Systems (CAHPS®) Hospital Survey contains 18 questions about hospital care. Internal consistency reliability of the discharge information scale is relatively low and some important domains of care are not represented.

Objective

To determine whether adding questions increases the reliability and validity of the survey.

Data Sources and Study Setting

Surveys of patients at 181 hospitals participating in the California Hospitals Assessment and Reporting Taskforce (CHART), an initiative for voluntary public reporting of hospital performance in California.

Study Design

CHART added nine questions to the CAHPS Hospital Survey; two to improve reliability of the discharge information domain, five to create a coordination of care domain, and two relating to interpreter services.

Data Collection

Surveys were sent to randomly selected patients from each CHART hospital.

Principal Findings

A total of 40,172 surveys were included. Adding the new discharge information questions improved the internal consistency reliability from 0.45 to 0.72 and the hospital-level reliability from 0.75 to 0.81. New coordination of care composites had good internal consistency reliabilities ranging from 0.58 to 0.70 and hospital-level reliabilities ranging from 0.84 to 0.87. The new coordination of care composites were more closely correlated with overall hospital ratings and willingness to recommend than six of the seven original domains.

Conclusions

The additional discharge information questions and the new coordination of care questions significantly improved the psychometric properties of the CAHPS Hospital Survey.     

Medicaid Primary Care Physician Fees and the Use of Preventive Services among Medicaid Enrollees

Objective

The Patient Protection and Affordable Care Act (ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force (USPSTF)–recommended preventive care use among Medicaid enrollees.

Data Sources/Study Session

We used data from the 2003 and 2008 Medical Expenditure Panel Survey (MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008.

Study Design

Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors.

Data Collection/Extraction Methods

Data were linked using state identifiers.

Principal Findings

Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant.

Conclusions

Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees.