IMPORTANCE Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care. OBJECTIVE To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument. EXPOSURES Receipt of postacute care at home vs in a skilled nursing facility. MAIN OUTCOMES AND MEASURES Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode. RESULTS A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (−2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (−1.9 percentage points; 95% CI,-12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility

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This cohort study of Medicare data from 2007 to 2015 examines disparities in readmission rates between white and black patients discharged from safety-net or non–safety-net hospitals after initiation of the Hospital Readmissions Reduction Program (HRRP).

Key Points Question How often do Medicare patients referred to home health care at hospital discharge receive a home health care visit, and are there disparities? Findings In this cross-sectional study of Medicare beneficiaries in 2016, only 54.0% of patients discharged from the hospital with a home health care referral received home health care services within 14 days of discharge. This rate was even lower among Black and Hispanic patients, those who were dually enrolled in both Medicare and Medicaid, and patients who lived in high-poverty, high-unemployment zip codes. Meaning These findings suggest that patients may face important differential barriers in access to home health care.

Addressing social determinants of health may help hospitals improve population health and outcomes that are tied to financial incentives, such as readmission rates. Whether this strategy is effective remains unknown. The authors measure the association between nonprofit hospital spending on their community's social needs and Medicare readmission rates. This is a retrospective cohort study ( July 2013 to June 2014) that combines Internal Revenue Service tax reports of community benefit spending by private, acute care, nonprofit hospitals with Medicare readmissions data for residents of their surrounding community, the hospital's zip code. Total community benefit spending and 2 of the largest subsets of spending-health care-related and communitydirected spending-were measured and normalized as the proportion of each hospital's total expenditure. Associations between quintiles of community benefit spending and Medicare readmission rates were measured using discharge-level multivariate linear regression, adjusting for patient, hospital, community characteristics, and local public health department spending. The sample consisted of 1405 nonprofit hospitals with 341,913 discharges. Associations between readmission rates and total community benefit spending and the health carerelated subset were not statistically significant. Discharges from hospitals in the upper quintiles of communitydirected spending were associated with lower readmission rates by 0.82 to 1.21 absolute percentage points (P = 0.01 to <0.001) compared to the lowest quintile. The magnitude of associations between communitydirected spending and readmissions was larger for preventable readmissions and smaller when including beneficiaries beyond the hospital's zip code. These associations suggest that community-directed spending may be associated with better health care outcomes.