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Reducing SNF Readmissions: At What Cost?
The landscape of postacute care in skilled nursing facilities (SNFs) in the United States is evolving. As the population ages, a growing number of elderly persons are being discharged to SNFs at an enormous cost and with clear evidence of disappointing outcomes. The reaction to these trends includes payment reforms that “bundle” hospital and postacute care, act as incentives to discourage SNFs, or penalize SNFs for undesired patient outcomes. Hospitalists are expected to increasingly feel the effect of these reforms.1
Thus, hospitals are demonstrating renewed interest in reducing readmissions from SNFs. In this issue of Journal of Hospital Medicine, Rosen and colleagues present the results of the Enhanced Care Program (ECP), a multicomponent intervention consisting of 9 nurse practitioners (NPs), a pharmacist, a pharmacy technician, a nurse educator, a program administrator, and a medical director.2 These providers are deployed to 8 SNFs around a large teaching hospital, providing direct clinical care as well as 24/7 call availability for enrolled patients, robust medication reconciliation, and monthly education for SNF nursing staff. A unique aspect of this model was that individual attending physicians in the associated SNFs could decide whether to enroll their patients in the model; patients not enrolled represented a contemporaneous control cohort. The authors found a nearly 30% reduction in the odds of 30-day readmission (OR 0.71 [0.60–0.85] after adjustment), which was robust to multiple sensitivity analyses, including a propensity-matched cohort comparison. The authors should be commended for working to mitigate these potential confounders, thereby strengthening their conclusions. Such a large reduction in readmissions reflects their high underlying prevalence (23% in the nonintervention cohort).
This report closely follows the evaluation of a similar program at the Cleveland Clinic called Connected Care Model (CCM), in which 4 physicians and 5 NPs or physician assistants provided care, including 24/7 call availability, in 7 associated SNFs.3 In a retrospective pre-post analysis comparing the 30-day readmission rates of these SNFs with those of others in the network, similar reductions in readmissions were observed. ECP and CCM represent important extensions of a much larger body of evidence, from the Evercare model4 to the Initiative to Reduce Avoidable Hospitalizations demonstration project, which suggests that adding NPs to nursing homes reduces hospitalizations.5
However, several factors have to be considered before disseminating ECP or CCM. First, other promising “proof of concept” quality improvement studies were not efficacious when rigorously tested in nursing homes.6 Second, these programs are representative of large academic medical centers, which may establish different relationships with different SNFs compared with smaller or less well-resourced hospitals. As the Initiative to Reduce Hospitalizations demonstrated, even a fundamentally similar intervention can have extremely different results depending on the nursing homes involved,5 and the science behind establishing effective hospital–SNF partnerships is still in its infancy.7 Third, both studies have significant methodological limitations, including most importantly that they are conducted within SNFs selected to be part of their hospitals’ network.
These significant early efforts also present an opportunity to reconsider the underlying assumption of these models: that adding more supervisory clinicians to SNFs is the right approach to reduce hospitalizations. Although adding resources is an attractive “plug and play” solution for many problems in healthcare delivery, placing only 1 NP in each of the 15,583 certified nursing facilities in the United States would employ fully 10% of the entire NP workforce. Amid rising concerns about costs related to our aging population, these interventions face substantial headwinds toward becoming the standard of care without demonstrating cost effectiveness. Furthermore, many SNF directors might suggest that hospitals and hospitalists working with them to address fundamental (but much more intransigent) problems in SNFs, such as high staff turnover, low concentration of highly skilled staff (RNs and MDs), regulatory burden, and hospitals using SNFs like stepdown units, could represent a generalizable and sustainable solution.
We realize that this argument is tricky for hospitalists because its underlying logic (care has become too complex, patients are too sick, and dedicated personnel are needed) also played a major role in establishing our existence. One possibility is that like hospitalists, NPs and a growing cadre of “SNFists” will become major drivers of quality improvement, education, and leadership locally at these facilities, thereby leading to sustainable change.8 Similarly, current conditions may drive recognition that a specific set of skills is required to function effectively in the SNF environment,9 just as we believe hospitalists need unique skills to excel in today’s hospital environment.
Studies such as that of Rosen et al. are valuable for JHM because they prompt us to recognize that we as hospitalists have much to share and learn from nursing homes and the dedicated practitioners who work there. In fact, we argue that few places in the healthcare system are more in need of innovation than hospital–nursing home relationships, and hospitalists do not just have a vested clinical interest; in many ways, we see a mirror of our own development as a “specialty.” We encourage hospitals and hospitalists to take up this challenge on behalf of some of the most vulnerable patients in our system during critical times in their care trajectory. As the Commission for Long-Term Care (www.ltccommission.org) wrote in its final report to Congress: “The need is great. The time to act is now.”
Disclosures
Dr. Burke is supported by a VA Health Services Research and Development (HSR&D) Career Development Award. All opinions are those of the authors and do not necessarily represent those of the Department of Veterans Affairs. Dr. Greysen has nothing to disclose.
1. Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017;12(1):46-51. 10.3810/hp.2012.02.958. PubMed
2. Rosen BT, Halbert RJ, Hart K, Diniz MA, Isonaka S, Black JT. The enhanced care program: Impact of a care transitions program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2018;13(4):229-235.
3. Rothberg MB. Impact of a connected care model on 30-day readmission rates from skilled nursing facilities. J Hosp Med. 2017;12(4):238-244. 10.12788/jhm.2710. PubMed
4. Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The effect of Evercare on hospital use. J Am Geriatr Soc. 2003;51(10):1427-1434. 10.1046/j.1532-5415.2003.51461.x. PubMed
5. Ingber MJ, Feng Z, Khatutsky G, et al. Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results. Health Aff Proj Hope. 2017;36(3):441-450. 10.1377/hlthaff.2016.1310. PubMed
6. Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: A randomized implementation trial of the INTERACT Program. JAMA Intern Med. 2017;177(9):1257-1264. 10.1001/jamainternmed.2017.2657. PubMed
7. Lage DE, Rusinak D, Carr D, Grabowski DC, Ackerly DC. Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization. J Am Geriatr Soc. 2015;63(4):804-808. 10.1111/jgs.13351. PubMed
8. Ryskina KL, Polsky D, Werner RM. Physicians and advanced practitioners specializing in nursing home care. JAMA. 2017;318(20):2040-2042. 10.1001/jama.2017.13378. PubMed
9. Gillespie SM, Levy CR, Katz PR. What exactly is an “SNF-ist?” JAMA Intern Med. 2018;178(1):153-154. 10.1001/jamainternmed.2017.7212. PubMed
The landscape of postacute care in skilled nursing facilities (SNFs) in the United States is evolving. As the population ages, a growing number of elderly persons are being discharged to SNFs at an enormous cost and with clear evidence of disappointing outcomes. The reaction to these trends includes payment reforms that “bundle” hospital and postacute care, act as incentives to discourage SNFs, or penalize SNFs for undesired patient outcomes. Hospitalists are expected to increasingly feel the effect of these reforms.1
Thus, hospitals are demonstrating renewed interest in reducing readmissions from SNFs. In this issue of Journal of Hospital Medicine, Rosen and colleagues present the results of the Enhanced Care Program (ECP), a multicomponent intervention consisting of 9 nurse practitioners (NPs), a pharmacist, a pharmacy technician, a nurse educator, a program administrator, and a medical director.2 These providers are deployed to 8 SNFs around a large teaching hospital, providing direct clinical care as well as 24/7 call availability for enrolled patients, robust medication reconciliation, and monthly education for SNF nursing staff. A unique aspect of this model was that individual attending physicians in the associated SNFs could decide whether to enroll their patients in the model; patients not enrolled represented a contemporaneous control cohort. The authors found a nearly 30% reduction in the odds of 30-day readmission (OR 0.71 [0.60–0.85] after adjustment), which was robust to multiple sensitivity analyses, including a propensity-matched cohort comparison. The authors should be commended for working to mitigate these potential confounders, thereby strengthening their conclusions. Such a large reduction in readmissions reflects their high underlying prevalence (23% in the nonintervention cohort).
This report closely follows the evaluation of a similar program at the Cleveland Clinic called Connected Care Model (CCM), in which 4 physicians and 5 NPs or physician assistants provided care, including 24/7 call availability, in 7 associated SNFs.3 In a retrospective pre-post analysis comparing the 30-day readmission rates of these SNFs with those of others in the network, similar reductions in readmissions were observed. ECP and CCM represent important extensions of a much larger body of evidence, from the Evercare model4 to the Initiative to Reduce Avoidable Hospitalizations demonstration project, which suggests that adding NPs to nursing homes reduces hospitalizations.5
However, several factors have to be considered before disseminating ECP or CCM. First, other promising “proof of concept” quality improvement studies were not efficacious when rigorously tested in nursing homes.6 Second, these programs are representative of large academic medical centers, which may establish different relationships with different SNFs compared with smaller or less well-resourced hospitals. As the Initiative to Reduce Hospitalizations demonstrated, even a fundamentally similar intervention can have extremely different results depending on the nursing homes involved,5 and the science behind establishing effective hospital–SNF partnerships is still in its infancy.7 Third, both studies have significant methodological limitations, including most importantly that they are conducted within SNFs selected to be part of their hospitals’ network.
These significant early efforts also present an opportunity to reconsider the underlying assumption of these models: that adding more supervisory clinicians to SNFs is the right approach to reduce hospitalizations. Although adding resources is an attractive “plug and play” solution for many problems in healthcare delivery, placing only 1 NP in each of the 15,583 certified nursing facilities in the United States would employ fully 10% of the entire NP workforce. Amid rising concerns about costs related to our aging population, these interventions face substantial headwinds toward becoming the standard of care without demonstrating cost effectiveness. Furthermore, many SNF directors might suggest that hospitals and hospitalists working with them to address fundamental (but much more intransigent) problems in SNFs, such as high staff turnover, low concentration of highly skilled staff (RNs and MDs), regulatory burden, and hospitals using SNFs like stepdown units, could represent a generalizable and sustainable solution.
We realize that this argument is tricky for hospitalists because its underlying logic (care has become too complex, patients are too sick, and dedicated personnel are needed) also played a major role in establishing our existence. One possibility is that like hospitalists, NPs and a growing cadre of “SNFists” will become major drivers of quality improvement, education, and leadership locally at these facilities, thereby leading to sustainable change.8 Similarly, current conditions may drive recognition that a specific set of skills is required to function effectively in the SNF environment,9 just as we believe hospitalists need unique skills to excel in today’s hospital environment.
Studies such as that of Rosen et al. are valuable for JHM because they prompt us to recognize that we as hospitalists have much to share and learn from nursing homes and the dedicated practitioners who work there. In fact, we argue that few places in the healthcare system are more in need of innovation than hospital–nursing home relationships, and hospitalists do not just have a vested clinical interest; in many ways, we see a mirror of our own development as a “specialty.” We encourage hospitals and hospitalists to take up this challenge on behalf of some of the most vulnerable patients in our system during critical times in their care trajectory. As the Commission for Long-Term Care (www.ltccommission.org) wrote in its final report to Congress: “The need is great. The time to act is now.”
Disclosures
Dr. Burke is supported by a VA Health Services Research and Development (HSR&D) Career Development Award. All opinions are those of the authors and do not necessarily represent those of the Department of Veterans Affairs. Dr. Greysen has nothing to disclose.
The landscape of postacute care in skilled nursing facilities (SNFs) in the United States is evolving. As the population ages, a growing number of elderly persons are being discharged to SNFs at an enormous cost and with clear evidence of disappointing outcomes. The reaction to these trends includes payment reforms that “bundle” hospital and postacute care, act as incentives to discourage SNFs, or penalize SNFs for undesired patient outcomes. Hospitalists are expected to increasingly feel the effect of these reforms.1
Thus, hospitals are demonstrating renewed interest in reducing readmissions from SNFs. In this issue of Journal of Hospital Medicine, Rosen and colleagues present the results of the Enhanced Care Program (ECP), a multicomponent intervention consisting of 9 nurse practitioners (NPs), a pharmacist, a pharmacy technician, a nurse educator, a program administrator, and a medical director.2 These providers are deployed to 8 SNFs around a large teaching hospital, providing direct clinical care as well as 24/7 call availability for enrolled patients, robust medication reconciliation, and monthly education for SNF nursing staff. A unique aspect of this model was that individual attending physicians in the associated SNFs could decide whether to enroll their patients in the model; patients not enrolled represented a contemporaneous control cohort. The authors found a nearly 30% reduction in the odds of 30-day readmission (OR 0.71 [0.60–0.85] after adjustment), which was robust to multiple sensitivity analyses, including a propensity-matched cohort comparison. The authors should be commended for working to mitigate these potential confounders, thereby strengthening their conclusions. Such a large reduction in readmissions reflects their high underlying prevalence (23% in the nonintervention cohort).
This report closely follows the evaluation of a similar program at the Cleveland Clinic called Connected Care Model (CCM), in which 4 physicians and 5 NPs or physician assistants provided care, including 24/7 call availability, in 7 associated SNFs.3 In a retrospective pre-post analysis comparing the 30-day readmission rates of these SNFs with those of others in the network, similar reductions in readmissions were observed. ECP and CCM represent important extensions of a much larger body of evidence, from the Evercare model4 to the Initiative to Reduce Avoidable Hospitalizations demonstration project, which suggests that adding NPs to nursing homes reduces hospitalizations.5
However, several factors have to be considered before disseminating ECP or CCM. First, other promising “proof of concept” quality improvement studies were not efficacious when rigorously tested in nursing homes.6 Second, these programs are representative of large academic medical centers, which may establish different relationships with different SNFs compared with smaller or less well-resourced hospitals. As the Initiative to Reduce Hospitalizations demonstrated, even a fundamentally similar intervention can have extremely different results depending on the nursing homes involved,5 and the science behind establishing effective hospital–SNF partnerships is still in its infancy.7 Third, both studies have significant methodological limitations, including most importantly that they are conducted within SNFs selected to be part of their hospitals’ network.
These significant early efforts also present an opportunity to reconsider the underlying assumption of these models: that adding more supervisory clinicians to SNFs is the right approach to reduce hospitalizations. Although adding resources is an attractive “plug and play” solution for many problems in healthcare delivery, placing only 1 NP in each of the 15,583 certified nursing facilities in the United States would employ fully 10% of the entire NP workforce. Amid rising concerns about costs related to our aging population, these interventions face substantial headwinds toward becoming the standard of care without demonstrating cost effectiveness. Furthermore, many SNF directors might suggest that hospitals and hospitalists working with them to address fundamental (but much more intransigent) problems in SNFs, such as high staff turnover, low concentration of highly skilled staff (RNs and MDs), regulatory burden, and hospitals using SNFs like stepdown units, could represent a generalizable and sustainable solution.
We realize that this argument is tricky for hospitalists because its underlying logic (care has become too complex, patients are too sick, and dedicated personnel are needed) also played a major role in establishing our existence. One possibility is that like hospitalists, NPs and a growing cadre of “SNFists” will become major drivers of quality improvement, education, and leadership locally at these facilities, thereby leading to sustainable change.8 Similarly, current conditions may drive recognition that a specific set of skills is required to function effectively in the SNF environment,9 just as we believe hospitalists need unique skills to excel in today’s hospital environment.
Studies such as that of Rosen et al. are valuable for JHM because they prompt us to recognize that we as hospitalists have much to share and learn from nursing homes and the dedicated practitioners who work there. In fact, we argue that few places in the healthcare system are more in need of innovation than hospital–nursing home relationships, and hospitalists do not just have a vested clinical interest; in many ways, we see a mirror of our own development as a “specialty.” We encourage hospitals and hospitalists to take up this challenge on behalf of some of the most vulnerable patients in our system during critical times in their care trajectory. As the Commission for Long-Term Care (www.ltccommission.org) wrote in its final report to Congress: “The need is great. The time to act is now.”
Disclosures
Dr. Burke is supported by a VA Health Services Research and Development (HSR&D) Career Development Award. All opinions are those of the authors and do not necessarily represent those of the Department of Veterans Affairs. Dr. Greysen has nothing to disclose.
1. Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017;12(1):46-51. 10.3810/hp.2012.02.958. PubMed
2. Rosen BT, Halbert RJ, Hart K, Diniz MA, Isonaka S, Black JT. The enhanced care program: Impact of a care transitions program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2018;13(4):229-235.
3. Rothberg MB. Impact of a connected care model on 30-day readmission rates from skilled nursing facilities. J Hosp Med. 2017;12(4):238-244. 10.12788/jhm.2710. PubMed
4. Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The effect of Evercare on hospital use. J Am Geriatr Soc. 2003;51(10):1427-1434. 10.1046/j.1532-5415.2003.51461.x. PubMed
5. Ingber MJ, Feng Z, Khatutsky G, et al. Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results. Health Aff Proj Hope. 2017;36(3):441-450. 10.1377/hlthaff.2016.1310. PubMed
6. Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: A randomized implementation trial of the INTERACT Program. JAMA Intern Med. 2017;177(9):1257-1264. 10.1001/jamainternmed.2017.2657. PubMed
7. Lage DE, Rusinak D, Carr D, Grabowski DC, Ackerly DC. Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization. J Am Geriatr Soc. 2015;63(4):804-808. 10.1111/jgs.13351. PubMed
8. Ryskina KL, Polsky D, Werner RM. Physicians and advanced practitioners specializing in nursing home care. JAMA. 2017;318(20):2040-2042. 10.1001/jama.2017.13378. PubMed
9. Gillespie SM, Levy CR, Katz PR. What exactly is an “SNF-ist?” JAMA Intern Med. 2018;178(1):153-154. 10.1001/jamainternmed.2017.7212. PubMed
1. Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017;12(1):46-51. 10.3810/hp.2012.02.958. PubMed
2. Rosen BT, Halbert RJ, Hart K, Diniz MA, Isonaka S, Black JT. The enhanced care program: Impact of a care transitions program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2018;13(4):229-235.
3. Rothberg MB. Impact of a connected care model on 30-day readmission rates from skilled nursing facilities. J Hosp Med. 2017;12(4):238-244. 10.12788/jhm.2710. PubMed
4. Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The effect of Evercare on hospital use. J Am Geriatr Soc. 2003;51(10):1427-1434. 10.1046/j.1532-5415.2003.51461.x. PubMed
5. Ingber MJ, Feng Z, Khatutsky G, et al. Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results. Health Aff Proj Hope. 2017;36(3):441-450. 10.1377/hlthaff.2016.1310. PubMed
6. Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: A randomized implementation trial of the INTERACT Program. JAMA Intern Med. 2017;177(9):1257-1264. 10.1001/jamainternmed.2017.2657. PubMed
7. Lage DE, Rusinak D, Carr D, Grabowski DC, Ackerly DC. Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization. J Am Geriatr Soc. 2015;63(4):804-808. 10.1111/jgs.13351. PubMed
8. Ryskina KL, Polsky D, Werner RM. Physicians and advanced practitioners specializing in nursing home care. JAMA. 2017;318(20):2040-2042. 10.1001/jama.2017.13378. PubMed
9. Gillespie SM, Levy CR, Katz PR. What exactly is an “SNF-ist?” JAMA Intern Med. 2018;178(1):153-154. 10.1001/jamainternmed.2017.7212. PubMed
© 2018 Society of Hospital Medicine
Post–Acute Care Reform Implications
The landscape of post–acute care (PAC), which is predominantly provided by inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home healthcare (HHC) providers, is rapidly changing. As hospitalizations shorten, PAC utilization is rising, resulting in rapidly increasing costs.1-5 However, patient outcomes in PAC are characterized by high rates of readmission and low rates of return to the community.6,7 Emerging evidence suggests these outcomes could be substantially improved through use of better in-hospital and transitional care processes.8-10
Legislators took notice of the spiraling costs, potential quality concerns, and undesirable patient outcomes in PAC. Provisions in the Patient Protection and Affordable Care Act of 2010 (ACA), the Protecting Access to Medicare Act of 2014 (PAMA), and the Improving Medicare Post–Acute Care Transformation (IMPACT) Act of 2014 affect patient selection, payment, and quality measurement in PAC. As older adults are increasingly being cared for by hospitalists,11 hospitalists must be aware of the implications of these reforms.
IMPLICATIONS FOR HOSPITALISTS
Choosing Patients Wisely for PAC
Because PAC-related decision making is not standardized, referral rates vary significantly.12 The variability in PAC use accounts for 79% of all regional variation in Medicare spending in the United States.13,14 Compared with other physicians, hospitalists are more likely to use PAC15 but typically receive little exposure to PAC during training.16
The IMPACT Act proposes 2 major changes to patient selection: a uniform assessment tool for patients being discharged to PAC and “site-neutral” payments for PAC. Starting in 2018, the Continuity Assessment Record and Evaluation (CARE) tool must be completed before a hospital discharge in order to better match PAC resources to patient needs. The current 26-page CARE tool includes questions about demographics and home support, medical complexity, physical function, cognitive status, and “transition items,” including discharge plans and advance directives. In pilot testing, significant amounts of missing data and average completion times of up to 60 minutes raised concerns about feasibility.17 CARE tool assessments accurately predicted what form of PAC patients actually received, but further testing is planned to validate whether the type of PAC selected was optimal for patient outcomes.. A plan for using CARE tool assessments to determine site-neutral payments is due to Congress by 2020. In the site-neutral payment system, the PAC provider will be reimbursed according to patient needs (identified by the CARE tool), regardless of PAC setting—a radical change from the current system, in which IRF, SNF, and HHC episodes show major differences in median costs (Table 1).18
Hospitalists may be concerned that use of the CARE tool will supplant clinical judgment about patients’ PAC needs. The burden of completing the CARE tool could inadvertently reduce the amount of attention hospitalists give to other aspects of a safe discharge rather than lead to the improvement desired.19-21 Hospitalists will benefit from developing interdisciplinary, iterative workflows to complete the tool, improving accuracy and reducing the burden.
A potential unintended consequence of the site-neutral payment system may be increased difficulty discharging elderly patients who have limited rehabilitation potential but are lacking sufficient social support to return home. In the current system, these patients are commonly discharged to SNFs as a bridge to long-term nursing home care. Hospitalists will need to become increasingly familiar with novel alternatives to nursing home–based care, such as home-based primary care, medical foster homes, and Medicare/Medicaid’s Program of All-Inclusive Care of the Elderly (PACE).22-25
Choosing PAC Providers Wisely
Medicare’s Nursing Home Compare tool (https://www.medicare.gov/nursinghomecompare/search.html) provides a “5-star” system for rating SNFs on several quality metrics; these metrics, however, are not correlated with readmission or mortality rates.26,27 Improving quality measurement in PAC and tying payment to quality and outcomes are major emphases of the IMPACT Act and PAMA, respectively. PAC providers must publicly report an expanded list of quality measures and outcomes by 2018. In 2017, SNFs will begin reporting rates of “potentially preventable” readmissions, and starting in 2019 they will face penalties for having high
risk-adjusted rates.
These reforms coincide with an increased emphasis on hospitals and PAC providers sharing responsibility for costs and outcomes. One model of the Bundled Payments for Care Improvement (BPCI) initiative includes a single payment for an acute hospitalization and PAC up to 90 days after hospital discharge for select conditions. The Medicare Spending Per Beneficiary (MSPB) measure compares hospitals on their spending for Medicare beneficiaries from 3 days before hospital admission to 30 days after hospital discharge, and penalizes outliers with high costs.28 PAC spending is the main driver of costs in both BPCI and MSPB.29 One way that hospitals have responded to the BPCI is by drastically reducing their referrals to SNFs and increasing their referrals to HHC providers; unfortunately, this response has resulted in increases in post-discharge emergency department visits.29,30 Taking a novel step in November 2015, the Centers for Medicare & Medicaid Services (CMS) ruled that hospitals in more than 67 metropolitan service areas will be involuntarily enrolled in the BPCI initiative, using elective lower extremity joint replacement as the sample condition.31 This ruling signaled that these reforms are not meant solely for “high-performing” hospital and PAC systems able to volunteer for novel models of payment.
These changes have direct implications for hospitalists. Bundled payments incentivize hospitalists to reduce hospital length of stay and choose PAC alternatives with lower costs. SNFs may start accepting fewer “high-risk” patients in order to avoid readmission penalties. Hospitals will need to identify and partner with high-performing PAC providers in their community to maximize outcomes for their patients. On their websites, the Society of Post-Acute and Long-Term Care Medicine (AMDA) lists its state chapters,32 and the National Association for Home Care & Hospice lists national HHC agencies.33 Reviewing early lessons learned in the evaluation of PAC providers as potential hospital partners in Pioneer accountable care organizations may be helpful,34 though the PAC cost savings in these organizations largely resulted from redirecting patients from SNFs to HHC providers.35,36 In many markets, the relationships between hospitals and PAC providers may become more formalized, leading to vertical integration.37 Hospitalists may increasingly be asked to work with, or even in, SNFs.38 For hospitalists who begin working in PAC, the AMDA is developing an educational curriculum to maximize efficacy in a new practice setting.39 In other markets, hospitals may turn to for-profit entities that provide “integrated post-acute care services,”40 taking over PAC decision making from inpatient teams and sharing any resulting profits
from bundled payments.
OPPORTUNITIES FOR HOSPITALISTS
Improve Hospital and Transitional Care to Ensure Successful Early Outcomes in PAC
Payment reform ensures hospitalists will increasingly have a stake in these matters, as joint responsibility for costs and outcomes increases for patients discharged to PAC. Hospitalists play a major role in these outcomes by deciding when and where to discharge patients and ensuring that optimal transition-of-care processes are used.8-10,41-45 Although no single intervention has been prospectively found to improve hospital-to-PAC transitional care outcomes, areas in need of improvement are known. Table 2 lists these within 9 of the Ideal Transition of Care Framework domains.43,46
Advocate Patient-Centered PAC Placement That Maximizes Long-Term Outcomes
Payment reforms could reinforce the cynical view that the optimal PAC setting is the least costly one that avoids hospital readmission. This view does not incorporate evidence that, in some cases, placement in a more costly PAC setting results in better long-term outcomes (eg, community discharge rates).47,48 It is also incongruent with a holistic view of the patient’s needs, particularly for patients who may otherwise be suitable for home-based PAC but have limited social support.49 Finally, it does not acknowledge the reality that patients who are inadequately rehabilitated often transition to long-term nursing home care,50 which could result in significant cost-shifting from Medicare to Medicaid, the predominant payer for long-term care.51 Given the extraordinary cost of long-term nursing home care, attending only to short-term costs and outcomes could increase national healthcare expenditures.
With most PAC-related decisions being made in the hospital, hospitalists find themselves at the center of a care team that must advocate the PAC that is best for the patient over the long term. This endeavor requires that hospitalists and others work for improvements in at least 3 aspects of in-hospital care. First, systems for accurately and reliably identifying patient factors that could substantially affect ability to rehabilitate (eg delirium) must be developed or enhanced.52-54 Second, more formal evaluation of the ability of patients and their caregivers to succeed at home is needed.55-60 Patients and caregivers may not understand their home needs without first “testing” the experience prior to discharge.61 Third, hospitalists must understand PAC in order to provide safe transitions.16 It is logistically challenging to expose practicing hospitalists to PAC, and it is unclear which exposures are most effective in improving decision making.62 An alternative approach that provides hospitalists with feedback about the short- and long-term outcomes of patients they have discharged to PAC may iteratively improve decision making. However, despite the high rate of discharges to PAC, there are anecdotal reports that few hospitalists receive feedback on patient outcomes.
As these reforms are tested and implemented, advocacy at regional and national levels is needed. The American Geriatrics Society (AGS), the AMDA, and the American Academy of Home Care Medicine all have well-developed advocacy platforms hospitalists can access.63-65
Share Expertise to Improve Quality in a Constrained Environment
There are opportunities for synergy between robust quality improvement (QI) efforts in PAC (often as part of Quality Assurance and Performance Improvement programs) and similarly robust hospital QI efforts led by hospitalists.66-70 These efforts have largely occurred in parallel, but now some important bridging QI interventions (eg, collaborative root cause analyses for patients readmitted after PAC) are starting at some sites, and these may drive improvement across the care spectrum.45 The Society of Hospital Medicine, the AGS, and the AMDA have written White Papers on care transitions that may serve as starting points for
discussion.41,71,72
CONCLUSION
PAC is rapidly changing in response to reform legislation that is intended to address poor outcomes and high costs. Hospitalists will increasingly feel the effects of these reforms in their day-to-day practices. To continue to deliver high-value care, hospitalists should review their in-hospital and transitional care practices and start building relationships with high-quality PAC providers in their community.
Disclosures: Dr. Burke was supported by a VA Health Services Research and Development Service career development award and by National Institute on Aging grant R03 AG050885. The funders had no role in the design, conduct, interpretation, or presentation of the data. The other authors have nothing to report. The views represented here are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
1. Kosecoff J, Kahn KL, Rogers WH, et al. Prospective payment system and impairment at discharge. The ‘quicker-and-sicker’ story revisited. JAMA. 1990;264(15):1980-1983. PubMed
2. Burke RE, Juarez-Colunga E, Levy C, Prochazka AV, Coleman EA, Ginde AA. Patient and hospitalization characteristics associated with increased postacute care facility discharges from US hospitals. Med Care. 2015;53(6):492-500. PubMed
3. Jones CD, Ginde AA, Burke RE, Wald HL, Masoudi FA, Boxer RS. Increasing home healthcare referrals upon discharge from U.S. hospitals: 2001-2012. J Am Geriatr Soc. 2015;63(6):1265-1266. PubMed
4. Burke RE, Juarez-Colunga E, Levy C, Prochazka AV, Coleman EA, Ginde AA. Rise of post-acute care facilities as a discharge destination of US hospitalizations. JAMA Intern Med. 2015;175(2):295-296. PubMed
5. Chandra A, Dalton MA, Holmes J. Large increases in spending on postacute care in Medicare point to the potential for cost savings in these settings. Health Aff (Millwood). 2013;32(5):864-872. PubMed
6. Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64. PubMed
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10. Ouslander JG, Naharci I, Engstrom G, et al. Lessons learned from root cause analyses of transfers of skilled nursing facility (SNF) patients to acute hospitals: transfers rated as preventable versus nonpreventable by SNF staff. J Am Med Dir Assoc. 2016;17(7):596-601. PubMed
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32. Society for Post-Acute and Long-Term Care Medicine. State chapters; AMDA state chapter network. http://www.paltc.org/state-chapters. Accessed June 6, 2016.
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35. Nyweide DJ, Lee W, Cuerdon TT, et al. Association of Pioneer accountable care organizations vs traditional Medicare fee for service with spending, utilization, and patient experience. JAMA. 2015;313(21):2152-2161. PubMed
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38. IPC Healthcare. Post-acute care services. http://www.ipchealthcare.com/advantage/post-acute-care. Accessed January 11, 2016.
39. Society for Post-Acute and Long-Term Care Medicine. Competencies curriculum for post-acute and long-term care medicine. http://www.paltc.org/competencies-curriculum-post-acute-and-long-term-care-medicine. Accessed May 26, 2016.
40. NaviHealth. Leading the way in a rapidly changing PAC marketplace. http://www.navihealth.us/home/solutions/services. Accessed January 11, 2016.
41. Arbaje AI, Kansagara DL, Salanitro AH, et al. Regardless of age: incorporating principles from geriatric medicine to improve care transitions for patients with complex needs. J Gen Intern Med. 2014;29(6):932-939. PubMed
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45. Ouslander JG, Naharci I, Engstrom G, et al. Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned for reducing unnecessary hospitalizations. J Am Med Dir Assoc. 2016;17(3):256-262. PubMed
46. Burke RE, Guo R, Prochazka AV, Misky GJ. Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res. 2014;14:423. PubMed
47. Kane RL, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M. Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare. J Am Geriatr Soc. 1998;46(12):1525-1533. PubMed
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49. Greysen SR, Harrison JD, Kripalani S, et al. Understanding patient-centred readmission factors: a multi-site, mixed-methods study [published online January 14, 2016]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004570. PubMed
50. Goodwin JS, Howrey B, Zhang DD, Kuo YF. Risk of continued institutionalization after hospitalization in older adults. J Gerontol A Biol Sci Med Sci. 2011;66(12):1321-1327. PubMed
51. Reaves EL, Musumeci M. Medicaid and Long-Term Services and Supports: A Primer. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Report 8617-02. Henry J. Kaiser Family Foundation website. http://files.kff.org/attachment/report-medicaid-and-long-term-services-and-supports-a-primer. Published December 15, 2015. Accessed May 18, 2016.
52. Bell SP, Vasilevskis EE, Saraf AA, et al. Geriatric syndromes in hospitalized older adults discharged to skilled nursing facilities. J Am Geriatr Soc. 2016;64(4):
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53. Cawthon C, Mion LC, Willens DE, Roumie CL, Kripalani S. Implementing routine health literacy assessment in hospital and primary care patients. Jt Comm J Qual Patient Saf. 2014;40(2):68-76. PubMed
54. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565. PubMed
55. Coleman EA, Roman SP. Family caregivers’ experiences during transitions out of hospital. J Healthc Qual. 2015;37(1):12-21. PubMed
56. Coleman EA, Min SJ. Patients’ and family caregivers’ goals for care during transitions out of the hospital. Home Health Care Serv Q. 2015;34(3-4):173-184. PubMed
57. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11):1817-1825. PubMed
58. Coleman EA, Ground KL, Maul A. The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy. Jt Comm J Qual Patient Saf. 2015;41(11):502-507. PubMed
59. Cain CH, Neuwirth E, Bellows J, Zuber C, Green J. Patient experiences of transitioning from hospital to home: an ethnographic quality improvement project. PubMed
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61. Coleman EA. Extending simulation learning experiences to patients with chronic health conditions. JAMA. 2014;311(3):243-244. PubMed
62. Meade LB, Hall SL, Kleppel RW, Hinchey KT. TRACER: an ‘eye-opener’ to the patient experience across the transition of care in an internal medicine resident program. J Community Hosp Intern Med Perspect. 2015;5(2):26230. PubMed
63. American Geriatrics Society. Public policy & advocacy. http://www.americangeriatrics.org/advocacy_public_policy. Accessed May 26, 2016.
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65. American Academy of Home Care Medicine. Public policy. http://www.aahcm.org/?page=Public_Policy. Accessed May 26, 2016.
66. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. PubMed
67. Unroe KT, Nazir A, Holtz LR, et al. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care approach: preliminary data from the implementation of a Centers for Medicare and Medicaid Services nursing facility demonstration project. J Am Geriatr Soc. 2015;63(1):165-169. PubMed
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71. Snow V, Beck D, Budnitz T, et al. Transitions of Care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364-370. PubMed
72. Lett JE 2nd. AMDA national engagement in care transitions. J Am Med Dir Assoc. 2011;12(5):387. PubMed
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74. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014;94(9):1252-1261. PubMed
75. Bowles KH, Ratcliffe SJ, Holmes JH, Liberatore M, Nydick R, Naylor MD. Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients’ 12-week outcomes. Med Care. 2008;46(2):158-166. PubMed
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79. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of physical therapists in reducing hospital readmissions: optimizing outcomes for older adults during care transitions from hospital to community. Phys Ther. 2016;96(8):1125-1134. PubMed
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The landscape of post–acute care (PAC), which is predominantly provided by inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home healthcare (HHC) providers, is rapidly changing. As hospitalizations shorten, PAC utilization is rising, resulting in rapidly increasing costs.1-5 However, patient outcomes in PAC are characterized by high rates of readmission and low rates of return to the community.6,7 Emerging evidence suggests these outcomes could be substantially improved through use of better in-hospital and transitional care processes.8-10
Legislators took notice of the spiraling costs, potential quality concerns, and undesirable patient outcomes in PAC. Provisions in the Patient Protection and Affordable Care Act of 2010 (ACA), the Protecting Access to Medicare Act of 2014 (PAMA), and the Improving Medicare Post–Acute Care Transformation (IMPACT) Act of 2014 affect patient selection, payment, and quality measurement in PAC. As older adults are increasingly being cared for by hospitalists,11 hospitalists must be aware of the implications of these reforms.
IMPLICATIONS FOR HOSPITALISTS
Choosing Patients Wisely for PAC
Because PAC-related decision making is not standardized, referral rates vary significantly.12 The variability in PAC use accounts for 79% of all regional variation in Medicare spending in the United States.13,14 Compared with other physicians, hospitalists are more likely to use PAC15 but typically receive little exposure to PAC during training.16
The IMPACT Act proposes 2 major changes to patient selection: a uniform assessment tool for patients being discharged to PAC and “site-neutral” payments for PAC. Starting in 2018, the Continuity Assessment Record and Evaluation (CARE) tool must be completed before a hospital discharge in order to better match PAC resources to patient needs. The current 26-page CARE tool includes questions about demographics and home support, medical complexity, physical function, cognitive status, and “transition items,” including discharge plans and advance directives. In pilot testing, significant amounts of missing data and average completion times of up to 60 minutes raised concerns about feasibility.17 CARE tool assessments accurately predicted what form of PAC patients actually received, but further testing is planned to validate whether the type of PAC selected was optimal for patient outcomes.. A plan for using CARE tool assessments to determine site-neutral payments is due to Congress by 2020. In the site-neutral payment system, the PAC provider will be reimbursed according to patient needs (identified by the CARE tool), regardless of PAC setting—a radical change from the current system, in which IRF, SNF, and HHC episodes show major differences in median costs (Table 1).18
Hospitalists may be concerned that use of the CARE tool will supplant clinical judgment about patients’ PAC needs. The burden of completing the CARE tool could inadvertently reduce the amount of attention hospitalists give to other aspects of a safe discharge rather than lead to the improvement desired.19-21 Hospitalists will benefit from developing interdisciplinary, iterative workflows to complete the tool, improving accuracy and reducing the burden.
A potential unintended consequence of the site-neutral payment system may be increased difficulty discharging elderly patients who have limited rehabilitation potential but are lacking sufficient social support to return home. In the current system, these patients are commonly discharged to SNFs as a bridge to long-term nursing home care. Hospitalists will need to become increasingly familiar with novel alternatives to nursing home–based care, such as home-based primary care, medical foster homes, and Medicare/Medicaid’s Program of All-Inclusive Care of the Elderly (PACE).22-25
Choosing PAC Providers Wisely
Medicare’s Nursing Home Compare tool (https://www.medicare.gov/nursinghomecompare/search.html) provides a “5-star” system for rating SNFs on several quality metrics; these metrics, however, are not correlated with readmission or mortality rates.26,27 Improving quality measurement in PAC and tying payment to quality and outcomes are major emphases of the IMPACT Act and PAMA, respectively. PAC providers must publicly report an expanded list of quality measures and outcomes by 2018. In 2017, SNFs will begin reporting rates of “potentially preventable” readmissions, and starting in 2019 they will face penalties for having high
risk-adjusted rates.
These reforms coincide with an increased emphasis on hospitals and PAC providers sharing responsibility for costs and outcomes. One model of the Bundled Payments for Care Improvement (BPCI) initiative includes a single payment for an acute hospitalization and PAC up to 90 days after hospital discharge for select conditions. The Medicare Spending Per Beneficiary (MSPB) measure compares hospitals on their spending for Medicare beneficiaries from 3 days before hospital admission to 30 days after hospital discharge, and penalizes outliers with high costs.28 PAC spending is the main driver of costs in both BPCI and MSPB.29 One way that hospitals have responded to the BPCI is by drastically reducing their referrals to SNFs and increasing their referrals to HHC providers; unfortunately, this response has resulted in increases in post-discharge emergency department visits.29,30 Taking a novel step in November 2015, the Centers for Medicare & Medicaid Services (CMS) ruled that hospitals in more than 67 metropolitan service areas will be involuntarily enrolled in the BPCI initiative, using elective lower extremity joint replacement as the sample condition.31 This ruling signaled that these reforms are not meant solely for “high-performing” hospital and PAC systems able to volunteer for novel models of payment.
These changes have direct implications for hospitalists. Bundled payments incentivize hospitalists to reduce hospital length of stay and choose PAC alternatives with lower costs. SNFs may start accepting fewer “high-risk” patients in order to avoid readmission penalties. Hospitals will need to identify and partner with high-performing PAC providers in their community to maximize outcomes for their patients. On their websites, the Society of Post-Acute and Long-Term Care Medicine (AMDA) lists its state chapters,32 and the National Association for Home Care & Hospice lists national HHC agencies.33 Reviewing early lessons learned in the evaluation of PAC providers as potential hospital partners in Pioneer accountable care organizations may be helpful,34 though the PAC cost savings in these organizations largely resulted from redirecting patients from SNFs to HHC providers.35,36 In many markets, the relationships between hospitals and PAC providers may become more formalized, leading to vertical integration.37 Hospitalists may increasingly be asked to work with, or even in, SNFs.38 For hospitalists who begin working in PAC, the AMDA is developing an educational curriculum to maximize efficacy in a new practice setting.39 In other markets, hospitals may turn to for-profit entities that provide “integrated post-acute care services,”40 taking over PAC decision making from inpatient teams and sharing any resulting profits
from bundled payments.
OPPORTUNITIES FOR HOSPITALISTS
Improve Hospital and Transitional Care to Ensure Successful Early Outcomes in PAC
Payment reform ensures hospitalists will increasingly have a stake in these matters, as joint responsibility for costs and outcomes increases for patients discharged to PAC. Hospitalists play a major role in these outcomes by deciding when and where to discharge patients and ensuring that optimal transition-of-care processes are used.8-10,41-45 Although no single intervention has been prospectively found to improve hospital-to-PAC transitional care outcomes, areas in need of improvement are known. Table 2 lists these within 9 of the Ideal Transition of Care Framework domains.43,46
Advocate Patient-Centered PAC Placement That Maximizes Long-Term Outcomes
Payment reforms could reinforce the cynical view that the optimal PAC setting is the least costly one that avoids hospital readmission. This view does not incorporate evidence that, in some cases, placement in a more costly PAC setting results in better long-term outcomes (eg, community discharge rates).47,48 It is also incongruent with a holistic view of the patient’s needs, particularly for patients who may otherwise be suitable for home-based PAC but have limited social support.49 Finally, it does not acknowledge the reality that patients who are inadequately rehabilitated often transition to long-term nursing home care,50 which could result in significant cost-shifting from Medicare to Medicaid, the predominant payer for long-term care.51 Given the extraordinary cost of long-term nursing home care, attending only to short-term costs and outcomes could increase national healthcare expenditures.
With most PAC-related decisions being made in the hospital, hospitalists find themselves at the center of a care team that must advocate the PAC that is best for the patient over the long term. This endeavor requires that hospitalists and others work for improvements in at least 3 aspects of in-hospital care. First, systems for accurately and reliably identifying patient factors that could substantially affect ability to rehabilitate (eg delirium) must be developed or enhanced.52-54 Second, more formal evaluation of the ability of patients and their caregivers to succeed at home is needed.55-60 Patients and caregivers may not understand their home needs without first “testing” the experience prior to discharge.61 Third, hospitalists must understand PAC in order to provide safe transitions.16 It is logistically challenging to expose practicing hospitalists to PAC, and it is unclear which exposures are most effective in improving decision making.62 An alternative approach that provides hospitalists with feedback about the short- and long-term outcomes of patients they have discharged to PAC may iteratively improve decision making. However, despite the high rate of discharges to PAC, there are anecdotal reports that few hospitalists receive feedback on patient outcomes.
As these reforms are tested and implemented, advocacy at regional and national levels is needed. The American Geriatrics Society (AGS), the AMDA, and the American Academy of Home Care Medicine all have well-developed advocacy platforms hospitalists can access.63-65
Share Expertise to Improve Quality in a Constrained Environment
There are opportunities for synergy between robust quality improvement (QI) efforts in PAC (often as part of Quality Assurance and Performance Improvement programs) and similarly robust hospital QI efforts led by hospitalists.66-70 These efforts have largely occurred in parallel, but now some important bridging QI interventions (eg, collaborative root cause analyses for patients readmitted after PAC) are starting at some sites, and these may drive improvement across the care spectrum.45 The Society of Hospital Medicine, the AGS, and the AMDA have written White Papers on care transitions that may serve as starting points for
discussion.41,71,72
CONCLUSION
PAC is rapidly changing in response to reform legislation that is intended to address poor outcomes and high costs. Hospitalists will increasingly feel the effects of these reforms in their day-to-day practices. To continue to deliver high-value care, hospitalists should review their in-hospital and transitional care practices and start building relationships with high-quality PAC providers in their community.
Disclosures: Dr. Burke was supported by a VA Health Services Research and Development Service career development award and by National Institute on Aging grant R03 AG050885. The funders had no role in the design, conduct, interpretation, or presentation of the data. The other authors have nothing to report. The views represented here are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
The landscape of post–acute care (PAC), which is predominantly provided by inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home healthcare (HHC) providers, is rapidly changing. As hospitalizations shorten, PAC utilization is rising, resulting in rapidly increasing costs.1-5 However, patient outcomes in PAC are characterized by high rates of readmission and low rates of return to the community.6,7 Emerging evidence suggests these outcomes could be substantially improved through use of better in-hospital and transitional care processes.8-10
Legislators took notice of the spiraling costs, potential quality concerns, and undesirable patient outcomes in PAC. Provisions in the Patient Protection and Affordable Care Act of 2010 (ACA), the Protecting Access to Medicare Act of 2014 (PAMA), and the Improving Medicare Post–Acute Care Transformation (IMPACT) Act of 2014 affect patient selection, payment, and quality measurement in PAC. As older adults are increasingly being cared for by hospitalists,11 hospitalists must be aware of the implications of these reforms.
IMPLICATIONS FOR HOSPITALISTS
Choosing Patients Wisely for PAC
Because PAC-related decision making is not standardized, referral rates vary significantly.12 The variability in PAC use accounts for 79% of all regional variation in Medicare spending in the United States.13,14 Compared with other physicians, hospitalists are more likely to use PAC15 but typically receive little exposure to PAC during training.16
The IMPACT Act proposes 2 major changes to patient selection: a uniform assessment tool for patients being discharged to PAC and “site-neutral” payments for PAC. Starting in 2018, the Continuity Assessment Record and Evaluation (CARE) tool must be completed before a hospital discharge in order to better match PAC resources to patient needs. The current 26-page CARE tool includes questions about demographics and home support, medical complexity, physical function, cognitive status, and “transition items,” including discharge plans and advance directives. In pilot testing, significant amounts of missing data and average completion times of up to 60 minutes raised concerns about feasibility.17 CARE tool assessments accurately predicted what form of PAC patients actually received, but further testing is planned to validate whether the type of PAC selected was optimal for patient outcomes.. A plan for using CARE tool assessments to determine site-neutral payments is due to Congress by 2020. In the site-neutral payment system, the PAC provider will be reimbursed according to patient needs (identified by the CARE tool), regardless of PAC setting—a radical change from the current system, in which IRF, SNF, and HHC episodes show major differences in median costs (Table 1).18
Hospitalists may be concerned that use of the CARE tool will supplant clinical judgment about patients’ PAC needs. The burden of completing the CARE tool could inadvertently reduce the amount of attention hospitalists give to other aspects of a safe discharge rather than lead to the improvement desired.19-21 Hospitalists will benefit from developing interdisciplinary, iterative workflows to complete the tool, improving accuracy and reducing the burden.
A potential unintended consequence of the site-neutral payment system may be increased difficulty discharging elderly patients who have limited rehabilitation potential but are lacking sufficient social support to return home. In the current system, these patients are commonly discharged to SNFs as a bridge to long-term nursing home care. Hospitalists will need to become increasingly familiar with novel alternatives to nursing home–based care, such as home-based primary care, medical foster homes, and Medicare/Medicaid’s Program of All-Inclusive Care of the Elderly (PACE).22-25
Choosing PAC Providers Wisely
Medicare’s Nursing Home Compare tool (https://www.medicare.gov/nursinghomecompare/search.html) provides a “5-star” system for rating SNFs on several quality metrics; these metrics, however, are not correlated with readmission or mortality rates.26,27 Improving quality measurement in PAC and tying payment to quality and outcomes are major emphases of the IMPACT Act and PAMA, respectively. PAC providers must publicly report an expanded list of quality measures and outcomes by 2018. In 2017, SNFs will begin reporting rates of “potentially preventable” readmissions, and starting in 2019 they will face penalties for having high
risk-adjusted rates.
These reforms coincide with an increased emphasis on hospitals and PAC providers sharing responsibility for costs and outcomes. One model of the Bundled Payments for Care Improvement (BPCI) initiative includes a single payment for an acute hospitalization and PAC up to 90 days after hospital discharge for select conditions. The Medicare Spending Per Beneficiary (MSPB) measure compares hospitals on their spending for Medicare beneficiaries from 3 days before hospital admission to 30 days after hospital discharge, and penalizes outliers with high costs.28 PAC spending is the main driver of costs in both BPCI and MSPB.29 One way that hospitals have responded to the BPCI is by drastically reducing their referrals to SNFs and increasing their referrals to HHC providers; unfortunately, this response has resulted in increases in post-discharge emergency department visits.29,30 Taking a novel step in November 2015, the Centers for Medicare & Medicaid Services (CMS) ruled that hospitals in more than 67 metropolitan service areas will be involuntarily enrolled in the BPCI initiative, using elective lower extremity joint replacement as the sample condition.31 This ruling signaled that these reforms are not meant solely for “high-performing” hospital and PAC systems able to volunteer for novel models of payment.
These changes have direct implications for hospitalists. Bundled payments incentivize hospitalists to reduce hospital length of stay and choose PAC alternatives with lower costs. SNFs may start accepting fewer “high-risk” patients in order to avoid readmission penalties. Hospitals will need to identify and partner with high-performing PAC providers in their community to maximize outcomes for their patients. On their websites, the Society of Post-Acute and Long-Term Care Medicine (AMDA) lists its state chapters,32 and the National Association for Home Care & Hospice lists national HHC agencies.33 Reviewing early lessons learned in the evaluation of PAC providers as potential hospital partners in Pioneer accountable care organizations may be helpful,34 though the PAC cost savings in these organizations largely resulted from redirecting patients from SNFs to HHC providers.35,36 In many markets, the relationships between hospitals and PAC providers may become more formalized, leading to vertical integration.37 Hospitalists may increasingly be asked to work with, or even in, SNFs.38 For hospitalists who begin working in PAC, the AMDA is developing an educational curriculum to maximize efficacy in a new practice setting.39 In other markets, hospitals may turn to for-profit entities that provide “integrated post-acute care services,”40 taking over PAC decision making from inpatient teams and sharing any resulting profits
from bundled payments.
OPPORTUNITIES FOR HOSPITALISTS
Improve Hospital and Transitional Care to Ensure Successful Early Outcomes in PAC
Payment reform ensures hospitalists will increasingly have a stake in these matters, as joint responsibility for costs and outcomes increases for patients discharged to PAC. Hospitalists play a major role in these outcomes by deciding when and where to discharge patients and ensuring that optimal transition-of-care processes are used.8-10,41-45 Although no single intervention has been prospectively found to improve hospital-to-PAC transitional care outcomes, areas in need of improvement are known. Table 2 lists these within 9 of the Ideal Transition of Care Framework domains.43,46
Advocate Patient-Centered PAC Placement That Maximizes Long-Term Outcomes
Payment reforms could reinforce the cynical view that the optimal PAC setting is the least costly one that avoids hospital readmission. This view does not incorporate evidence that, in some cases, placement in a more costly PAC setting results in better long-term outcomes (eg, community discharge rates).47,48 It is also incongruent with a holistic view of the patient’s needs, particularly for patients who may otherwise be suitable for home-based PAC but have limited social support.49 Finally, it does not acknowledge the reality that patients who are inadequately rehabilitated often transition to long-term nursing home care,50 which could result in significant cost-shifting from Medicare to Medicaid, the predominant payer for long-term care.51 Given the extraordinary cost of long-term nursing home care, attending only to short-term costs and outcomes could increase national healthcare expenditures.
With most PAC-related decisions being made in the hospital, hospitalists find themselves at the center of a care team that must advocate the PAC that is best for the patient over the long term. This endeavor requires that hospitalists and others work for improvements in at least 3 aspects of in-hospital care. First, systems for accurately and reliably identifying patient factors that could substantially affect ability to rehabilitate (eg delirium) must be developed or enhanced.52-54 Second, more formal evaluation of the ability of patients and their caregivers to succeed at home is needed.55-60 Patients and caregivers may not understand their home needs without first “testing” the experience prior to discharge.61 Third, hospitalists must understand PAC in order to provide safe transitions.16 It is logistically challenging to expose practicing hospitalists to PAC, and it is unclear which exposures are most effective in improving decision making.62 An alternative approach that provides hospitalists with feedback about the short- and long-term outcomes of patients they have discharged to PAC may iteratively improve decision making. However, despite the high rate of discharges to PAC, there are anecdotal reports that few hospitalists receive feedback on patient outcomes.
As these reforms are tested and implemented, advocacy at regional and national levels is needed. The American Geriatrics Society (AGS), the AMDA, and the American Academy of Home Care Medicine all have well-developed advocacy platforms hospitalists can access.63-65
Share Expertise to Improve Quality in a Constrained Environment
There are opportunities for synergy between robust quality improvement (QI) efforts in PAC (often as part of Quality Assurance and Performance Improvement programs) and similarly robust hospital QI efforts led by hospitalists.66-70 These efforts have largely occurred in parallel, but now some important bridging QI interventions (eg, collaborative root cause analyses for patients readmitted after PAC) are starting at some sites, and these may drive improvement across the care spectrum.45 The Society of Hospital Medicine, the AGS, and the AMDA have written White Papers on care transitions that may serve as starting points for
discussion.41,71,72
CONCLUSION
PAC is rapidly changing in response to reform legislation that is intended to address poor outcomes and high costs. Hospitalists will increasingly feel the effects of these reforms in their day-to-day practices. To continue to deliver high-value care, hospitalists should review their in-hospital and transitional care practices and start building relationships with high-quality PAC providers in their community.
Disclosures: Dr. Burke was supported by a VA Health Services Research and Development Service career development award and by National Institute on Aging grant R03 AG050885. The funders had no role in the design, conduct, interpretation, or presentation of the data. The other authors have nothing to report. The views represented here are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
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