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Policy PointsMisaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long‐stay nursing home residents.Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. Context: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education‐based interventions (Clinical‐Only) aimed to reduce hospitalizations among long‐stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment‐Only). Methods: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in‐person interviews to investigate aspects of implementation and a difference‐in‐differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. Findings: Three key components were necessary for successful implementation of the Initiative—staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical‐Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment‐Only interventions were successful in reducing hospitalizations. Conclusions: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct‐care staff in the nursing home, as well as hands‐on care. Use of Medicare payment incentives alone to encourage on‐site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve. [ABSTRACT FROM AUTHOR]

The current study examined the policy and market context existing in the seven states where the Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents took place. Stakeholder organizations with knowledge of the skilled nursing facility environment but who were not directly involved with the CMS Initiative were interviewed to assess the impact of policies and programs affecting transfers to the hospital from long-term care facilities. Focused interviews were used to identify areas of quality improvement as well as market forces that contributed to hospitalization rates. Interviews were qualitatively coded and emerging patterns and themes were identified. Market pressures were similar across states. Few policies were found that may have affected the Initiative, but most states had regional coalitions focused on improving some aspect of care. When asked what else could be done to reduce hospitalizations among nursing facility residents, participants across the stakeholder organizations suggested greater presence of physicians and nurse practitioners in nursing facilities, better training around behavioral health issues for frontline staff, and more advance care planning and education for families regarding end of life. [Journal of Gerontological Nursing, 48(8), 10–16.] [ABSTRACT FROM AUTHOR]

Background: Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home. Purpose: Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems. Methods: Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems. Results: Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017. Conclusion: As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value. [ABSTRACT FROM AUTHOR]

Objective: This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff.Design: We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process.Participants: Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets.Approach: Interviews were qualitatively analyzed to identify overarching themes.Key Results: Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown.Conclusions: Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives To describe individuals' experiences during the hospital discharge planning and skilled nursing facility ( SNF) selection process. Design Semistructured interviews focusing on discharge planning and nursing facility selection, including how facilities were chosen, who was involved, and what factors were important in decision-making. Setting 14 SNFs in five cities across the United States. Participants Newly admitted, previously community-dwelling SNF residents (N = 98) and their family members. Measurement Semistructured interviews were qualitatively coded to identify underlying themes. Results Most respondents reported receiving only a list of SNF names and addresses from discharge planners and that hospital staff were minimally involved. Proximity to home and prior experience with the facility most often influenced choice of SNF. Most respondents reported being satisfied with their placement, although many stated that they would have been willing to travel further to another SNF were it recommended. Many reported feeling rushed and unprepared, stating that they did not know where or how to get help. Conclusion SNF placement is a stressful transition, occurring when people are physically vulnerable and with limited guidance from discharge planners. Therefore, most people select a facility based on its location, perhaps because they are provided with no other information. Given Centers for Medicare and Medicaid Services' proposed changes to the discharge planning process, this research highlights the value of providing people and family caregivers with quality data and assistance in interpreting it. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents. Design We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes. Settings All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011. Results Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS discharge records. More than 99% of the variation in nursing home–level 30-day rehospitalization rate calculated using claims data can be explained by the same rates calculated using MDS. Nursing home structural characteristics explain only 5% of the variation in nursing home–level sensitivity and 3% of the variation in nursing home–level specificity. Conclusion The new MDS 3.0 discharge record matches Medicare enrollment and hospitalization claims events with a high degree of accuracy, meaning that hospitalization rates calculated based on MDS offer a good proxy for the “gold standard” Medicare data. [ABSTRACT FROM AUTHOR]

Nursing home culture change is becoming more prevalent, and research has demonstrated its benefits for nursing home residents and staff—but little is known about the role of nursing home administrators in culture change implementation. The purpose of this study was to determine what barriers nursing home administrators face in implementing culture change practices, and to identify the strategies used to overcome them. The authors conducted in-depth individual interviews with 64 administrators identified through a nationally representative survey. Results showed that a key barrier to culture change implementation reported by administrators was staff, resident, and family member resistance to change. Most nursing home administrators stressed the importance of using communication, education and training to overcome this resistance. Themes emerging around the concepts of communication and education indicate that these efforts should be ongoing, communication should be reciprocal, and that all stakeholders should be included. [ABSTRACT FROM AUTHOR]

Purpose of the Study: To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence. Design and Methods: In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state’s average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used. Results: Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results. Implications: Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended. [ABSTRACT FROM PUBLISHER]

Establishing preferred provider networks of skilled nursing facilities (SNFs) is one approach hospital administrators are using to reduce excess thirty-day readmissions and avoid Medicare penalties or to reduce beneficiaries' costs as part of value-based payment models. However, hospitals are also required to provide patients at discharge with a list of Medicare-eligible providers and cannot explicitly restrict patient choice. This requirement complicates the development of a SNF network. Furthermore, there is little evidence about the effectiveness of network development in reducing readmission rates. We used a concurrent mixed-methods approach, combining Medicare claims data for the period 2009-13 with qualitative data gathered from interviews during site visits to hospitals in eight US markets in March-October 2015, to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal SNF networks. Four hospitals had developed formal SNF networks as part of their care management efforts. These hospitals saw a relative reduction from 2009 to 2013 in readmission rates for patients discharged to SNFs that was 4.5 percentage points greater than the reduction for hospitals without formal networks. Interviews revealed that those with networks expanded existing relationships with SNFs, effectively managed patient data, and exercised a looser interpretation of patient choice. [ABSTRACT FROM AUTHOR]