Patient choice of post-acute care provider and hospital accountability
Emily Gadbois | Brown University
Objective: In the US, patients covered by Medicare, the health insurance program for those over age 65, often require post-acute care after a hospitalization. This care is commonly provided in nursing homes. In recent years, Medicare policy changes and market-based pressures have resulted in reductions in median post-acute care length of stay in nursing homes. The purpose of this research was to identify the key challenges that reductions in length of stay pose for nursing homes, the unintended consequences of reduced length of stay for nursing homes and their patients and nursing home responses to these.
Data and methods: We conducted case studies in eight US cities and interviewed approximately 20 clinical and administrative staff from hospitals, nursing homes and Medicare managed care organizations in each market, yielding about 160 interviews. This included approximately 70 interviews with administrators, directors of nursing and admissions coordinators in 25 nursing homes. We used data on risk adjusted nursing home median length of stay for 2012-2014 created for another project to identify the nursing homes with reductions in length of stay and those with no reductions in length of stay. Data from interviews with staff in nursing homes with no reduction in median length of stay were then compared and contrasted with data from interviews with staff in nursing homes with reductions in length of stay.
Results: Among the 12 nursing homes where median length of stay dropped, the average reduction in length of stay was 4.0 days. Staff reported several challenges related to reductions in length of stay. They reported not having time to help patients unable to return to the community to find appropriate long-term care and reported having to discharge patients who they felt were unsafe. Some overcame these challenges by developing programs to follow-up with patients post-discharge. While these programs served to ease concerns about patients, they also involved non-reimbursable costs for nursing homes. Some nursing home respondents also noted ways they avoided admitting patients who had the potential to become long-stay. Staff in nursing homes that did not have reductions in length of stay reported not being reimbursed by managed care organizations and other payers for patient stays that had surpassed their pre-determined length. Some also reported patients becoming unexpectedly responsible for the costs of part of their stay.
Policy implications: The push for shorter nursing home length of stay has resulted in challenges for nursing homes and possible unintended consequences for patients, including increased costs for care and potentially unsafe discharges. Patients may also have difficulty finding facilities willing to accept them if they may eventually need long-term care. Policymakers should address these issues in ways that ensure patients receive the care they need, are not left responsible for unexpected costs and are not discharged unsafely or to a location that cannot provide the long-term care they may need.