Preventability of Hospital Readmissions From Skilled Nursing Facilities: A Consumer Perspective

Analysis of Functional Recovery in Older Adults Discharged to Skilled Nursing Facilities and Then Home

IMPORTANCE

Although many older adults are discharged to skilled nursing facilities (SNFs) after hospitalization, rates of patients recovery afterward are unknown.

OBJECTIVE

To examine postacute functional recovery among older adults.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among older adults treated in SNFs, then at home with home health care (HHC). Participants were a 5% random sample of Medicare fee-for-service beneficiaries discharged to community HHC after SNF stay from 2014 to 2016 with continuous part A and B enrollment in the prior 6 months. Medicare claims data from 2014 to 2016 were used, including inpatient, SNF, hospice, HHC, outpatient, carrier, and durable medical equipment data and Minimum Data Set (MDS) and Outcome Assessment Information Set (OASIS) for SNF and HHC assessments, respectively. Data were analyzed from July 20, 2020, to June 5, 2022.

EXPOSURES

Frailty was measured with a validated claims-based frailty index (CFI) (range, 0-1; higher scores indicate worse frailty) and categorized into not frail (<0.20), mildly frail (0.20-0.29), and moderately to severely frail (≥0.30).

MAIN OUTCOMES AND MEASURES

The primary outcome was functional recovery, defined by discharge from HHC with stable or improved ability to perform activities of daily living (ADL). Recovery status was examined at 15, 30, 45, 60, 75, and 90 days after discharge to HHC using OASIS. Covariates were obtained from the MDS admission file at SNF admission, including age, race and ethnicity, cognitive status, functional status, and geographic region.

RESULTS

Among 105 232 beneficiaries (mean [SD] age, 79.1 [10.6] years; 68 637 [65.2%] women; 8951 Black [8.5%], 3109 Hispanic [3.0%], and 88 583 White [84.2%] individuals), 65 796 individuals (62.5%) were discharged from HHC services with improved function over 90 days of follow-up. Among 39 436 beneficiaries not recovered, 19 612 individuals (49.7%) had mild frailty and 15 818 individuals (40.1%) had moderate to severe frailty. While 10 492 of 17 576 beneficiaries who were not frail recovered by 45 days (59.7%), 10 755 of 32 212 individuals with moderate to severe frailty had recovered (33.4%). Overall, frailty was negatively associated with functional recovery after adjustment for demographic characteristics, geographic census regions, and health-related variables, with a hazard ratio for moderate to severe frailty of 0.62 (95% CI, 0.60-0.63) compared with nonfrailty.

CONCLUSIONS AND RELEVANCE

This study found that recovery after posthospitalization SNF stay was particularly prolonged for individuals with frailty. Functional dependence in activities of daily living remained common among individuals with frailty long after discharge home.

Recevoir un soutien aux capacités d’autosoins lors de la transition posthospitalisation en résidence pour aînés en perte d’autonomie : un besoin non comblé

INTRODUCTION

Elderly people who receive appropriate transitional care after hospitalization experience fewer complications.

CONTEXT

However, in Quebec, transitional care for the elderly is limited to case management and targets elderly people who are in need of resources. This often excludes those who remain in homes for the elderly.

OBJECTIVES

The objective of this study was to identify the unmet needs of elderly people during the posthospitalization transition to intermediate care facilities in Quebec, as well as the strategies they use on a daily basis to cope with these needs.

METHODS

A descriptive qualitative study was conducted as part of an intervention research process. Eleven elderly participants and health professionals were recruited (n=11).

RESULTS

The results presented suggest a need to support patients' capacity for self-care, unmet during the post-hospitalization transition to intermediate care facilities.

DISCUSSION

Supporting the self-care abilities of elderly people can help ensure their safety when living in homes for the elderly.

CONCLUSION

Supporting the capacity for self-care is an important component of transitional care after hospitalization, including for elderly people with disabilities.

Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions

Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.

Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study

INTRODUCTION

People living with dementia (PLWD) are more likely to experience hospitalisation events (hospitalisation, rehospitalisation) than those without dementia. Many hospitalisation events, particularly rehospitalisation within 30 days of discharge, are thought to be avoidable. Yet our understanding of dementia-specific risk and protective factors surrounding avoidable hospitalisation is limited to specific intersetting transitions and predominantly clinician perspectives. Broader insights are needed to design accessible and effective solutions for reducing avoidable hospitalisations. We have designed the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) Study to address these gaps. The objectives of the SUPPORT Study are to elicit and examine family caregiver, community and hospital providers' perspectives on avoidable hospitalisation events among PLWD, and to identify opportunities for effective prevention.

METHODS AND ANALYSIS

We will conduct a multisite, descriptive qualitative study to interview around 100 family caregivers, community and hospital providers. We will identify and sample from regions and communities with higher socio-contextual disadvantage and hospital utilisation, and will aim to recruit individuals representing diverse racial/ethnic backgrounds. Interviews will follow a descriptive qualitative design in conjunction with constant comparison techniques to sample divergent situations and events. We will employ a range of analytical approaches to address specific research questions including thematic (inductive and deductive), comparative and dimensional analysis. Interviews will be conducted individually or in focus groups and follow a semistructured interview guide.

ETHICS AND DISSEMINATION

The study is approved by the University of Wisconsin-Madison Institutional Review Board. Informed consent procedures will incorporate steps to evaluate capacity to provide informed consent in the event that participants express concerns with thinking or memory or demonstrate challenges recalling study details during the consent process to ensure capacity to consent to participation. A series of publicly available reports, seminars and symposia will be undertaken in collaboration with collaborating organisation partners.

Association of Online Consumer Reviews of Skilled Nursing Facilities With Patient Rehospitalization Rates

Importance

There are areas of skilled nursing facility (SNF) experience of importance to the public that are not currently included in public reporting initiatives on SNF quality. Whether patients, hospitals, and payers can leverage the information available from unsolicited online reviews to reduce avoidable rehospitalizations from SNFs is unknown.

Objectives

To assess the association between rehospitalization rates and online ratings of SNFs; to compare the association of rehospitalization with ratings from a review website vs Medicare Nursing Home Compare (NHC) ratings; and to identify specific topics consistently reported in reviews of SNFs with the highest vs lowest rehospitalization rates using natural language processing.

Design, Setting, and Participants

A retrospective cross-sectional study of 1536 SNFs with online reviews on Yelp (a website that allows consumers to rate and review businesses and services, scored on a 1- to 5-star rating scale, with 1 star indicating the lowest rating and 5 stars indicating the highest rating) posted between January 1, 2014, and December 31, 2018. The combined data set included 1536 SNFs with 8548 online reviews, NHC ratings, and readmission rates.

Main Outcomes and Measures

A mean rating from the review website was calculated through the end of each year. Risk-standardized rehospitalization rates were obtained from NHC. Linear regression was used to measure the association between the rehospitalization rate of a SNF and the online ratings. Natural language processing was used to identify topics associated with reviews of SNFs in the top and bottom quintiles of rehospitalization rates.

Results

The 1536 SNFs in the sample had a median of 6 reviews (interquartile range, 3-13 reviews), with a mean (SD) review website rating of 2.7 (1.1). The SNFs with the highest rating on both the review website and NHC had 2.0% lower rehospitalization rates compared with the SNFs with the lowest rating on both websites (21.3%; 95% CI, 20.7%-21.8%; vs 23.3%; 95% CI, 22.7%-24.0%; P = .04). Compared with the NHC ratings alone, review website ratings were associated with an additional 0.4% of the variation in rehospitalization rates across SNFs (adjusted R2 = 0.009 vs adjusted R2 = 0.013; P = .003). Thematic analysis of qualitative comments on the review website for SNFs with high vs low rehospitalization rates identified several areas of importance to the reviewers, such as the quality of physical infrastructure and equipment, staff attitudes and communication with caregivers.

Conclusions and Relevance

Skilled nursing facilities with the best rating on both a review website and NHC had slightly lower rehospitalization rates than SNFs with the best rating on NHC alone. However, there was marked variation in the volume of reviews, and many SNF characteristics were underrepresented. Further refinement of the review process is warranted.

Implementation of a skilled nursing facility readmission review process

30-day readmissions for patients at skilled nursing facilities (SNF) are common and preventable. We implemented a readmission review process for patients readmitted from two SNFs, involving an electronic review tool and monthly conferences. The electronic review tool captures information related to preventability and factors contributing to readmission. The study included 128 patients, readmitted within 30 days from 1 October 2015 through 1 May 2017, at a tertiary care academic medical centre in Boston, MA, and two partnering SNFs. There was a discrepancy in preventability rating between SNF and hospital reviewers, with 79.7% of cases rated not preventable by the SNF, and 58.6% by the hospital. There was moderate positive correlation between the hospital's and SNFs' preventability ratings (r_s=0.652, p<0.001). In most cases, the SNF reviewers felt that no factors contributed (57.8%), and hospital reviewers felt that issues with end-of-life planning (14.1%) and medical complexity (12.5%) were major factors. Despite the lack of strong correlation between SNF and hospital responses, several cross-continuum quality improvement projects were developed. We found that implementation of a SNF readmission review process employing bidirectional review by SNF and hospital was feasible, and facilitated systems-based improvement in the transition from hospital to postacute care.