Target Audience and Goal Statement: Health policy specialists, hospitalists, geriatricians, family physicians, internists
The goal was to understand the association of patient outcomes and Medicare costs of discharge to home with home health care versus discharge to a skilled nursing facility.
Question Addressed:
- How are patient outcomes and Medicare spending affected by the decision to discharge patients to home with home health care versus to a skilled nursing facility for post-acute care?
Synopsis and Perspective:
Post-acute care transitions a patient who no longer requires acute care in a hospital to another skilled setting or to home. Post-acute care use and costs have risen over the past eighteen years: more than 40% of Medicare beneficiaries receive such care after a hospital discharge. Medicare spent more than $60 billion on post-acute care in 2015 and this number is likely to increase with an aging population.
Most patients (90%) are discharged to a skilled nursing facility or to home with care from a home health agency. However, medical care provided at home has lagged behind hospital referrals of patients to skilled nursing facilities. Notably, the average cost of a skilled nursing facility stay is $11,357 versus just $2,720 for a home health care episode. Little is known about the impact the choice of a post-discharge setting has on patient outcomes and costs.
Because previous studies provided inconsistent results and there is currently a proliferation in the use of post-acute care, Rachel Werner, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues, investigated differences in rates of 30-day readmission, 30-day mortality, functional outcomes, and Medicare payment in a very large national sample of Medicare beneficiaries discharged to home with home health care versus to a skilled nursing facility.
From 2010 to 2016, more than 17 million hospitalized patients (62.2% women and 37.8% men; mean age = 80.5 years) were discharged to home with home health care (38.8%) or to a skilled nursing facility (61.2%).
Patients recuperating at home with home health care had a similar mean number of 3.2 comorbidities compared to patients referred to a skilled nursing facility. Discharge to home health care occurred more frequently for total knee or hip replacements, congestive heart failure, and pneumonia. Patients were less frequently discharged to this setting following hospitalizations for sepsis and urinary tract infections.
Overall, patients discharged to home with home health care were 5.6% more likely to be readmitted at 30 days compared with discharge to a skilled nursing facility.
No significant differences were observed in 30-day mortality rates or improved functional status. Medicare reimbursement for a discharge to home was $5,384 less than to a skilled nursing facility. Total Medicare payment within the first 60 days after admission was also reduced by $4,514.
Study limitations included the possibility of residual confounding (although lessened by the instrumental variable strategy adopted by the authors). In addition, the results apply only to Medicare beneficiaries, particularly marginal patients. Werner and colleagues defined these patients as those discharged to home with home health care solely because of their closer proximity to a home health agency than to a skilled nursing facility, conditional on health characteristics.
These marginal patients may be interpreted as those whose need for home health versus a skilled nursing facility was borderline — i.e., either setting would have been considered reasonable. Within the context of the study, the marginal patient was less likely than the average patient in the full sample to be older than 80 years (47.2% vs 54.2%), less likely to be white (78.3% vs 86.3%), more likely to be dually enrolled in Medicare and Medicaid (22.2% vs 17.7%), and less likely to be enrolled in Medicare Advantage (21.8% vs 24.6%) or to have six or more comorbidities (16.6% vs 20.6%).
The authors noted that the marginal patient was most likely to be affected by current policies that might encourage substitution among settings.
Source Reference: JAMA Internal Medicine, Mar. 11, 2019; DOI:10.1001/jamainternmed.2018.7998
Study Highlights: Explanation of Findings
Among Medicare beneficiaries who are eligible for either home health care or a skilled nursing facility after hospital discharge, discharge to home with home health care was associated with a 5.6% higher rate of readmission, but lower total payments, the team wrote.
Readmissions is a critical metric for hospitals because of its value-for-care and financial dimensions. Medicare has been penalizing hospitals for readmissions for targeted conditionssuch as pneumonia. Therefore, the higher readmission rate for patients sent home was a noteworthy finding.
“There is a tradeoff between how much we spend on health care and what we get out of it. While patients at SNFs [skilled nursing facilities] were less likely to be readmitted to the hospital, caring for patients in SNFs is expensive. There are likely alternative approaches such as providing more intensive treatment at home, that could balance these tradeoffs,” Werner told MedPage Today.
Prior investigations yielded inconsistent results and have been small and assessed few conditions, and the majority inadequately controlled for the considerable differences in patient characteristics across settings, the study authors noted. Werner and colleagues then commented on the fact that this was the first study to provide large-scale and recent estimates of the differences in patient outcomes and Medicare payments between patients discharged to home with home health care compared with those discharged to a skilled nursing facility, and that addresses confounding by indication.
“Combine the ease and standardization of transferring a patient to another medical facility with the administrative complexity and effort required to coordinate simultaneous delivery of medications, equipment, and multiple staff to a Medicare beneficiary’s home and it becomes clear why there is a structural preference for discharge to an SNF,” wrote Vincent Mor, PhD, of Brown University in Providence, Rhode Island, in an accompanying editorial.
The editorialist further noted that “what separates clinically similar patients going home from those going to a skilled nursing facility probably comes down to the intangibles: the unmeasured factors of family support, living arrangements, the number of stairs in the home, and patients’ insistence on independence.”
Mor raised two possibilities to account for differences between skilled nursing facilities and home health care in the adjusted rates of rehospitalization (that were probably due to discretionary transfers). It was possible that inadequate quality monitoring would be more amenable to skilled home health input. Alternatively, it may be that more rehospitalizations due to inadequate home health care services is the price that must be paid to prevent needless institutional care and lower Medicare post-acute expenditures by $4,500. Addressing this question was important, according to the editorialist, as a small improvement in clinician quality, better training to improve family engagement, or better targeting of who can use home health care might eliminate excess rehospitalizations without reducing the cost savings.
“These results warrant further investigation of these post-acute care settings and others given the common use and high costs associated with post-acute care,” Werner and colleagues concluded.
Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College and Heidi Wynn Maloni, PhD, ANP-BC, CNRN, MSCN, Nurse Planner
Primary Source
JAMA Internal Medicine
Secondary Source
JAMA Internal Medicine
Additional Source
MedPage Today
Source Reference: Lyles A “Post-Acute Care Location Matters for Readmissions” 2019.
