Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility

Werner, Rachel M.; Coe, Norma B.; Qi, Mingyu; Konetzka, R. Tamara

doi:10.1001/jamainternmed.2018.7998

Cited by 181 publications

(202 citation statements)

References 22 publications

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“…Prior work has indicated that SNF stays may also be protective against readmission . Avoiding “posthospital syndrome” in patients with HF may require SNF care and then HHC after discharge home as they are vulnerable to swift decline if recommended treatment is not followed.…”

Section: Discussionmentioning

confidence: 99%

Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization

Weerahandi

Bao

Herrin

et al. 2019

J American Geriatrics Society

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BACKGROUND/OBJECTIVE Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization. DESIGN Retrospective cohort study. SETTING Fee‐for‐service Medicare data, 2012 to 2015. PARTICIPANTS Beneficiaries, aged 65 years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home. MEASUREMENTS The primary outcome was unplanned readmission within 30 days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model. RESULTS Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30‐day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P < .0001) and a longer time to readmission. In an adjusted model, the hazard for readmission was 0.91 (0.86‐0.95) with receipt of HHC. CONCLUSIONS Recipients of HHC were less likely to be readmitted within 30 days vs those discharged home without HHC. This is unexpected, as patients discharged with HHC likely have more functional impairments. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may particularly benefit from restorative therapy through HHC; however, only approximately 20% received such services. J Am Geriatr Soc 68:96–102, 2019

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Section: Discussionmentioning

confidence: 99%

Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization

Weerahandi

Bao

Herrin

et al. 2019

J American Geriatrics Society

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“…Finally, there is a possibility that our focus on discharge home whenever safe and feasible and the educational and follow‐up components of the STAR program may have led to a higher rate of hospital returns than we anticipated. Medicare patients discharged home have higher rates of hospital readmissions, but lower overall costs than those discharged to an SNF . The rates of readmission we report are lower than they would otherwise have been because we only ascertained readmissions to the same hospital.…”

Section: Discussionmentioning

confidence: 53%

Evaluation of a Multicomponent Care Transitions Program for High‐Risk Hospitalized Older Adults

Huckfeldt

Reyes

Engström

et al. 2019

J American Geriatrics Society

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OBJECTIVES To test the effectiveness of a multicomponent care transition intervention targeted at hospitalized patients, aged 75 years and older, at high risk for hospital readmissions, return emergency department (ED) visits, and related complications. DESIGN Implementation as a quality improvement program with propensity‐matched preintervention and concurrent comparison groups over a 12‐month period. SETTING A 400‐bed community teaching hospital. PARTICIPANTS Patients, aged 75 years and older, admitted to non–intensive care unit beds who met specific high‐risk criteria. The intervention group included 202 patients, and the concurrent and preintervention comparison groups included 4142 and 4592 patients, respectively. MEASUREMENTS Primary outcomes were 30‐day hospital readmissions and returns to the ED; 7‐day readmissions and ED visits were secondary measures. RESULTS Among the 202 patients enrolled in the “Safe Transitions for At‐Risk Patients” (“STAR”) program, 37 (18.3%) were readmitted within 30 days, in contrast to 14.3% and 14.6% in the concurrent and preintervention comparison groups, respectively. Rates for 30‐day return ED visits that did not result in hospitalization were 10.9% in the intervention group, and 7.2% and 7.9% in the comparison groups. STAR patients had greater 30‐day ED use than patients in the preintervention comparison group (5.0 percentage points; 95% confidence interval = 0.8‐9.3 percentage points; P = .020). Implementation challenges included suboptimal involvement of the participating hospital and post–acute care organizations and a relatively high proportion of patients who did not receive the intervention as planned, despite agreeing to participate before leaving the hospital. CONCLUSION A multicomponent care transitions intervention targeting high‐risk patients, aged 75 years and older, admitted to a community teaching hospital was not effective in reducing 30‐ or 7‐day readmissions or return ED visits. Our implementation experience offers many lessons for future programs for similar high‐risk geriatric populations. J Am Geriatr Soc 67:2634–2642, 2019

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“…Further reductions in postacute care use—both in SNF as a discharge destination and in length of stay once admitted to a SNF—are likely as health systems seek to further tamp down the costs of care and improve the value of the health care they deliver. Prior research has found that discharging patients directly home, instead of to SNF, has adverse consequences for patient outcomes . These current results suggest that even among patients who are discharged to SNF, declines in SNF length of stay may be accompanied by an increase in rehospitalizations and yield only modest cost savings for insurers.…”

Section: Discussionmentioning

confidence: 60%

“…On the other hand, with the large increase in copayment on the 21st day of a SNF stay, the associated financial pressures may result in lengths of stay that are shorter than optimal. Recent research has shown that sending patients home with home health care results in worse outcomes for patients than discharging them to SNF, which may imply that insufficient length of SNF stay would also result in worse outcomes. In this case, cost savings from shortening SNF stays would have to be balanced against adverse consequences for patients to determine overall welfare effects.…”

Section: Introductionmentioning

confidence: 99%

The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs

Werner

Konetzka

et al. 2019

Health Services Research

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Objective To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. Data Sources and Study Setting Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee‐for‐service beneficiaries. Study Design We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. Principal Findings From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1‐day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4‐1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8‐1.0), lower total Medicare payment for the 90‐day episode after hospital discharge ($396; 95% CI 361‐431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149‐210, P < .001), offsetting the lower payment for the shorter index SNF stay. Conclusions Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes.

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Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility

Cited by 181 publications

References 22 publications

Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization

Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization

Evaluation of a Multicomponent Care Transitions Program for High‐Risk Hospitalized Older Adults

The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs

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