Postacute Destination Research Articles

THE LOOMING POST-ACUTE REORGANIZATION: IMPLICATIONS FOR OLDER ADULTS TRANSITIONING FROM THE HOSPITAL

Abstract Post-acute volume plays an important role in the care of millions of older adults transitioning from a hospital stay. To help reduce the total cost of care, many hospitals have been shifting more volume from institutional skilled nursing care to less expensive home health care. In fact, in 2017, home health volume eclipsed skilled nursing facility volume as the preferred post-acute destination for the first time. The COVID-19 pandemic further exacerbated this trend with many older adults preferring to avoid institutional care. Using 2016-2019 MedPAR data, we explored changes over time in hospital discharges to skilled nursing facilities versus to home health. We regress the ratio of home health to skilled nursing facility volume on a month-year variable. We find that the ratio of discharges to home health versus to skilled nursing facility increases by .07 percentage points per month (coefficient = .00073, 95% CI [.00063 to .00084]). This translates to a nearly one percentage point change in the ratio of home health to skilled nursing volume per year. These trends vary by patient characteristics (e.g. hospital diagnosis), organizational characteristics (e.g. hospital market relationships), and indicators of market capacity of post-acute services. This growing trend has implications on vulnerable older adults; health system leaders need policy guidance and incentives to invest in value-oriented care practices across this changing post-acute landscape.

Geriatric syndrome risk factors among hospitalized postacute Medicare patients.

To assess the association of geriatric syndrome risk factors with postacute utilization among hospitalized Medicare patients (both Medicare Advantage [MA] and fee-for-service [FFS] cohorts) and to examine patterns of postacute care for MA and FFS cohorts with high geriatric syndrome risk. Secondary data analysis using encounter-level data from the State Inpatient Databases (SID) of the Healthcare Cost and Utilization Project. The sample included 3.1 million Medicare hospitalizations from the Florida SID (2010 to 2014). We used multivariate linear regression to examine the impact of a geriatric syndrome risk measure, assessed as high risk, moderate risk, or nonrisk, on outcomes in MA and FFS cohorts. Outcome measures included postacute destination and inpatient utilization. We then examined if this risk measure was associated with differences in outcomes between MA and FFS cohorts. Patients with high geriatric syndrome risk (in both MA and FFS cohorts) are less likely to be discharged to home or to home health care. They also have longer inpatient lengths of stay and higher inpatient costs. This risk measure also explains differences in postacute skilled nursing destination between MA and FFS cohorts. Geriatric syndrome risk factors not only play a role in postacute care and inpatient utilization in MA and FFS cohorts but also explain different utilizations between MA and FFS cohorts. This study's results can be applied to guide discharge planning among a group of high-risk patients and evaluate alternative delivery models for this high-cost, high-need cohort.

Post-acute pathways among hip fracture patients: a system-level analysis.

BackgroundHip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system.MethodsThis study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients’ post-acute destinations within each region were retrieved by linking patients’ records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values.ResultsThirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region.ConclusionsThe observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1524-1) contains supplementary material, which is available to authorized users.