Hospital-based Skilled Nursing Facility Research Articles

Hospital-based skilled nursing facility survival: Organizational and market-level predictors.

Rising health care costs and consequent increases in Medicare reimbursements have led to many payment reforms over the years. Implementation of the prospective payment system (PPS) for hospitals in 1983 incentivized hospitals to either purchase skilled nursing facilities (SNFs) or utilize their excess capacity to establish one within the hospital. With PPS reimbursement being applied to SNFs in 1998, prior monetary incentives for hospitals to own an SNF disappeared. However, despite the reduction in numbers, many hospitals continued to operate their hospital-based skilled nursing facilities (HBSNFs). This study examines the organizational and market-level factors associated with the survival of HBSNFs using the population ecology of organizations framework. Using American Hospital Association survey data, event histories of all U.S. acute care hospitals with an open HBSNF in 1998 were plotted to examine if a hospital closed its HBSNF during a 22-year period (1998-2020). The primary independent variables included hospital size, ownership, total margin, market competition, and Medicare Advantage penetration. The independent and control variables were lagged by 1 year. Cox regressions were conducted to estimate the hazard ratios capturing the risk of HBSNF closure. The results showed that HBSNFs located in large, not-for-profit hospitals and those operating in less competitive markets had greater odds of surviving. The HBSNF administrators of small, for-profit hospitals and those operating in highly competitive markets could utilize the findings of this study to judiciously allocate slack resources to their HBSNFs to keep those open given the current emphasis on continuity of care by regulatory bodies.

Outbreak investigation in a COVID-19 designated hospital: The combination of phylogenetic analysis and field epidemiology study suggesting airborne transmission.

Healthcare-associated COVID-19 infections caused by SARS-CoV-2 have increased morbidity and mortality. Hospitals and skilled nursing facilities (SNFs) have been challenged by infection control and management. This case study presents an outbreak investigation in a COVID-19-designated hospital and a hospital-based SNF. Real-time polymerase chain reaction (PCR) and other studies were performed on samples obtained from SNF residents, hospital patients, and healthcare workers (HCWs). The results of the laboratory tests and field epidemiological data were analyzed. Genome sequencing and phylogenetic analysis of SARS-CoV-2 were performed to identify the associations between cases. The tracer gas was released and recorded by a thermal imaging camera to investigate the spatial relations within clusters. During the outbreak, 29 COVID-19 infections in 3 clusters were identified through hospital-wide, risk-guided, and symptom-driven PCR tests. This included 12 HCWs, 5 patients, and 12 SNF residents who had been hospitalized for at least 14 days. Serology tests did not identify any cases among the PCR-negative individuals. The phylogenetic analysis revealed that viral strains from the 3 clusters shared a common mutation of G3994T and were phylogenetically related, which suggested that this outbreak had a common source rather than multiple introductions from the community. Linked cases exhibited vertical spatial distribution, and the sulfur hexafluoride release test confirmed a potential airborne transmission. This report addressed the advantage of a multi-disciplinary team in outbreak investigation. Identifying an airborne transmission within an outbreak highlighted the importance of regular maintenance of ventilation systems.

Reducing sepsis-related unplanned 30-day readmissions at a hospital-based skilled nursing facility

Background: Sepsis is a common and costly medical emergency, often leading to unplanned readmissions. The purpose of this quality improvement project is to integrate staff education, every 4 hours vital signs monitoring guided by sepsis screening score, and structured response via a process map to reduce unplanned 30-day readmission rate by 25% from baseline at a hospital-based skilled nursing facility (HBSNF).Methods: This project was conducted at an 18-bed HBSNF. Prior to implementing this project, all registered nurses and patient care assistants received education on sepsis. Registered nurses were also trained in the proper use of Nursing Sepsis Management Order Set and How to Respond: A Patient with Suspected Sepsis Process Map. From September 1 to November 30, 2020, the project gradually increased vital signs monitoring frequency from every 12 hours to every 4 hours based on patients’ sepsis risk stratified by sepsis screening score in 3 phases. Systemic Inflammatory Response Syndrome criteria was used to identify sepsis-related unplanned readmissions.Results: Overall, the 3-month vital signs monitoring compliance rate was 96% (5019/5223). The sepsis-related unplanned 30-day readmission rate was reduced from baseline 47% (17/36) to 21% (4/19) at the end of this project, about a 55% decrease from baseline.Conclusions: The combination of an evidence-based electronic surveillance system and change in management strategies significantly reduced sepsis-related unplanned 30-day readmissions at this HBSNF. Dissemination of these innovations could improve sepsis management in other HBSNFs and positively impact patients’ health outcomes and healthcare costs.

The association of vertically integrated care with health care use and outcomes.

To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes. Medicare provider, beneficiary, and claims data from 2012 to 2014. We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias. We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data. Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P<.001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2days, P=.001) and shorter initial SNF stays (adjusted difference: -2.7days, P=.049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias. Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.

Examination of nursing home financial distress via Porter's five competitive forces framework.

Nursing homes face increased risk of closure because of poor financial performance. Using resource dependency theory, Porter's Five Forces of Competition framework, and Altman's Z -score model, this study examines the relationship between market factors and nursing home financial distress. This study utilizes Medicare Cost Reports, LTCFocus, Certification and Survey Provider Enhanced Reporting, Online Survey Certification and Reporting, and the Area Health Resource File to examine an average of 10,454 nursing homes per year from 2000 to 2015. Using Porter's framework, market factors were conceptualized as the bargaining power of buyers and suppliers, threat of substitutes and new entrants, and industry rivalry. Organizational control variables include occupancy, payer mix, size, and chain affiliation. Data were analyzed using multinomial logistic regression with robust clustering, year, and state fixed effects. Distressed nursing homes (Relative Risk Ratios [RRR] = 0.991) were less likely to be in counties with higher Medicaid concentration. Distressed (RRR = 0.717) and at-risk-of-distress nursing homes (RRR = 0.807) were less likely to be in markets with home health agencies, and nursing homes at risk of distress (RRR = 1.005) were more likely to be in markets with a higher number of hospital-based skilled nursing facility beds compared to healthy organizations. The organizational-level variables, occupancy, payer mix, size, and chain affiliation had a significant impact on nursing home financial distress. The effects of external market forces on nursing home financial distress were limited; however, organizational-level variables had a significant impact on nursing home financial distress. Study findings can inform policy makers on specific factors associated with nursing home financial distress and provide greater insight as it relates to designing new policies and interventions.

Incidence and Management of Candida Auris in a Skilled Nursing Home

<h3>Background</h3> Candida auris is an emerging multidrug resistant fungal infection that causes nosocomial transmission. <h3>Methods</h3> We describe the incidence and management of C. auris in a hospital-based skilled nursing facility (SNF). Data on resident demography, concurrent medical comorbidities, and medical interventions were obtained through medical records review. <h3>Results</h3> Nineteen residents were identified with C. auris in the SNF. Seventeen (89%) were admitted from hospitals and other SNFs. Two (10%) were identified with C. auris colonization after a point prevalence screening done by the New York State Department of Health (NYSDOH). Infection control and prevention measures were instituted, including isolation precautions, environmental cleaning and disinfection, and education. Among nineteen residents, six (31%) were cleared using NYSDOH screening criteria. <h3>Conclusions</h3> Aggressive implementation of infection control measures is key in the control and prevention of transmission of C. auris.

Reduction in Hospitals' Readmission Rates: Role of Hospital-Based Skilled Nursing Facilities.

Hospital readmission within 30 days of discharge is an important quality measure given that it represents a potentially preventable adverse outcome. Approximately, 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Many strategies such as the hospital readmission reduction program have been proposed and implemented to reduce readmission rates. Prior research has shown that coordination of care could play a significant role in lowering readmissions. Although having a hospital-based skilled nursing facility (HBSNF) in a hospital could help in improving care for patients needing short-term skilled nursing or rehabilitation services, little is known about HBSNFs’ association with hospitals’ readmission rates. This study seeks to examine the association between HBSNFs and hospitals’ readmission rates. Data sources included 2007-2012 American Hospital Association Annual Survey, Area Health Resources Files, the Centers for Medicare and Medicaid Services (CMS) Medicare cost reports, and CMS Hospital Compare. The dependent variables were 30-day risk-adjusted readmission rates for acute myocardial infarction (AMI), congestive heart failure, and pneumonia. The independent variable was the presence of HBSNF in a hospital (1 = yes, 0 = no). Control variables included organizational and market factors that could affect hospitals’ readmission rates. Data were analyzed using generalized estimating equation (GEE) models with state and year fixed effects and standard errors corrected for clustering of hospitals over time. Propensity score weights were used to control for potential selection bias of hospitals having a skilled nursing facility (SNF). GEE models showed that the presence of HBSNFs was associated with lower readmission rates for AMI and pneumonia. Moreover, higher SNFs to hospitals ratio in the county were associated with lower readmission rates. These findings can inform policy makers and hospital administrators in evaluating HBSNFs as a potential strategy to lower hospitals’ readmission rates.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

Organizational and Market-level Predictors of Hospital-based Skilled Nursing Facility Closures

ABSTRACT Objective: This study examines the organizational and market- level factors associated with the closure of hospital-based skilled nursing facilities (HBSNFs) using the population ecology o...

Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition.

Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition.

Cardiac rehabilitation in skilled nursing facilities: A missed opportunity

BackgroundAfter hospitalization for a cardiac event, older adults are frequently discharged to a skilled nursing facility (SNF) for postacute care. The American Association of Cardiopulmonary Rehabilitation recommends that cardiac care be integrated into procedures at SNFs. ObjectiveWe undertook this research to describe the characteristics of patients in SNFs after a cardiac event and the cardiac care delivered at SNFs. MethodsA dual approach included (1) a retrospective medical record review of consecutive patients admitted to 2 hospital-based SNFs after a cardiac event (n = 80), and (2) surveys from healthcare professionals (n = 21) working in these facilities. ResultsThirty-two percent of patients were not candidates for cardiac rehabilitative interventions because they had been rehospitalized, discharged to long-term care facilities, or manifested contraindications to exercise. No standard assessment of exercise tolerance was evident, and although 70% of patients were discharged home, cardiac-specific discharge education was seldom evident. Healthcare professionals in SNFs reported that standard procedures for cardiac care services were lacking. ConclusionThe integration of cardiac care into SNFs is important to ensure the safety of therapy and improve the transition of patients from SNFs to outpatient cardiac rehabilitation programs.

*Poster 112: Obesity and Postacute Rehabilitation Outcomes in Different Settings Following Total Knee Replacement

Objective: To determine whether body mass index (BMI) differences are associated with differences in rehabilitation outcomes following total knee replacement (TKR). Design: Prospective observational cohort study. Setting: Inpatient rehabilitation facilities (IRFs), hospital-based skilled nursing facilities, and freestanding skilled nursing facilities (SNFs). Participants: 1372 patients with a TKR were stratified by BMI (in kg/m2) into nonobese (BMI<30), obese (BMI 30–40), and morbidly obese (BMI>40) groups.

Characterizing Rehabilitation Services for Patients With Knee and Hip Replacement in Skilled Nursing Facilities and Inpatient Rehabilitation Facilities

DeJong G, Hsieh C-H, Gassaway J, Horn SD, Smout RJ, Putman K, James R, Brown M, Newman EM, Foley MP. Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities. Objective To characterize rehabilitation services for patients with knee and hip replacement in 3 types of postacute facilities in the U.S. Design Multi-site prospective observational cohort study. Setting Eight freestanding skilled nursing facilities (SNFs), 1 hospital-based SNF, and 11 inpatient rehabilitation facilities (IRFs). Participants Patients (N=2158) with knee or hip replacement. Interventions No new interventions. Main Outcome Measures Length of stay (LOS), amount and intensity of physical therapy (PT) and occupational therapy (OT), types of therapy activities. Results Average LOS was about 15 days for freestanding SNF patients, and 9 to 10 days for hospital-based SNF and IRF patients. Freestanding SNFs and IRFs provide about the same number of hours of PT and OT; the hospital-based SNF provided 27% fewer hours. Freestanding SNFs and the hospital-based SNF provided fewer hours a day than did IRFs. Joint replacement patients across all 3 types of facilities spent, on average, 70% to 75% of their PT time in just 2 activities—exercise and gait and spent 56% to 66% of their OT time in 3 activities—exercise, functional mobility, and dressing lower body. Conclusions Both freestanding SNFs and IRFs provided similar amounts of PT with a similar emphasis on exercise and gait activities. IRFs, however, provided more OT than freestanding SNFs. IRFs had shorter LOSs and more intensive therapy services than freestanding SNFs. Study freestanding SNFs exhibited greater variation in LOS and intensity of therapy than IRFs.

Long-Term Outcomes of Joint Replacement Rehabilitation Patients Discharged From Skilled Nursing and Inpatient Rehabilitation Facilities

DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh C-H, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities. Objective To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design Postdischarge follow-up interview study at 7.5 months after admission. Setting Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs. Participants Patients (N=856): 561 with knee replacement and 295 with hip replacement. Interventions None. Main Outcome Measures FIM and Short-Form 12-Item Health Survey (SF-12). Results Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12–related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes. Conclusions At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.

Use of Rehabilitation and Other Health Care Services by Patients With Joint Replacement After Discharge From Skilled Nursing and Inpatient Rehabilitation Facilities

DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Smith P, Gassaway J, DaVanzo JE. Use of rehabilitation and other health care services by patients with joint replacement after discharge from skilled nursing and inpatient rehabilitation facilities. Objective To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF). Design Follow-up interview study at 7.5 months after discharge. Setting Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States. Participants Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295). Interventions No interventions. Main Outcome Measures Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications. Results After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects. Conclusions Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes.

Joint Replacement Rehabilitation Outcomes on Discharge From Skilled Nursing Facilities and Inpatient Rehabilitation Facilities

DeJong G, Horn SD, Smout RJ, Tian W, Putman K, Gassaway J. Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities. Objective To compare functional outcomes at discharge across postacute settings. Design Prospective observational cohort study. Setting Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States. Participants Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751). Interventions None; examination of existing practice patterns. Main Outcome Measure FIM discharge motor score. Results Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome. Conclusions As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes.

Simply the Best: Teaching Gerontological Nursing Students to Teach Evidence-Based Practice

This article describes a teaching strategy used in an undergraduate gerontological nursing clinical course to familiarize students with evidence-based practice. Students are required to read and summarize an assigned evidence-based practice guideline published by The University of Iowa Gerontological Nursing Interventions Research Center. They then develop a "tip sheet," based on the assigned guideline, to disseminate to health care staff at their practicum sites, which is either a long-term care facility or a hospital-based skilled nursing facility. Nursing students' reactions to the assignment and nursing staff's responses to the tip sheets are discussed.

Using Propensity Stratification to Compare Patient Outcomes in Hospital-Based versus Freestanding Skilled-Nursing Facilities

Medicare skilled-nursing facility (SNF) patients exhibit differences in resource use and outcomes by whether the SNF is hospital-based or freestanding. Some of the differences may be attributable to patient selection rather than underlying institutional differences. This study adjusts for patient selection by stratifying Medicare SNF patients by their likelihood of hospital-based SNF referral. Three outcomes are analyzed to illustrate this approach: Medicare SNF length of stay, discharge to home within 30 days, and preventable hospital readmissions. The estimations use claims and patient-assessment data merged with facility and market characteristics. The results provide strong evidence that good candidates for faster recovery and discharge to the community are preferentially selected into hospital-based units. While the unstratified regression approach controls for much of the selection, stratified regressions provide further reductions in setting-specific differences. Remaining differences may be because of patterns of care or reflect residual bias from unobserved factors.

What happens when hospital-based skilled nursing facilities close? A propensity score analysis.

To assess the effects of hospital-based skilled nursing facility (HBSNF) closures on health care utilization, spending, and outcomes among Medicare fee-for-service beneficiaries. One hundred percent Medicare fee-for-service claims files for 1997-2002 were merged with Medicare Provider of Services files and beneficiary-level enrollment records. Medicare spending, the use of postacute care, and health outcomes, were compared among hospitals that did and did not close their HBSNFs between 1997 and 2001. Hospitals were stratified according to propensity scores (i.e., predicted probability of closure from a logistic regression) and analyses were conducted within these strata. HBSNF closures were associated with increased utilization of alternative postacute care settings, and longer acute care hospital stays. Because of increased use of alternative settings, HBSNF closures were associated with a slight increase in total Medicare spending. There are no statistically robust associations between HBSNF closures and changes in either mortality or rehospitalization. HBSNF closures altered utilization patterns, but there is no indication that closures adversely affect beneficiaries' health outcomes.

Hospital-Based and Freestanding Skilled Nursing Facilities: Any Cause for Differential Medicare Payments?

Differential Medicare payments for hospital-based and freestanding skilled nursing facilities (SNFs) were eliminated by the SNF prospective payment system initiated in 1998. Closures and high negative margins of hospital-based facilities have prompted consideration of the need to revisit payment adjustments for this group of SNFs. We examine case mix-related and other factors behind the cost differences between hospital-based and freestanding SNFs. Some payment adjustment, notably for nontherapy ancillary services, may be reasonable for the short term.