No abstract

Accountable Care Organizations (ACOs) seeking to decrease health care expenditure may endeavor to decrease the use of institutional postacute care. The implementation of transitional care planning strategies that consider the question, "why not home?" for every patient discharging from the hospital, embraces the spirit of discharging to the least restrictive next site of care. Previous studies indicate that reductions in skilled nursing facility (SNF) spending increase as ACOs mature, partly as a result of efforts to decrease rates of discharge to the SNF setting of care (McWilliams et al., 2017). Claims-based data analyses can be leveraged to inform multifaceted interventions and to inform and drive change. The purpose of this study is to investigate how an intervention to transform the transitional care approach to align with discharging patients to the lowest level of care, as appropriate, impacts patient outcomes.Our previous retrospective cohort study analyzed the association between discharge dispositions of home health (HH) compared with SNF, and the outcomes of readmission rates and cost of care, specifically for Medicare ACO patients discharged from the hospital (Chovanec et al., 2021