Do Internal Medicine Residents Know Enough About Skilled Nursing Facilities To Orchestrate a Good Care Transition?

Journal of the American Medical Directors Association

Whitfield

Hittle³

et al. 2016

121

122

Objectives Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. Design Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003–2009. Setting The MCBS is a nationally-representative survey of beneficiaries matched with claims data. Participants Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. Intervention/Exposure Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. Measurements Hospital readmission during the PAC stay, return to community residence, and all-cause mortality. Results Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21–7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39–1.92), and for-profit PAC ownership (1.43, 1.21–1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9 vs. 8.6%, p<0.001) and 100 days (39.9 vs. 14.5%, p<0.001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60–2.54; 100 days: OR 3.79, 95% CI 3.13–4.59). Conclusions Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

Section: Discussionmentioning

confidence: 99%

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

Journal of the American Medical Directors Association

Whitfield

Hittle³

et al. 2016

121

122

“…Hospitalists decrease length of stay and costs in the acute setting, but there is evidence of cost-shifting to the post-acute environment, including increased discharges to PAC facilities. 24 This may in part be due to the limited training 25 or feedback on the use of PAC facilities hospitalists receive, leaving significant uncertainly about the role of PAC for individual patients. 26 …”

Section: Discussionmentioning

confidence: 99%

Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges From US Hospitals

Juaréz-Colunga

Levy³

et al. 2015

Medical Care

Background/Objectives The number of patients discharged to post-acute care(PAC) facilities after hospitalization increased by 50% nationally between 1996 and 2010. We sought to describe payors and patients most affected by this trend and to identify diagnoses for which PAC facility care may be substituting for continued hospital care. Design Retrospective analysis of the National Hospital Discharge Surveyfrom 1996 to 2010. Setting Adult discharges from a national sample of non-Federal hospitals. Participants/Exposures Adults admitted and discharged to a PAC facilitybetween 1996 and 2010. Our analysis includes 2.99 million sampled discharges, representative of 386million discharges nationally. Measurements Patient demographic and hospitalization characteristics, including length of stay(LOS) and diagnoses treated. Results More than half (50.7%) of all patients discharged to PAC facilities were 80 years old or older in 2010; 40% of hospitalizations in this age group ended with a PAC stay. Decreases in LOS and increases in PAC facility use were consistent across payors and patient demographics. PAC facilities may be substituting for continued inpatient care for patients with pneumonia, hip fracture, and sepsis as these diagnoses demonstrated the clearest trends of decreasing LOS and increasing discharges to PAC facilities. Conclusions The rise in discharges to PAC facilities is occurring in all age groups and payors, though the predominant population is the very old Medicare patient, for whom successful rehabilitation may be most unsure. PAC facility care may be increasingly substituted for prolonged hospitalizations for patients with pneumonia, hip fracture, and sepsis.

“…There is substantial variability in patient selection for SNFs across regions and providers; regional variability in the use of postacute care explains 73% of all geographic variability in Medicare spending in the United States . Furthermore, hospitalists who care for older adults in the hospital may have little familiarity with SNFs broadly or in their area. Because there are no validated tools available in the public domain that reliably predict benefit from a SNF stay, recommendations vary between clinicians with different training …”

mentioning

confidence: 99%

How Hospital Clinicians Select Patients for Skilled Nursing Facilities

J American Geriatrics Society

Lawrence

Ladebue

et al. 2017

Background/Objective Hospitalized older adults are frequently transferred to skilled nursing facilities (SNFs) for post-discharge care. Hospitals and SNFs are increasingly held jointly accountable for costs and outcomes of this care. However, it is unclear how clinicians select patients for SNF care; we sought to understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a SNF for post-acute care. Design Semi-structured interviews paired with a qualitative analytic approach informed by Social Constructivist theory. Setting Inpatient care units in three hospitals. We used purposive sampling to maximize variability in hospitals, units within hospitals, and staff on those units. Participants Twenty-five clinicians involved in evaluation and decision-making regarding post-acute care, including hospitalists, nurses, therapists, social workers, and case managers. Measurements Central themes related to clinician evaluation and discharge decision-making. Results Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNF as a “safety net” for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in the lack of a standardized evaluation process or a clear primary decision-maker. Conclusion Hospital clinician evaluation and decision-making about post-acute care in a SNF may be characterized as rushed, without a clear system or framework for making decisions, and uninformed by knowledge of SNF or patient outcomes in those discharged to SNF. This leads to SNF being used as a “safety net” for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of patients transitioning between hospital and SNF, novel solutions for improving evaluation and decision-making are urgently needed.