Post-acute Care In Skilled Nursing Facilities Research Articles

Did Avoiding Post-Acute Skilled Nursing Facility Care During the COVID-19 Pandemic Save Lives?

Context: During the COVID-19 pandemic, patients using post-acute care generally avoided skilled nursing facilities, presumably to reduce their chance of illness and death. However, staying at home after an acute inpatient hospitalization carries its own risks. Objectives: To assess whether avoiding skilled nursing facilities in 2020 saved lives and whether this behavior also led to a change in readmission rates. Methods: Retrospective cohort study using Medicare Fee-for-Service medical claims data for patients in Michigan. Findings: Between 2019 and 2020, use of skilled nursing facilities fell by 8 percentage points, which was not due to a change in patient characteristics. The reduction in use of post-acute skilled nursing facility care was associated with a 23.3% lower 90-day mortality rate during the COVID-19 pandemic than otherwise expected, and 117 saved lives. There was also a small increase in the readmission rate across years. Finally, between-group disparities worsened, with the vast majority of the reduction in both mortality and readmissions seen among patients who were not dually eligible for Medicaid. Limitations: The data are limited to the state of Michigan. Implications: Findings from this study should be used to inform health professionals of the benefits and risk of post-acute care following hospitalization during times of increased disease transmission. Extra consideration should be given to the post-acute care and outcomes of dual-eligible patients.

Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis.

To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes. Comparative effectiveness analysis. Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535). We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community. The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different. RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.

Post-Acute Care Setting After Hip Fracture Hospitalization and Subsequent Opioid Use in Older Adults.

Pain management in post-acute care (PAC) requires careful balance, with both opioid use and inadequate pain treatment linked to poor outcomes. We describe opioid use among older adults following discharge from PAC for hip fracture in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). Retrospective cohort. Medicare beneficiaries with Medicare Provider Analysis (MedPAR) claims, aged 66years and older with a hip fracture hospitalization between 2012 and 2018 followed by PAC in SNFs or IRFs and then discharge to the community. Individuals were followed from PAC discharge for up to 1 year to assess opioid use. Covariate-standardized risk ratios (RR) and risk differences (RD) for opioid use within 7 days of PAC discharge were estimated via parametric g-formula with modified Poisson regression, and hazard ratios (HRs) for any post-PAC opioid use and long-term opioid use via Fine-Gray sub-distribution hazards regression. Of 101,021 individuals, 80% (n= 80,495) were discharged from SNFs and 20% (n= 20,526) from IRFs. Opioids were dispensed to 50,433 patients (50%) overall and the 1-year cumulative incidence was notably higher in IRF (68%) than SNF (46%) patients. The adjusted risk of discharge from PAC with an opioid was 41% lower after SNFs versus IRFs [RR: 0.59; 95% confidence limits (CLs): 0.57-0.61; and RD:-0.16; 95% CLs:-0.17 to-0.15]. The adjusted rate of any opioid use in the year after PAC discharge was 44% lower (HR: 0.56; 95% CLs: 0.54-0.57) and of long-term opioid use was 17% lower (HR: 0.83; 95% CLs: 0.80-0.87) after SNFs versus IRFs. Opioid use is highly prevalent upon discharge from PAC after hip fracture, with lower use after SNF versus IRF care. Future research should assess the benefits and harms of post-PAC opioid prescribing and whether care practices during PAC can be improved to optimize long-term opioid use.

Incidence and Outcomes of SARS-CoV-2 in Post-Acute Skilled Nursing Facility Care.

ObjectivesTo examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death.DesignCohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive.Setting and ParticipantsThe sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded.MethodsSARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2.ResultsThe sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment.Conclusions and ImplicationsThe absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.

Functional Trajectories and Quality of Life in Post-Acute Skilled Nursing Facility care after hospitalization

Frailty predicts readmissions and mortality after acute hospitalizations. Understanding whether frailty predicts functional recovery after acute hospitalizations may help guide post-acute care and rehabilitation. This feasibility study enrolled 24 adults aged ≥65 years from a skilled nursing facility (SNF) after acute hospitalization. We calculated a deficit-accumulation frailty index (FI range: 0-1; non-frail [≤0.25], mild frailty [0.26-0.35], moderate [0.36-0.45], and severe [>0.45]) via in-person assessment on SNF admission. We measured weekly functional improvement with modified Barthel Index, as well as quality of life. Modified Barthel Index and quality of life were measured weekly by Patient-Reported Outcome Measurement Information System (PROMIS) (standardized score with mean 50 and SD 10, higher is better). The mean age was 83.3 years [SD 8.0], and 17 (71.8%) were female. Length of stay for those with severe frailty (FI>0.45) was 26.8 days [10.7] compared to those who were not frail, mildly frail, or moderately frail (13.3 [7.3], 9.4 [4.4], and 15.2 [4.9] respectively). Those with severe frailty also had delayed functional improvement (mean Barthel Index 48.6, 53.4, and 56.6 on admission, week 1, and week 2 of SNF admission respectively), compared to those with moderate frailty (mean Barthel Index 47.5, 69, 73) or mild frailty (68.3, 86, 90.5). Self-reported mental and physical health-related quality of life was relatively unchanged across SNF episode for all frailty categories. These findings suggest that older adults with moderate or severe frailty may experience a typical course of delayed functional recovery and that further monitoring may be necessary for prognostication.

What’s Driving SNF Readmission Rates? Exploring Differences in Processes Between High and Low Performing Hospitals

Despite the increasing national focus on improving post-acute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this rapid ethnographic study was to observe processes used to prepare older patients for post-acute care in SNFs, and to explore differences between hospital-SNF pairs with high or low thirty-day readmission rates. We stratified hospitals according to readmission rates from SNF and used convenience sampling to identify two high and two low performing sites and associated SNFs (n=5). We conducted intensive multi-day observations (n=148 hours) and key informant interviews (n=30 clinicians) to describe hospital processes for discharging patients to SNF. We used thematic analysis of interviews and fieldnotes to identify differences in transitional care processes of hospitals discharging patients to SNFs. Hospitals used five major processes prior to SNF discharge that could affect care transitions for older adults: recognizing the need for post-acute care, deciding level of care, selecting SNF facility, negotiating patient fit, and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to a SNF as an iterative team-based process; and 3) anticipating barriers with knowledge of transitional and SNF care processes. Identifying variations in processes used to prepare patients for SNF provides critical insight into the best-practices for transitioning patients to SNFs and areas to target for improving care of older adults.

CAPABLE Transitions: A Home Health Agency-Based Intervention to Optimize the SNF-to-Home Transition

Community Aging in Place-Advancing Better Living for Elders (CAPABLE) consists of an interprofessional team of a registered nurse (RN), occupational therapist (OT), and handyworker that delivers an in-home client-specific package of interventions to optimize function. CAPABLE aims to reduce functional impairment, home hazards, and acute medical services use and is being widely disseminated. To expand CAPABLE to older adults transitioning from the skilled nursing facility (SNF) to home, we developed CAPABLE Transitions, which makes several important modifications to CAPABLE. First, CAPABLE Transitions will be implemented within a Medicare-certified home health agency (CHHA) and delivered to CHHA clients. Second, it will be delivered to CHHA clients with and without dementia. Adding urgency to CAPABLE Transitions’ development, including persons with dementia has the potential to decrease high utilization of services and meet care transition needs. Third, it includes an initial RN care transition visit. Fourth, its services are more intensely delivered at the beginning of the intervention, shortly after SNF discharge. Beginning in the fall of 2020, CAPABLE Transitions will be tested in a feasibility study of 60 older adults discharged from post-acute SNF care to CHHA services in Rochester, NY. We have designed this 3-year feasibility study to consist of yearly recruitment waves that will enable us to iteratively assess and refine the intervention. Following this study, we hope to test CAPABLE Transitions’ effect on improving home time, quality of life, and the use of acute medical services in order to assist older adults in aging in place.

Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care

Our study examined the proportion of skilled nursing facility (SNF) post-acute care residents who did not receive timely primary care provider (PCP) services following discharge, factors associated with lack of timely PCP services, and factors associated with perfect 30-day home time among those who did not receive timely PCP services. Longitudinal cohort study; data sources included Medicare claims and other administrative databases. 25,357 fee-for-service New York State Medicare beneficiaries aged 65years and older admitted to SNFs for post-acute care in 2014 and then discharged to the community. Our outcomes were a timely PCP visit (within 7days of SNF discharge) and perfect 30-day home time, and we examined their association with patient, SNF, and county factors. Among SNF discharges, 60.6% had a timely PCP visit. In multivariate regression analyses, female sex, nonwhite race, Medicare only status, less functional impairment and medical comorbidity, asurgical hospitalization, fewer hospital days, more SNF days, absence of home health services, for-profit SNF status, higher SNF star rating, lower ratio of registered nurse/total nursing hours, and ruralcounties were associated with lower odds of a timely PCP visit following SNF discharge. Among those without a timely PCP visit, female sex, less cognitive and functional impairment, less medical comorbidity, a surgical hospitalization, fewer hospital days, receipt of home health services, and higher SNF star rating were associated with increased odds of perfect 30-day home time following SNF discharge. That 4 in 10 post-acute care SNF patients did not have a timely PCP visit post-SNF discharge, with racial minority and rural county status associated with decreased odds of a timely PCP visit, is concerning. Examination of whether the timing and type of outpatient visit may have varying effects on different post-acute care subpopulations would build on this work.

Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach

BackgroundDespite the increased focus on improving patient’s postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe...

Improving Healthcare Value: COVID-19 Emergency Regulatory Relief and Implications for Post-Acute Skilled Nursing Facility Care.

Rarely, if ever, does a national healthcare system experience such rapid and marked change as that seen with the COVID-19 pandemic. In March 2020, the president of the United States declared a national health emergency, enabling the Department of Health & Human Services authority to grant temporary regulatory waivers to facilitate efficient care delivery in a variety of healthcare settings. The statutory requirement that Medicare beneficiaries stay three consecutive inpatient midnights to qualify for post-acute skilled nursing facility coverage is one such waiver. This so-called Three Midnight Rule, dating back to the 1960s as part of the Social Security Act, is being scrutinized more than half a century later given the rise in observation hospital stays. Despite the tragic emergency circumstances prompting waivers, the Centers for Medicare & Medicaid Services and Congress now have a unique opportunity to evaluate potential improvements revealed by COVID-19 regulatory relief and should consider permanent reform of the Three Midnight Rule.

TRANSITIONAL CARE OUTCOMES IN VETERANS RECEIVING POST-ACUTE CARE IN A SKILLED NURSING FACILITY

More than 200,000 Veterans transition between hospital and skilled nursing facility (SNF) annually. Capturing outcomes of these transitions has been challenging because older adult Veterans receive care at VA and non-VA hospitals, and four different kinds of SNFs: VA-owned and -operated Community Living Centers (CLCs), VA-contracted community nursing homes (CNHs), State Veterans Homes (SVHs), and non-VA community SNFs. We used a novel data source which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans, to calculate the rate of adverse outcomes associated with the transition from hospital to SNF in all enrolled Veterans age 65 and older undergoing this transition 2012-2014. The composite primary outcome included Emergency Department (ED) visits, rehospitalizations, and mortality (not in the context of hospice) within 7 days of hospital discharge to SNF. We used multivariable logistic regression to adjust for Veteran and hospital characteristics and hospital random effects. In the 388,339 Veterans discharged from 1502 hospitals in our sample, we found more than 4 in 5 Veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7%. After adjustment, VA hospitals had lower adverse outcome rates than non-VA hospitals (OR 0.80, 95% CI 0.74-0.86). VA hospital-CLC transitions had the lowest adverse outcome rates; in comparison, non-VA hospital-CNH (OR 2.51, 95% CI 2.09-3.02) and non-VA hospital-CLC (OR 2.25, 95% CI 1.81-2.79) had the highest rates. These findings raise important questions about the VA’s role as a major provider and payer of post-acute care in SNF.

Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility.

Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions. To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases. Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians. Three hospitals and three SNFs in a single metropolitan area. Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings. We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases. Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs. Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.

Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility

BACKGROUND: Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions. OBJECTIVE: To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases. DESIGN: Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians. SETTING: Three hospitals and three SNFs in a single metropolitan area. PATIENTS: Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings. MEASUREMENTS: We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases. RESULTS: Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs. CONCLUSIONS: Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.

How Hospital Clinicians Select Patients for Skilled Nursing Facilities.

To understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care. Semistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory. Inpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units. Clinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision-making regarding postacute care (N=25). Central themes related to clinician evaluation and discharge decision-making. Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a "safety net" for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision-maker. Hospital clinician evaluation and decision-making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a "safety net" for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision-making are urgently needed.

Medicare Expenditures of Individuals with Alzheimer's Disease and Related Dementias or Mild Cognitive Impairment Before and After Diagnosis.

To characterize Medicare expenditure and usage trends in individuals with a coded diagnosis of Alzheimer's disease and related dementia (ADRD) or mild cognitive impairment (MCI) during the periods leading up to and after diagnosis. Retrospective observational cohort study. Five percent sample of the 2009 to 2013 Medicare claims files. Individuals newly diagnosed with ADRD (n = 25,916) or MCI (n = 2,784), each with a propensity-score matched control subject. Medicare expenditures and usage during the 24 months before and after a new diagnosis of ADRD or MCI. Medicare expenditures were 42% higher in participants with ADRD ($10,622 vs $15,091, P < .001) and 41% higher in those with MCI ($9,728 vs $13,691, P < .001) during the year before diagnosis than in matched controls. Medicare expenditures of participants with ADRD increased to $27,126 for the first 12 months immediately after diagnosis and decreased to $17,257 during the 12 months after that. For participants with MCI, average Medicare expenditures were $20,386 for the 12 months after diagnosis and $14,286 for the 12 months after that. Use of inpatient care, postacute skilled nursing facility care, and home health care increased substantially after diagnosis of ADRD or MCI. Participants with ADRD and MCI incurred significantly higher Medicare expenditures than matched controls, even before they received a formal diagnosis. Medicare expenditures of individuals with ADRD and MCI may start to increase at least 12 months before their diagnosis, peak during the first few months immediately after diagnosis, and decrease afterward but remain at a higher level than before diagnosis. These findings highlight the importance of early diagnosis and indicate the need for complex case management to coordinate care transitions for individuals with ADRD and MCI.

Effect of Postacute Rehabilitation Setting on Mental and Emotional Health Among Persons With Dysvascular Amputations

To examine the effect of postacute rehabilitation settings on depression and emotional and social functioning among patients undergoing major lower extremity dysvascular amputations. A population-based, prospective cohort study. Two racially diverse metropolitan areas (Baltimore, Maryland, and Milwaukee, Wisconsin). Persons undergoing major amputation. Data were collected from medical records and patient interviews during acute hospitalization, and 6-month postamputation data were analyzed with use of multivariate regression techniques. Multivariate regressions were used to examine the independent effect of postacute rehabilitation setting on the probability of experiencing depression, low mental health, low social functioning, and low emotional role functioning 6 months postindex amputation, while controlling for preamputation functioning and an array of potential confounders, including pre-existing medical conditions, sociodemographic characteristics, baseline health, and functional status described previously. Of the 297 patients participating in the study, 43.4% received most of their inpatient postacute care at an inpatient rehabilitation facility (IRF), 32% at a skilled nursing facility (SNF), and 24.6% were discharged home with no inpatient rehabilitation. Even after we adjusted for preamputation characteristics and potential selection bias into the postacute care setting, patients receiving postacute care at an IRF were significantly less likely than those receiving postacute care at an SNF or home to experience depressive symptoms. Patients receiving care at IRFs were also less likely to report low emotional functioning than their counterparts receiving postamputation care at home or in an SNF. Patients in IRFs also reported better social functioning than did those who received postacute care in SNFs. This study showed an association between reduction in depressive symptoms and emotional suffering and management after lower limb amputation on an inpatient rehabilitation unit. These results add to the growing body of literature suggesting better outcomes for persons with vascular-related amputations who receive care at an IRF relative to other postacute care settings.

Is Higher Volume of Postacute Care Patients Associated With a Lower Rehospitalization Rate in Skilled Nursing Facilities?

This study determined whether higher patient volume of skilled nursing facility (SNF) care was associated with a lower hospital transfer rate. Using the nursing home Minimum Data Set and the Online Survey, Certification, and Reporting file, we assembled a national cohort of Medicare SNF postacute care admissions between January and September of 2008. Multivariable analyses based on Cox proportional hazards models found that patients admitted to high-volume SNFs (annual number of admissions in the top tertile group) showed an approximately 15% reduced risk for 30-day rehospitalization and an approximately 25% reduced risk for 90-day rehospitalization, compared with patients admitted to low-volume SNFs (annual number of admissions in the bottom tertile group, or <45). Similar patterns of volume-outcome associations were found for hospital-based and freestanding facilities separately. The inverse volume-outcome association in postacute SNF care may reflect a "practice makes perfect" effect, a "selective referral" effect, or both.