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Objective: To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). Data Sources: 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Data Collection/Extraction Methods: Not Applicable. Study Design: We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Principal Findings: Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% Cl:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Conclusions: Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes. KEYWORDS disability, post-acute care; functional improvement; health disparities; home health agency; Medicare home health, 1 | INTRODUCTION One of the primary responsibilities of home health (HH) is to improve the functional status of HH patients. Home health care is the provision of skilled care [...]

Objective: The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners. Data Sources: The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019. Study Design: We model and compare the estimated effect of facility 'preferredness' on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. Data Collection: Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. Principal Findings: Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD. Conclusions: Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems). KEYWORDS care transitions, dementia, Medicare, postacute care, 1 | INTRODUCTION Hospitals discharge nearly one in five Medicare patients to a skilled nursing facility (SNF) every year, resulting in over 1.5 million observed transitions. (1) The transition from [...]

Objective: To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID-19 pandemic. Data Sources and Study Setting: We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021. Study Design: We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis. Data Collection Methods: In-depth, semi-structured qualitative interviews were conducted virtually or by phone, and audio-recorded, with participants' consent. Audio recordings were transcribed. Principal Findings: Interviews with nursing home administrators revealed a number of important cross-cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID-19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID-19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID-19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID-19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media. Conclusions: Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID-19 and have substantial implications for policy and practice. KEYWORDS COVID-19, nursing homes, pandemic, qualitative, residents, skilled nursing facilities, staffing What is known on this topic * COVID-19 has had an enormous negative impact on nursing homes, their staff, and their residents. * Existing research is largely quantitative and does not capture the depth of experiences and perspectives regarding the COVID-19 crisis in nursing homes. * Our research helps to fill this gap through repeated, semi-structured, in-depth interviews with nursing home administrators across the country, conducted over the course of the pandemic. What this study adds * Through 156 repeated interviews with 40 nursing home administrators around the country, we learned about the daily and persistent challenges nursing homes faced and the strategies used to respond to COVID-19. * Administrators discussed challenges in implementing governmental policies and expressed a need for additional support and resources, collaborative relationships with policymakers, and a place at the table in decision-making. * Administrators described concerns for the sustainability of the nursing home industry due to costs associated with responding to COVID-19, reductions in revenue, and negative portrayal of nursing homes by the media., 1 | INTRODUCTION The COVID-19 pandemic has had a devastating impact on United States nursing homes. As of October 2022, more than 1.2 million nursing home residents had confirmed cases [...]

Objective: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection. Data Sources: We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website. Data Collection/Extraction Methods: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users. Study Design: This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs. Principal Findings: The introduction of star ratings was associated with a 0.88-per-centage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries. Conclusions: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection. KEYWORDS home health care, patient experience, provider selection, public reporting, quality of care, star ratings, What is known on this topic * Although the Centers for Medicare and Medicaid Services (CMS) spends over $18 billion annually to care for 3.4 million home health beneficiaries, we [...]

Objective: To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. Data Sources/Collection: We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. Study Design: We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. Data Collection/Extraction Methods: We used previously collected MedPAR and OSCAR/CASPER survey data. Principal Findings: We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. Conclusions: We find evidence that freestanding SN Fs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs. KEYWORDS Healthcare Organizations and Systems, hospitals, long-term care: home care/nursing homes, Medicare, referrals and referral networks What Is Already Known? * Evolving payment models are changing the relationships between hospitals and skilled nursing facilities. * Hospitals concentrating referrals to SNFs have exhibited better outcomes (eg, lower readmissions). * No study has been done from the SNF perspective. What Does This Study Add? * SNFs with higher concentrations of hospital referrals are associated with less-risky patients at admission. * Certain patients may be facing more restrictive choices of nursing homes at discharge., 1 | INTRODUCTION Since the implementation of the Affordable Care Act (ACA) in 2011, many policies have targeted better integration of care provided in hospitals and skilled nursing facilities (SNF), [...]

With Medicare Advantage (MA) enrollment surpassing 50 percent of Medicare beneficiaries, accurate risk-adjusted plan payment rates are essential. However, artificially exaggerated coding intensity, where plans seek to enhance measured health risk through the addition or inflation of diagnoses, may threaten payment rate integrity. One factor that may play a role in escalating coding intensity is health risk assessments (HRAs)—typically in-home reviews of enrollees’ health status—that enable plans to capture information about their enrollees. In this study, we evaluated the impact of HRAs on Hierarchical Condition Categories (HCC) risk scores, variation in this impact across contracts, and the aggregate payment impact of HRAs, using 2019 MA encounter data. We found that 44.4 percent of MA beneficiaries had at least one HRA. Among those with at least one HRA, HCC scores increased by 12.8 percent, on average, as a result of HRAs. More than one in five enrollees had at least one additional HRA-captured diagnosis, which raised their HCC score. Potential scenarios restricting the risk-score impact of HRAs correspond with $4.5–$12.3 billion in reduced Medicare spending in 2020. Addressing increased coding intensity due to HRAs will improve the value of Medicare spending and ensure appropriate payment in the MA program.

Objective. To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes.Data Sources/Study Setting. Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015.Study Design/Data Collection. Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared.Principal Findings. Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals.Conclusions. Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.Key Words. Postacute care, hospital readmission, integration, interorganizational linkage, Each year nearly four million Medicare beneficiaries are discharged from hospitals to skilled nursing facilities (SNFs) for postacute care (PAC). About 20 percent of these patients are readmitted to a [...]

Objective. To examine the effects of Medicare's Medical Review (MR) program on short-stay inpatient hospitalization.Data Sources/Study Setting. One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007-2010).Study Design. Retrospective observational study using a difference-indifferences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed size, system membership, and inpatient admission rate to test for differential effects. The comparison group was hospital visits occurring in those MACs that had yet to implement, as well as those that did not implement during the period of interest.Data Collection. None.Principal Findings. Medical Review significantly reduced the likelihood of inpatient admission for patients with an intake diagnosis of 'Non-Specific Chest Pain' by 1.29 percentage points (p < .001). This effect was stronger in larger hospitals (-2.03, p < .001), nonsystem hospitals (-2.54, p < .001), and those with a lower inpatient rate (-1.86, p< .001).Conclusions. Short inpatient hospitalizations were emphasized by MR, and our results show that MR modestly reduced their prevalence among certain patients and certain hospitals. Future work should examine whether this resulted in adverse patient outcomes.Key Words. Medical review, observation, hospital, Medicare, inpatient, BackgroundShort inpatient hospital stays (i.e., two days or fewer) have long been an area of emphasis for the Centers for Medicare & Medicaid Services in their efforts to reduce costs [...]

Objective. The Medicare Modernization Act of 2004 allowed Medicare Advantage (MA) contracts to form provider networks in order to concentrate their patients among preferred providers. We focus on the skilled nursing facility (SNF) industry to assess patients' health when treating SNFs concentrate more patients from the same MA contract.Data Sources/Study Setting. We use Medicare Beneficiary Summary File and Health, HEDIS, and the Minimum Data Set for patient attributes and OSCAR, LTCfocus.org, and Nursing Home Compare for SNF attributes. We include 1,069,436 MA enrollees newly admitted to SNF between 2012 and 2014.Study Design. Using a MA contract fixed-effect model, we examine the effect of prevalence of a patient's MA contract in the treating SNF on patient's health outcomes including 180-day survival, 30-day hospital readmission, 30-day home discharge, and nursing home length of stay. We use an Instrumental Variable (IV), the expected share of admissions in a SNF from patient's MA contract calculated using a McFadden choice model.Principal Findings. We find no relationship between SNF contract concentration and patients' outcomes after applying the IV.Conclusions. While MA plans appear to steer patients to specific SNFs, we do not observe significant returns to patient outcomes related to concentration.Key Words. Medicare advantage, skilled nursing facility, preferred provider network, In Medicare Advantage (MA), the Medicare program pays private insurance companies on a capitated basis to manage Medicare beneficiaries' care needs. In 2003, Congress passed the Medicare Modernization Act (MMA) [...]

Objective. To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization. Data Sources/Settings. Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization. Study Design. [...]

Objective. To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity. Settings. Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization. Study Design. We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV. Principal Findings. The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013. Conclusions. Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection. Key Words. Skilled nursing facility, quality of care, rehospitalization, readmission, ACA, The Centers for Medicare and Medicaid Services' (CMS) Hospital Readmission Reduction Program now holds hospitals responsible for their Medicare patients' readmission rates in the 30 days post discharge. One major [...]