Skilled Nursing Facility Patients Research Articles

Preferences for Postacute Care at Home vs Facilities

Two in 5 US hospital stays result in rehabilitative postacute care, typically through skilled nursing facilities (SNFs) or home health agencies (HHAs). However, a lack of clear guidelines and understanding of patient and caregiver preferences make it challenging to promote high-value patient-centered care. To assess preferences and willingness to pay for facility-based vs home-based postacute care among patients and caregivers, considering demographic variations. In September 2022, a nationally representative survey was conducted with participants 45 years or older. Using a discrete choice experiment, participants acting as patients or caregivers chose between facility-based and home-based postacute care that best met their preferences, needs, and family conditions. Survey weights were applied to generate nationally representative estimates. Preferences and willingness to pay for various attributes of postacute care settings were assessed, examining variation based on demographic factors, socioeconomic status, job security, and previous care experiences. A total of 2077 adults were invited to participate in the survey; 1555 (74.9%) completed the survey. In the weighted sample, 52.9% of participants were women, 6.5% were Asian or Pacific Islander, 1.7% were American Indian or Alaska Native, 11.2% were Black or African American, 78.4% were White; the mean (SD) age was 62.6 (9.6) years; and there was a survey completion rate of 74.9%. Patients and caregivers showed a substantial willingness to pay for home-based and high-quality care. Patients and caregivers were willing to pay an additional $58.08 per day (95% CI, 45.32-70.83) and $45.54 per day (95% CI, 31.09-59.99) for HHA care compared with a shared SNF room, respectively. However, increased demands on caregiver time within an HHA scenario and socioeconomic challenges, such as insecure employment, shifted caregivers' preferences toward facility-based care. There was a strong aversion to below average quality. To avoid below average SNF care, patients and caregivers were willing to pay $75.21 per day (95% CI, 61.68-88.75) and $79.10 per day (95% CI, 63.29-94.91) compared with average-quality care, respectively. Additionally, prior awareness and experience with postacute care was associated with willingness to pay for home-based care. No differences in preferences among patients and caregivers based on race, educational background, urban or rural residence, general health status, or housing type were observed. The findings of this survey study underscore a prevailing preference for home-based postacute care, aligning with current policy trends. However, attention is warranted for disadvantaged groups who are potentially overlooked during the shift toward home-based care, particularly those facing caregiver constraints and socioeconomic hardships. Ensuring equitable support and improved quality measure tools are crucial for promoting patient-centric postacute care, with emphasis on addressing the needs of marginalized groups.

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care. To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents. This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023. Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually. This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition. Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]). This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Dysphagia and Diets in Skilled Nursing Facilities When Patient's Health Status Changes: The Role of Imaging

ObjectivesResearch suggests that clinical decision making for assessing and treating patients with swallowing dysfunction varies significantly, and decisions may harm patients. The study aimed to investigate clinical practice of speech-language pathologists (SLPs) assessing and treating swallowing in skilled nursing facilities (SNFs). DesignRetrospective review of 120 medical records of patients recommended for a flexible endoscopic evaluation of swallowing (FEES). Setting and Participants120 SNF patients. MethodsRecords from 25 SNFs were reviewed to determine which patients were receiving swallowing therapy, their diet level pre- and post-FEES, and if they received prior imaging studies. Recordings of FEES were assigned severity ratings based on the Dynamic Imaging Grade of Swallowing Toxicity-FEES scores to determine the relationship between diet and liquid recommendations before and after FEES, how often patients consume a modified diet in the absence of dysphagia, percentage of patients without dysphagia receiving swallowing treatment, percentage of patients receiving alternative means of nutrition without dysphagia, and the percentage of patients with a feeding tube without an imaging assessment. ResultsChi-square tests revealed no agreement between pre- and postimaging diet levels. Ordinal regressions indicated preimaging diets did not fit the DIGEST severity rating model; however, investigators found a good fit with postimaging diet recommendations. Descriptive statistics indicated that 67% of the patients receiving a modified solid and/or liquid did not have dysphagia. Treatment was provided to 100% of the patients without dysphagia. Sixty-one percent of patients with feeding tubes had no dysphagia. Forty-five percent of NPO (nothing by mouth) patients had imaging during their acute stay. Conclusions and ImplicationsThe results strongly suggest that the practice of continuing acute care diet recommendations in a SNF increases cost and may negatively impact patient quality of life. The practice may also lead to negative health consequences. A new imaging assessment is required to inform treatment when medical status changes.

Increasing illness severity of skilled nursing facility patients over time: Implications for readmission penalties.

Current financial penalties for rehospitalization of skilled nursing facilities (SNFs) patients are based in part on the studies by Ouslander et al., 2011, and Mor et al., 2010, demonstrating that many SNF hospitalizations were avoidable. With increasing age, complex illness severity, and use of SNFs for subacute rehabilitation, readmission metrics and financial penalties based on previous data may be due for reevaluation. Retrospective electronic medical record (EMR) review of 21,591 admissions and discharges between 2010 and 2019 inclusive. Data extracted included demographics, LACE, Charlson comorbidity index (CCI), and simplified HOSPITAL score parameters. The scores were calculated for the study years from the extracted data. Patients readmitted to the hospital within 30 days were identified. Mean yearly score of all three indices rose steadily: LACE score 10.76-12.04 (0.43 estimated annual increase, 95% CI [0.39, 0.46]), CCI 4.26-5.05 (0.31 estimated annual increase, 95% CI [0.27, 0.34]), and simplified HOSPITAL score 3.46-4.03 (0.21 estimated annual increase, 95% CI [0.18, 0.24]). The estimated probability of readmission across observed CCI scores ranged from 15.4% to 15.9%, 95% CI bounds (10.8%, 22.7%). The estimated probability of readmission across observed LACE scores ranged from 4.7% to 36.3%, 95% CI bounds (3.4%, 54.7%). The estimated probability of readmission across observed HOSPITAL scores ranged from 5.8% to 54.1%, 95% CI bounds (6.2%, 66.0%). The study confirms anecdotal experience that the illness acuity of patients admitted to SNFs increased progressively over time and was associated with an increased risk of 30-day readmissions to the hospital. Our study suggests that the use of clinically validated readmission risk assessment tools instead of the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP) current risk adjustors may be a more accurate reflection of the current illness severity of a facility's patient population at the time of payment adjustment.

Emergency department visits by older adults receiving postacute care in skilled nursing facilities.

Skilled nursing facilities (SNF) represent a common postdischarge destination for hospitalized older adults. The goals of SNF care include the completion of extended skilled nursing care and physical rehabilitation to enable patients to safely return home. However, nearly one in four older adults discharged to SNF are rehospitalized and one in five seek care in the emergency department (ED) but are discharged back to SNF. Our aim was to measure the national prevalence and costs to Medicare of ED visits by SNF patients. Of the 1,551,703 Medicare beneficiaries discharged to SNF in 2019, 16.3% had an ED visit within 14 days (n = 253,104). Of those ED visits, 25.5% resulted in a same-day discharge back to SNF (n = 64,472), costing Medicare $24.6 million. Novel care models that can leverage SNF staff and resources while providing rapid diagnostic services are urgently needed.

Economic and Humanistic Burden Among Medicare-Aged Women With Fragility Fracture in the United States.

Describe patient characteristics, health care resource utilization, costs, and humanistic burden of women with Medicare insurance with incident fragility fracture who were admitted to post-acute-care (PAC). Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) data. Community-dwelling female Medicare beneficiaries with incident fragility fracture January 1, 2017, to October 17, 2019, resulting in PAC admission to a skilled nursing facility (SNF), home-health care, inpatient-rehabilitation facility, or long-term acute-care hospital. Patient demographic/clinical characteristics were measured during 1-year baseline. Resource utilization and costs were measured during baseline, PAC event, and PAC follow-up. Humanistic burden was measured among SNF patients with linked Minimum Data Set assessments. Multivariable regression examined predictors of PAC costs after discharge and changes in functional status during SNF stay. A total of 388,732 patients were included. Compared with baseline, hospitalization rates were 3.5, 2.4, 2.6, and 3.1 times higher and total costs 2.7, 2.0, 2.5, and 3.6 times higher for SNF, home-health, inpatient-rehabilitation, and long-term acute-care, respectively, following PAC discharge. Utilization of dual-energy X-ray absorptiometry (DXA) and osteoporosis medications remained low: 8.5% to 13.7% received DXA during baseline vs 5.2% to 15.6% following PAC; 10.2% to 12.0% received osteoporosis medication during baseline vs 11.4% to 22.3% following PAC. Dual eligibility for Medicaid (ie, low income) was associated with 12% higher costs; Black patients had 14% higher costs. Activities of daily living scores improved 3.5 points during SNF stay, but Black patients had 1.22-point lower improvement than White patients. Pain intensity scores showed small improvement (-0.8 points). Women admitted to PAC with incident fracture had high humanistic burden with little improvement in pain and functional status and significantly higher economic burden after discharge compared with baseline. Disparities in outcomes related to social risk factors were observed, with consistently low utilization of DXA and osteoporosis medications even after fracture. Results indicate a need for improved early diagnosis and aggressive disease management to prevent and treat fragility fractures.

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.

Clostridioides difficile infection in a skilled nursing facility (SNF): cost savings of an automated, standardized probiotic antimicrobial stewardship programme (ASP) policy.

With multiple comorbidities and frequent exposures to antibiotics, patients in skilled nursing facilities (SNFs) are much more vulnerable to healthcare-acquired infections. We conducted a quality-improvement, retrospective analysis of all patients with Clostridioides difficile infection (CDI) from 2009 to 2021 at an SNF. Probiotics were initially added to a bundle of antimicrobial stewardship programme (ASP) CDI prevention strategies. Formulations and durations of probiotics were standardized for both oral and enteral administration. To reach all eligible patients, an ASP probiotic policy provided probiotics with every antibiotic course. To assess the value of providing probiotic therapy to SNF patients at risk for CDI. Patients receiving oral or enteral feeding with antibiotics ordered were eligible to receive probiotics. The incremental cost of CDI prevention, treatment and related care were calculated and compared for each phase of probiotic policy change and feeding type. ASP records for the oral probiotic and level of treatment were used in modelling the cost-effectiveness. From quality improvement initiatives aimed at preventing facility-onset (FO) CDI, to ASP policies, probiotic formulations and delegation of ordering authority, the days of acute care treatment required was significantly reduced over the different phases of implementation [152 to 48, OR = 0.22 (0.16-0.31) to 4, OR = 0.08 (0.03-0.23)] after reducing total CDI from 5.8 to 0.3 cases per 10 000 patient-days. The annual cost of oral probiotics increased from $6019 to $14 652 but the modelled net annual savings for the facility was $72 544-$154 085. With optimization, the use of probiotics for CDI prevention at an SNF was safe, efficacious and cost-effective.

Impact of Telehealth on Hospitalization of Skilled Nursing Facility Patients During the COVID-19 Pandemic

Importance: This very large claims data analysis documents lower rates of hospitalization among patients receiving telehealth during a skilled nursing facility stay compared to patients who did not receive telehealth. These findings from care during the COVID-19 pandemic support the call for telehealth to become a routine option even after the public health emergency has ended.
 Objective: The COVID-19 Telehealth Impact Study was designed to describe the natural experiment of telehealth adoption during the pandemic. This focused analysis can assist program development for the large population of patients cared for in skilled nursing facilities. 
 Design, Setting, Participants: In March 2020, the MITRE Corporation and Mayo Clinic founded the COVID-19 Healthcare Coalition (C19HCC) and Telehealth Impact Study to respond to the pandemic. We report trends using a data set of 668,533 patients cared for in skilled nursing facilities (SNF) between January 2020 and March 2021.
 Main Outcomes and Measures: We compared rates of hospitalization within 60 days of admission to the skilled nursing facility for patients who received telehealth and those who did not receive telehealth during their SNF stay. We analyzed subgroups of patients based upon the clinical diagnoses for which they received professional services from physicians and other providers.
 Results: Of the 668,533 patients meeting criteria for an admission to a SNF facility, 97,204 (14.5%) had one or more telehealth visits. 40.1% of patients received one TH visit per 30 days during their SNF stay; 9.4% received ten or more TH visits per 30 days. Patients in all six diagnostic cohorts experienced significantly lower rates of hospitalization compared to patients who received no telehealth despite having a higher average disease burden measured by the Charlson Comorbidity Index. Absolute rates of hospitalization rates dropped between 1.25% (dementia) and 1.87% (orthopedic) for clinical groups. The relative rates of hospitalization dropped between 22% (cardiovascular) and 33% (dementia). 
 Conclusions and Relevance: This study underscores the potential benefits of using virtual care in skilled nursing facilities to lower rates of hospitalization and improve outcomes. We encourage continued study of the use digital health services for patients in post-acute settings and promotion of insurance coverage in the years to come as new best practices emerge.

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.

Frailty and Time at Home After Post-Acute Care in Skilled Nursing Facilities.

To examine the association of a claims-based frailty index with time at home, defined as the number of days alive and spent out of hospital or skilled nursing facility (SNF). Cohort Study. A 5% Medicare random sample of fee-for-service beneficiaries, who had continuous part A and B enrollment in the prior 6months, that were discharged from a short SNF admission in 2014‒2016. Frailty was measured with a validated claims-based frailty index (CFI) (range: 0‒1, higher scores indicating worse frailty) and categorized into nonfrail (CFI <0.25), mild frailty (CFI 0.25‒0.34), and moderate-to-severe frailty (CFI ≥0.35). We measured home time in the 6months following SNF discharge (range: 0‒182days with higher values representing more days at home and thus a better outcome). We used logistic regression to assess the association between frailty and short home time, defined as <173days, adjusting for age, sex, race, region, a comorbidity index, clinical SNF admission characteristics in the Minimum Data Set, and SNF characteristics. In our sample of 144,708 beneficiaries (mean age, 80.8years, 64.9% female, 85.9% white) who were discharged to community after SNF stay, the mean CFI was 0.26 (standard deviation, 0.07). The mean home time was 165.6 (38.1) days in nonfrail, 154.4 (47.4) days in mild frailty, 145.0 (52.0) days in moderate-to-severe frailty group. After full model adjustments, moderate to severe frailty was associated with a 1.71 (95% CI 1.65‒1.78) higher odds of having short time at home in the 6months following SNF discharge. Higher CFI is associated with short time at home in Medicare beneficiaries who are discharged to the community after post-acute SNF stay. Our results support the utility of CFI in identifying SNF patients who need additional resources and interventions to prevent health decline and poor quality of life.

Potentially avoidable emergency department use by patients discharged to skilled nursing facilities.

One-third of patients discharged from hospitals to skilled nursing facilities (SNF) are sent back to the Emergency Department (ED) within 30 days. Little is known about those patients who are discharged from the ED directly back to SNF. We considered these ED visits as potentially avoidable since they did not result in observation or hospitalization stay. Using a retrospective chart review of 1010 patients with ED visits within 14-days of discharge to SNF from University of Pennsylvania health system (UPHS) in 2020-2021, we identified 202 patients with potentially avoidable ED visits among medical and surgical patients. The most common reasons for these ED visits were mechanical falls (17.3%), postoperative problems (16.8%), and cardiac or pulmonary complaints (11.4%). Future interventions to decrease avoidable ED visits from SNFs should aim to provide access for SNF patients to receive timely outpatient lab and imaging services and postoperative follow-ups.

Abstract WP62: Skilled Nursing Facilities As A Bridge For Acute Rehabilitation In Acute Stroke Patients Who Are Not Immediate Candidates For Intensive Therapy

Background: Rehabilitation after hospital discharge is an essential component of stroke recovery. However, many stroke patients are not immediately ready for an Inpatient Rehabilitation Facility (IRF) after hospital discharge because of poor endurance, weakness, cognitive status, or medical condition. The purpose of this study is to demonstrate the efficacy of skilled nursing facilities (SNF) as a bridge to improve the number of post-stroke IRF admissions, and better understand the factors that allow transfer from a SNF to IRF by assessing differences between patients who are discharged from a SNF with vs. without an IRF referral. Methods: We included subjects with a primary diagnosis of ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage who were admitted to an urban CSC and discharged to a SNF from 1/2015 to 12/2021. Baseline demographics including gender, race, age, and risk factors were abstracted. Data were retrieved from both our EMR and Get With the Guidelines Stroke Database. Wilcoxon rank sum tests and chi square tests were used to analyze the data. Results: 1120 patients with a stroke diagnosis were discharged to a SNF, of which 173 (15%) received an IRF referral after SNF discharge. Nine to 19% (mean=15, SD=3) of SNF patients received an IRF referral between 2015 and 2021. Patients with an IRF referral were younger (mean age: 61.90, SD=14.05 vs 73.09, SD=12.12; p &lt; 0.0001). There were no statistically significant differences in length of stay, discharge mRS, and prevalence of hypertension, diabetes mellitus, coronary artery disease, dyslipidemia, heart failure, and smoking. Men more frequently received an IRF referral (20% vs 11%, p &lt; 0.0001). Racial differences in referral patterns were not significant (p = 0.19). Conclusions: SNFs are an effective bridge between the hospital and IRF settings, given that 15% of all stroke patients discharged to a SNF were ultimately referred to an IRF. SNFs should be considered as an alternate route for post-stroke patients who are not immediately ready for IRFs after hospital discharge but may still benefit from IRF therapy.

PATIENT AND CAREGIVER PERCEPTIONS OF MOBILITY AFTER DISCHARGE FROM SKILLED NURSING FACILITIES TO HOME

Abstract Functional outcomes of older adults in post-acute care is poorly understood. The purpose of this study was to describe skilled nursing facility (SNF) patient or caregiver perceptions of patient mobility and factors associated with patient mobility in 30 days after discharge from SNF to home. We conducted a secondary analysis of data from a stepped-wedge cluster randomized trial of the Connect-Home intervention set in 6 SNFs in North-Carolina. The sample included SNF patients (N=249) and their caregivers (N=249). In 30 days after discharge, SNF patients or their caregivers (as proxies) rated patient mobility using the Life-Space Assessment (LSA). LSA total-scores (range= 0-120), with higher scores indicating greater mobility. Linear mixed models, with random effects to adjust for clustering in SNFs, were used to describe associations between LSA total-score and patient, caregiver, and health-system factors. Participants were typically female (63%), White (74%), and average age of 76.3 years. In 30 days after discharge, LSA total-scores ranged from 0-90 with a mean score of 22 (SD=16.01). Most (85%) required caregiver and/or assistive devices to transfer inside and outside of their homes. In the mixed models, lower LSA scores were associated with older age [-0.232(0.108), p&amp;lt; 0.05], lower cognition score [1.182(0.384), p&amp;lt; 0.005], diagnosis of dementia [-6.863(3.057), p&amp;lt; 0.05], lower baseline mobility in the SNF [0.296(0.142), p&amp;lt; 0.05] and longer SNF stay [-0.200(0.068), p&amp;lt; 0.005]. Low LSA scores in this sample suggest the need for caregiver support to continue rehabilitation and promote functional ability at home. Studies are needed to augment transitional care and address these care needs.

The Value of an Additional Day of Post-acute Care in a Skilled Nursing Facility

With ongoing efforts to improve the value of health care in the United States and reduce wasteful spending, we examine empirically the value trade-offs involved in an additional day in a skilled nursing facility (SNF) after hospital discharge. To control for potential endogeneity, we use the percentage of Medicare beneficiaries enrolled in Medicare Advantage in each county-year as an instrument for individuals’ SNF length of stay among Traditional Medicare beneficiaries, as local Medicare Advantage penetration puts downward pressure on SNF length of stay for all SNF patients but does not directly affect utilization management of those enrolled in Traditional Medicare. We also test for heterogeneity in treatment effect across patients by clinical complexity and two non-health-related factors, marital status and nursing home profit status. We find that one additional day in a SNF lowers short-term readmission rates, but this effect is small and heterogeneous across patient types. The most clinically complex patients (those with the longest predicted SNF stays) benefit the most from an additional SNF day, as do patients whose stays are shorter because of non-health-related factors. The cost savings from reduced readmission rates are small and do not offset the additional SNF costs.

1225. The Perfect Storm: A Hardy and Lethal Pathogen and a Unit Filled with Immunocompromised Patients with Large Open Wounds. Troubles with Candida Auris in a Burn Intensive Care Unit

Abstract Background C auris is an emerging often multidrug resistant pathogen capable of causing severe morbidity and mortality. C auris has been increasingly isolated from patients in skilled nursing facilities and hospitals, and has been associated with facility outbreaks. A resilient pathogen, C. auris survives harsh disinfectants, desiccation and readily colonizes the environment posing an especially great risk to immunocompromised patients with large open wounds and long lengths of stay. Methods From 7/1/21 - 8/30/21 we noted a cluster of 4 patients with C auris in clinical cultures from the Burn ICU (BICU). A multidisciplinary team involving infection prevention, nursing/medical directors, health and safety, engineering, environmental services, and hospital leadership investigated the cluster as a potential outbreak. Mitigation measures involved a multi-modal response of C auris admission screening, weekly point prevalence testing of all BICU patients, environmental surface cultures, enhanced room cleaning, staff education, hand hygiene and personal protective equipment usage audits. Results 11 cases of C auris were identified on our BICU from 7/1/21 - 2/28/22. 5 (45.5%) cases from clinical isolates, 1 (9.1%) from a BICU point prevalence screen on 12/15/21, 5 (45.5%) as a part of weekly point prevalence screens started on 1/1/22. 6 (54.5%) patients were admitted for burn related injuries, 2 (18.2%) for Steven Johnson Syndrome, 2 (18.2%) for necrotizing wounds, and 1 (9.1%) for COVID-19 pneumonia. Cases occurred in 6/10 rooms in the Burn ICU. One (9.1%) patient expired during this outbreak (not deemed to be from C auris infection). Conclusion Resilient infections like C auris pose a risk of nosocomial transmission and potential high morbidity and mortality to burn patients with impaired immune defense and large open wounds. A multidisciplinary team using targeted interventions including screening, education, enhanced cleaning eradicated the outbreak in our BICU. As of 5/1/22, we went 13 + weeks without identifying a new case. The last patient with C auris was discharged 3/16/22. To prevent future outbreaks, we created a standardized response plan and instituted a universal screening protocol for C auris targeting all patient admissions from skilled nursing facilities and admissions to all ICUs. Disclosures Jorge Paiva Parada, MD MPH, Shionogi: Honoraria.

Benefits of Specialized Subacute Stroke Rehabilitation in a Skilled Nursing Facility: Comparison to Nationwide Outcomes

<h3>Research Objectives</h3> To characterize the benefits of specialized, multi-disciplinary, neuro-intensive rehabilitation provided to individuals with stroke in a Skilled Nursing Facility (SNF) evaluating change in Minimum Data Set (MDS) functional outcomes and discharge location. A descriptive comparison to national SNF data for individuals with stroke reported by the American Physical Therapy and American Occupational Therapy Association's "Therapy Outcomes in Post-Acute Care Settings" (TOPS) study is presented. <h3>Design</h3> Retrospective chart review using electronic medical records and MDS data. <h3>Setting</h3> SNF specializing in transitional rehabilitation for complex neurologic diagnoses. <h3>Participants</h3> 207 adults 21-92 years with an ICD-10 stroke diagnosis admitted after 1/1/18 and discharged before 3/14/20. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Discharge location and MDS G-codes: dressing, bathing, walking/locomotion (average of on and off unit walking), transferring, toileting, and feeding. Scores were inverted and multiplied by 1.5 to allow comparison to the TOPS data. <h3>Results</h3> Paired t-tests compared admission to discharge MDS change with an average gain of 8.2 points (95% CI 7.15-9.24) and average length of stay (LOS) of 9.38 weeks (95% CI 8.74-10.02). The top 34% of responders gained an average of 17.5 points. Several variables (age, sex, LOS, case mix index, therapy minutes, admission time post onset) correlated to improvements measured by the G-code change and discharge location, however, the correlations were weak (r=0.154-0.266, p<.001-.027) and explained little of the variability. Age had the strongest correlation (r=0.266). 84% of individuals discharged to a community setting. Intensity cannot be directly compared to the TOPS study as total hours of therapy were reported but LOS was not. TOPS reported an average 3.27 point gain for moderate (29.6 to 39 hours) and 3.09 point gain for high intensity (128 to 219.3 hours) interventions, which were 2.5 times less than average gains for our SNF patients. <h3>Conclusions</h3> A preliminary comparison to the TOPS study indicates potential superiority in functional improvement for individuals cared for in a specialized neuro-intensive rehabilitation program in a SNF. Identification of rehabilitation factors and patient characteristics of high responders is needed. <h3>Author(s) Disclosures</h3> None.

Disparities in access to specialty care and emergency department use after hospital discharge to a skilled nursing facility.

Patterns in access to specialists among patients in skilled nursing facilities (SNFs) have not been previously described. To measure access to outpatient specialty follow-up and subsequent emergency department (ED) visits by patient characteristics, including race/ethnicity and those who received specialty care during the hospitalization that preceded the SNF stay. This retrospective cohort study used the minimum data set and 100% Medicare fee-for-service claims for beneficiaries admitted to an SNF between 2012 and 2014. Hospital stays for surgical procedures were excluded. The associations between ED visits, follow-up, and race/ethnicity were measured using logistic and linear regression, adjusting for patient demographic and clinical characteristics. The sample included 1,117,632 hospitalizations by Medicare beneficiaries ≥65 with a consult by a medical subspecialist followed by discharge to SNF. Of the sample, 85.4% were non-Hispanic White (NHW) and 14.6% were Black, indigenous, and people of color (BIPOC), according to Medicare beneficiary records. During the SNF stay, BIPOC patients had lower odds of specialty follow-up compared to NHW patients (odds ratio [OR]: 0.96, 95% confidence intervals [CI]: 0.94-0.99, p = .004). BIPOC patients had higher rates of ED visits compared to NHW patients (with follow-up: 24.1% vs. 23.4%, and without follow-up: 27.4% vs. 25.9%, p < .001). Lack of follow-up was associated with a 0.8 percentage point difference in ED visits between BIPOC and NHW patients (95% CI: 0.3-1.3, p = .003). There is a racial/ethnic disparity in subspecialty follow-up after hospital discharge to SNF that is associated with a higher rate of subsequent ED visits by BIPOC patients.

Higher cost of arthroplasty for hip fractures in patients transferred from outside hospitals vs primary emergency department presentation.

BACKGROUNDIn 2016 Centers for Medicare and Medicaid Services proposed bundled payments for hip fractures to improve the quality and decrease costs of care. Patients transferred from other facilities may be imposing a financial risk on the hospitals that accept these patients. AIMTo determine the costs associated with patients that either presented to the emergency department or were transferred from another hospital or skilled nursing facility (SNF) with the diagnosis of a hip fracture requiring operative intervention.METHODSA retrospective single institution review was conducted for all arthroplasty patients from 2010 to 2015. Inclusion criteria included a total or partial hip replacement for a hip fracture. Exclusion criteria included pathologic, periprosthetic, and fracture non-union. Data was collected to compare total observed costs for patients from the emergency department, patients from skilled nursing facilities, and patients from an outside hospital.RESULTSA total of 223 patients met the inclusion criteria. 135 (60.54%) of these patients presented primarily to the emergency department, 58 patients (26.01%) were transferred from an outside hospital, and 30 patients (13.43%) were transferred from a SNF. Cost data analysis showed that outside hospital patients demonstrated significantly greater total cost for their hospitalization ($43302) compared to emergency department patients ($28875, P = 0.000) and SNF patients ($28282, P = 0.000).CONCLUSIONPatients transferred from an outside hospital incurred greater costs for their hospitalization than patients presenting from an emergency department or SNF. This is a strong argument for risk-adjustment models when bundling payments for the care of hip fracture patients.

Occupational, Physical, and Speech Therapy Intensities in COVID-19 Patients in a Skilled Nursing Facility

Abstract Date Presented 04/01/2022 Two hundred forty-eight patients in a large urban skilled nursing facility (SNF) were studied, examining intensity of rehabilitation services among individuals with coronavirus disease 2019 (COVID-19). Of the population, 58.1% participated in OT and physical therapy services and 13.3% participated in speech therapy services. Significantly higher intensities of rehabilitation services were noted in the 71 patients who were postacute care. More research is needed to determine the most efficacious intensities for geriatric patients with COVID-19, which may vary on the basis of rehabilitation type and patient characteristics. Primary Author and Speaker: Benjamin E. Canter Contributing Authors: Himali Weerahandi, Orah Burack, Joann Reinhardt, Kenneth Boockvar, Lauren Siconolfi