Medicare policymakers have recently become interested in changing the payment incentives around rehospitalizations. Using merged claims data, our analyses indicate 23.5% of Medicare beneficiaries discharged from the hospital to a skilled nursing facility (SNF) were directly readmitted within 30 days at a cost to Medicare of $4.34 billion in 2006. Although these results indicate significant potential savings, we also found that SNF rehospitalizations were heterogeneous in nature and varied considerably across local areas based on practice patterns. Medicare payment reform needs to account for incentives that vary geographically and by type of hospitalization in order to be effective.

Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions.

Objective To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations including non-Medicare paid Nursing Home (NH) stays. Data Sources Online Survey Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (Parts A and B) and MDS assessments for 60,984 people who were present in one of these NHs in 2006. Methods The algorithm creating the RHF is outlined and the RHF for the study data is used to describe place of death. The identification of residents in nursing homes is compared to the reports in OSCAR and part B claims. Principal Findings The RHF correctly identified 84.8% of part B claims with place-of-service in NH, and identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5% non-Medicare NH decedents were transferred to the hospital to die versus 45.6% SNF decedents. Conclusions The population-based design of the RHF makes it possible to conduct policy relevant research to examine the variation in the rate and type of health care transitions across the United States.

Findings suggest that Medicare HMOs should consider the capacity of nursing facilities, especially in terms of medical care capacity and clinical resources, to limit hospital admissions.

Objective. Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations. Data Sources/Study Setting. Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently. Study Design. Prospective cohort study of 570,614 older ( ! 65-year-old), non-MCO (Medicare Managed Care), long-stay ( ! 90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics. Principal Findings. Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63). Conclusions. State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

(300 words) Objectives During the COVID-19 pandemic, U.S. nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during COVID-19 pandemic. Design We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare & Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs. Setting and participants 11,920 free-standing NHs. Measures The dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification And Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data. Results Of the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both > 25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio (AOR) = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having one-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages. Conclusions /Implications: Abundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.

BackgroundThe Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the "real world" in all U.S. nursing homes between 1999 and 2007.MethodsWe used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission.ResultsEach year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival.ConclusionThe MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for researc...

Context Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization. Objective To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment. Design, Setting, and Patients The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital’s care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered. Main Outcome Measure Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization. Results In 2797 acute care hospitals with 280 869 admissions among 163 022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6–9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21–1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35–1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20–3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement. Conclusion Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.