In the Journals

Medicare payments lower, readmission higher for patients discharged to home vs. skilled nursing facility

Rachel Werner
Rachel M. Werner

Although patients who were discharged from the hospital to home were 5.6% more likely to be readmitted within 30 days than those discharged to a skilled nursing facility, there were no significant differences in 30-day mortality or functional outcomes, and Medicare payments were lower, according to a study published in JAMA Internal Medicine.

”We were surprised how much of an impact skilled nursing facilities had on reducing readmission rates,” Rachel M. Werner, MD, PhD, of the division of general internal medicine at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, told Healio Primary Care Today. “On one hand, this shouldn’t be surprising because skilled nursing facilities have more capabilities than home health agencies to prevent and manage complications through 24-hour institutional care. On the other hand, there has been such a big push to send patients home instead of to a skilled nursing facility to reduce costs that it was surprising to see how big of an impact that might be having on patient outcomes like readmissions.”

To determine how patient outcomes and Medicare spending were affected by the decision to discharge patients to home with home health care or to a skilled nursing facility for post-acute care, researchers conducted a retrospective cohort study using Medicare claims data and skilled nursing facility and home health assessment data related to 17,235,854 patients (62.2% women) who were discharged to either home with home health care (38.8%) or to a skilled nursing facility (61.2%) from January 2010 to December 2016.

The primary outcome of the study was readmission within 30 days of hospital discharge. Secondary outcomes included mortality within 30 days of discharge, improvement in functional status during post-acute care, Medicare payment for post-acute care and total Medicare payment within the first 60 days after admission.

Researchers found that, compared with discharge to a skilled nursing facility, discharge to home was associated with a 5.6-percentage point higher rate of readmission within 30 days (95% CI, 0.8-10.3) but that there were no significant differences in 30-day mortality rates (–2 percentage points; 95% CI, 0.8-10.3) or improved functional status (–1.9 percentage points; 95% CI, –12 to 8.2).

In addition, researchers found that Medicare payment for post-acute care (–$5,384; 95% CI, –6,932 to –3,837) and total Medicare payment within the first 60 days after admission (–$4,514; 95% CI, –6,932 to –3,837) were both lower for those discharged to home than those discharged to a skilled nursing facility.

US map 
Although patients who were discharged from the hospital to home were 5.6% more likely to be readmitted within 30 days than those discharged to a skilled nursing facility, there were no significant differences in 30-day mortality or functional outcomes, and Medicare payments were lower.
Source: Adobe Stock

“There is a tradeoff between how much we spend on health care and what we get out of it,” Werner said. “While patients at skilled nursing facilities were less likely to be readmitted to the hospital, caring for patients in skilled nursing facilities is expensive. There are likely alternative approaches, such as providing more intensive treatment at home, that could balance these tradeoffs.”

In a related editorial, Vincent Mor, PhD, of the School of Public Health at Brown University and the VA Medical Center in Providence, Rhode Island, wrote: “In an era in which hospitals are penalized for higher than expected 30-day rates of rehospitalization, there may be greater comfort sending patients to skilled nursing facilities staffed with medical personnel who can manage medications and keep patients safe. Hospitals increasingly rely on preferred provider networks to which they discharge their skilled nursing facility patients, further smoothing interinstitutional arrangements. The finding by Werner et al that similar patients discharged to home health care vs. a skilled nursing facility were more likely to be rehospitalized may reinforce the institutional bias that appears to be present already. Combine the ease and standardization of transferring a patient to another medical facility with the administrative complexity and effort required to coordinate simultaneous delivery of medications, equipment, and multiple staff to a Medicare beneficiary’s home and it becomes clear why there is a structural preference for discharge to a skilled nursing facility.” – by Melissa J. Webb

For more information:

Rachel M. Werner, MD, PhD, can be reached at rwerner@upenn.edu.

Disclosures: Werner reports receiving grants from the Agency for Healthcare Research and Quality and grants from the National Institute on Aging. Please see the study for all other authors’ relevant financial disclosures.

 

Rachel Werner
Rachel M. Werner

Although patients who were discharged from the hospital to home were 5.6% more likely to be readmitted within 30 days than those discharged to a skilled nursing facility, there were no significant differences in 30-day mortality or functional outcomes, and Medicare payments were lower, according to a study published in JAMA Internal Medicine.

”We were surprised how much of an impact skilled nursing facilities had on reducing readmission rates,” Rachel M. Werner, MD, PhD, of the division of general internal medicine at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, told Healio Primary Care Today. “On one hand, this shouldn’t be surprising because skilled nursing facilities have more capabilities than home health agencies to prevent and manage complications through 24-hour institutional care. On the other hand, there has been such a big push to send patients home instead of to a skilled nursing facility to reduce costs that it was surprising to see how big of an impact that might be having on patient outcomes like readmissions.”

To determine how patient outcomes and Medicare spending were affected by the decision to discharge patients to home with home health care or to a skilled nursing facility for post-acute care, researchers conducted a retrospective cohort study using Medicare claims data and skilled nursing facility and home health assessment data related to 17,235,854 patients (62.2% women) who were discharged to either home with home health care (38.8%) or to a skilled nursing facility (61.2%) from January 2010 to December 2016.

The primary outcome of the study was readmission within 30 days of hospital discharge. Secondary outcomes included mortality within 30 days of discharge, improvement in functional status during post-acute care, Medicare payment for post-acute care and total Medicare payment within the first 60 days after admission.

Researchers found that, compared with discharge to a skilled nursing facility, discharge to home was associated with a 5.6-percentage point higher rate of readmission within 30 days (95% CI, 0.8-10.3) but that there were no significant differences in 30-day mortality rates (–2 percentage points; 95% CI, 0.8-10.3) or improved functional status (–1.9 percentage points; 95% CI, –12 to 8.2).

In addition, researchers found that Medicare payment for post-acute care (–$5,384; 95% CI, –6,932 to –3,837) and total Medicare payment within the first 60 days after admission (–$4,514; 95% CI, –6,932 to –3,837) were both lower for those discharged to home than those discharged to a skilled nursing facility.

US map 
Although patients who were discharged from the hospital to home were 5.6% more likely to be readmitted within 30 days than those discharged to a skilled nursing facility, there were no significant differences in 30-day mortality or functional outcomes, and Medicare payments were lower.
Source: Adobe Stock

“There is a tradeoff between how much we spend on health care and what we get out of it,” Werner said. “While patients at skilled nursing facilities were less likely to be readmitted to the hospital, caring for patients in skilled nursing facilities is expensive. There are likely alternative approaches, such as providing more intensive treatment at home, that could balance these tradeoffs.”

In a related editorial, Vincent Mor, PhD, of the School of Public Health at Brown University and the VA Medical Center in Providence, Rhode Island, wrote: “In an era in which hospitals are penalized for higher than expected 30-day rates of rehospitalization, there may be greater comfort sending patients to skilled nursing facilities staffed with medical personnel who can manage medications and keep patients safe. Hospitals increasingly rely on preferred provider networks to which they discharge their skilled nursing facility patients, further smoothing interinstitutional arrangements. The finding by Werner et al that similar patients discharged to home health care vs. a skilled nursing facility were more likely to be rehospitalized may reinforce the institutional bias that appears to be present already. Combine the ease and standardization of transferring a patient to another medical facility with the administrative complexity and effort required to coordinate simultaneous delivery of medications, equipment, and multiple staff to a Medicare beneficiary’s home and it becomes clear why there is a structural preference for discharge to a skilled nursing facility.” – by Melissa J. Webb

For more information:

Rachel M. Werner, MD, PhD, can be reached at rwerner@upenn.edu.

Disclosures: Werner reports receiving grants from the Agency for Healthcare Research and Quality and grants from the National Institute on Aging. Please see the study for all other authors’ relevant financial disclosures.