Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

Abstract

Background/Objectives The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use. Design Retrospective cohort study using administrative claims data. Setting SNFs providing post-acute care in North and South Carolina (N=1,474). Participants A cohort of Medicare beneficiaries aged 65 years and older (N=55,980) who were hospitalized, then transferred to a SNF for post-acute care, and subsequently discharged home (January 1, 2010, to August 31, 2011). Measurements Medicare institutional claims data (Part A and Part B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute-care use was explored. Cox proportional hazards regression models were used to describe patient, home care and nursing facility-level predictors. Results After SNF-to-home discharge, 22.1% of older adults had an episode of acute-care use within 30 days, including 7.25% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5 % of older adults had their first acute-care usewithin 90 days. Male gender, dual eligibility status, higher Charlson co-morbidity score, certain primary diagnoses at the index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient day were associated with higher risk for acute-care use. Conclusion Medicare patients have a high use of acute-care services after discharge from SNFs, and several factors associated with acute-care use are potentially modifiable. Findings suggest the need for interventions to support patients as they transition from SNFs to home.

Utilization of Acute Care among Patients with ESRD Discharged Home from Skilled Nursing Facilities

“…Older adults with ESRD have markedly higher rates of acute care use within 30 days of SNF discharge than reported for the wider population of older Medicare beneficiaries (1,2). In this cohort of older adults with ESRD, rates of acute care use after SNF discharge were higher among black patients, among those with Medicare-Medicaid dual enrollment, among those with a higher burden of comorbidity, and among those with hospital diagnoses of soft tissue infections.…”

“…We conducted a subgroup analysis among patients with ESRD included in a larger observational study of older Medicare beneficiaries discharged home from SNFs in North and South Carolina between January 1, 2010, and August 31, 2011 (1). Medicare Part A and Part B claims for 2008-2011 were used to ascertain the characteristics of each patient in the year before SNF admission and to measure outcomes within 30 days after SNF discharge.…”

“…We included race as a study variable because racial disparities exist in both prevalence of ESRD and use of SNFs (17,18). Race as recorded in the Medicare denominator file was aggregated into three categories (white, black, and other) because ,1% of the parent study's cohort had race besides white or black (1). We also included number of hospitalizations within 90 days before SNF admission, comorbid conditions and Charlson comorbidity score based on International Classification of Diseases-Ninth Revision (ICD-9) codes in inpatient Medicare claims (19) From NH Compare, we obtained information on the following SNF characteristics: facility bed count, ownership status (unknown, for-profit, government, or nonprofit), registered nurse hours per resident day, and licensed practical nurse hours per resident day (20).…”

“…As performed in the parent study (1), the following exclusions were applied: (1) SNF stays of patients who were not residents of North or South Carolina (n=7882) and not discharged home (n=104,572), (2) stays .106 days (n=678), (3) stays that were not preceded by an acute hospitalization (n=4771), (4) additional stays for patients who had .1 stay in the study period (n=8942), (5) duplicate stays or database sorting errors (n=864), and (6) stays that were not located in the Medicare denominator file (n=862). After identifying 64,864 unique patients, the following additional exclusions were applied in the parent study: (1) patients aged ,65 years (n=6161), (2) patients with stays in both states (n=1), (3) patients who did not have full Medicare coverage or had Medicare managed care (n=3657), and (4) patients who died before discharge (n=228) (1). Of the 55,980 patients identified in the parent study (1), 54,727 patients did not meet criteria for ESRD and an additional 30 patients were excluded because the SNF was not in North or South Carolina.…”

“…Recent studies among older Medicare beneficiaries admitted to the hospital show that nearly 20% are rehospitalized within 30 days of discharge from hospital to home and that 12%-15% are hospitalized within 30 days of discharge from a skilled nursing facility (SNF) to home (1)(2)(3). With the Affordable Care Act's Hospital Readmissions Reduction Program, there is now growing interest in transitional care interventions to lower rehospitalizations.…”