Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer?

The role of Medicaid home- and community-based services in use of Medicare post-acute care

OBJECTIVE

Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled.

DATA SOURCES

National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018.

STUDY DESIGN

We estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups.

DATA EXTRACTION METHODS

The primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018.

PRINCIPAL FINDINGS

We found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings.

CONCLUSION

Our findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts.

Emergency department claims among Medicare beneficiaries with HIV, STDs, viral hepatitis or tuberculosis before and during the COVID-19 pandemic

BACKGROUND

Changes in emergency department (ED) usage among US Medicare beneficiaries (MB) with fee-for-service claims for HIV, viral hepatitis, sexually transmitted diseases (STDs) or tuberculosis (TB) (HHST) services have not been assessed since the COVID-19 pandemic.

METHODS

During 2006-20, we assessed the annual number of MB with each HHST per 1000 persons with ED claims for all conditions, and changes in demographic and geographic distribution of ED claimants for each HHST condition.

RESULTS

Of all persons who attended an ED for any condition, 10.5 million (27.5%) were MB with ≥1 ED claim in 2006; that number (percentage) increased to 11.0 million (26.7%) in 2019 and decreased to 9.2 million (22.7%) in 2020; < 5 MB per 1000 ED population had HHST ED claims in 2020. The percentage increase in ED claims was higher for MB with STDs than for those with other HHST conditions, including a 10% decrease for MB with TB in 2020.

CONCLUSIONS

Trends in ED usage for HHST conditions were associated with changes in demographic and geographic distribution among MB during 2006-20. Updated ED reimbursement policies and primary care practices among MB might improve prevention, diagnosis and treatment of HHST conditions in the future.

The contributions of survey-based versus administrative measures of socioeconomic status in predicting type of post-acute care for hospitalized Medicare beneficiaries

OBJECTIVES

To assess and compare the associations between socioeconomic status (SES) measures from two sources (claims vs. survey data) and the type of post-acute care (PAC) locations following hospital discharge.

METHODS

This observational study included Medicare Fee-for-Service (FFS) beneficiaries age 65.5 years or older who participated in the Medicare Current Beneficiary Survey (MCBS) and were hospitalized in 2006-2011. Multiple data sets were used including: Area Deprivation Index; Medicare Cost Reports, Provider of Services files, and Area Health Resource File. Multinomial regression models estimated associations between beneficiary's SES and PAC type. SES measures came from surveys (income and education) and administrative records (dual enrollment and area deprivation). PAC types included home with self-care, home health agency, skilled nursing facility (SNF), or inpatient rehabilitation facility.

RESULTS

Low income and dual enrollment were associated with higher SNF use while living in a deprived area was associated with lower SNF use and higher use of home with self-care. Dual enrollment and area deprivation were associated with the largest differences.

CONCLUSIONS

If policies to modify payment based on SES are considered, administrative measures (dual enrollment and area deprivation) rather than survey measures (education and income) may be sufficient.

Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries s Discharged Home following a Stroke: Findings from the COMPASS Trial

OBJECTIVES

To examine the effect of a comprehensive transitional care model on the utilization of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke.

DESIGN

Cluster randomized pragmatic trial Setting: 41 acute care hospitals in North Carolina.

PARTICIPANTS

2,262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (standard deviation [SD]) age of 74.9 (10.2) years and a mean (SD) NIH stroke scale score of 2.3 (3.7).

INTERVENTION

Comprehensive transitional care model (COMPASS-TC) which consisted of a 2-day follow-up phone call from the post-acute care coordinator (PAC) and 14-day in-person visit with the PAC and advanced practice provider.

MAIN OUTCOME MEASURES

Time to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission.

RESULTS

Only 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (HR=1.20 [0.95 - 1.52]) compared to usual care. This estimate was robust to additional covariate adjustment (HR=1.23 [0.93-1.64]). Both clinical and non-clinical factors (i.e., insurance, geography) were predictors of SNF/IRF use.

CONCLUSIONS

COMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.

Do Skilled Nursing Facilities That Provide More Rehabilitation Therapy Have Lower Rehospitalization Rates?

This study examines whether skilled nursing facilities (SNFs) that consistently provided more rehabilitation therapy than other SNFs had lower 30-day rehospitalization rates. A cross-sectional analysis of 11 866 SNFs in the United States compared 30-day rehospitalization rates of SNFs that consistently provided more rehabilitation therapy to other SNFs using linear regression models. High-billing SNFs were defined as the 10% of SNFs with the highest proportions of Medicare fee-for-service claims that just surpassed the therapy minute threshold for the highest payment category. After controlling for patient and facility characteristics, high-billing SNFs had higher 30-day rehospitalization rates as well as longer median length of stay and greater mean cost per stay. Small reductions in the amount of therapy provided are unlikely to increase 30-day rehospitalization rates in SNFs. This has important consequences for the recently implemented patient-driven payment model, which incentivizes SNFs to provide less rehabilitation therapy.

Medicaid home- and community-based services and discharge from skilled nursing facilities

OBJECTIVE

To examine the association between the generosity of Medicaid home- and community-based services (HCBS) and the likelihood of community discharge among Medicare-Medicaid dually enrolled older adults who were newly admitted to skilled nursing facilities (SNFs).

DATA SOURCES

National datasets, including Medicare Master Beneficiary Summary File (MBSF), Medicare Provider and Analysis Review (MedPAR), Medicaid Analytic eXtract (MAX), minimum data set (MDS), and publicly available data at the SNF or county level, were linked.

STUDY DESIGN

We measured Medicaid HCBS generosity by its breadth and intensity and described their variation at the county level. A set of linear probability models with SNF fixed effects were estimated to characterize the association between HCBS generosity and likelihood of community discharge from SNFs. We further stratified the analyses by the type of index hospitalizations (medical vs surgical events), age group, and the Medicaid cost-sharing policy for SNF services.

DATA EXTRACTION METHODS

The final analytical sample included 224 229 community-dwelling dually enrolled older duals who were newly admitted to SNFs after an acute inpatient event between October 1, 2010, and September 30, 2013.

PRINCIPAL FINDINGS

We observed substantial cross-sectional and over-time variations in HCBS breadth and intensity. Regression results indicate that on average, a 10 percentage-point increase in HCBS breadth was associated with a 0.7 percentage-point increase (P < 0.01) in the likelihood of community discharge. Such relationship could be modified by individual factors and state policies: significant effects of HCBS breadth were detected among medical patients (0.7 percentage-point, P < 0.05), individuals aged older than 85 (1.5 percentage-point, P < 0.01), and states with and without lesser-of policies (0.5 and 2.3 percentage-point, respectively, P < 0.05). No significant relationship between HCBS intensity and community discharge was detected.

CONCLUSIONS

Higher Medicaid HCBS breadth but not intensity was associated with a greater likelihood of community discharge, and such relationship could be modified by individual factors and state policies.

Misclassification of Medicaid Participation by Dual Eligibles: Evidence From the Medicare Current Beneficiary Survey

Previous studies show that survey-based reports of Medicaid participation are measured with error, but no prior study has examined measurement error in an important segment of the Medicaid population-low-income adults enrolled in Medicare. Using the Medicare Current Beneficiary Survey, we examine whether respondent self-reports of Medicaid enrollment match administrative records and present several key findings. First, among low-income Medicare beneficiaries, the false negative rate is 11.5% when the self-report is interpreted as full Medicaid and 3.7% when the self-report is interpreted as full or partial Medicaid. Second, the likelihood of a false negative report is systematically associated with respondent traits. Third, systematic measurement error results in biased coefficient estimates in models of Medicaid participation defined from self-reports, and the bias is more significant when the researcher interprets self-reports as full Medicaid coverage only. Researchers should use caution when interpreting survey reports as pertaining to full Medicaid coverage only.

The Quality of Nursing Homes That Serve Patients With Human Immunodeficiency Virus

BACKGROUND/OBJECTIVES

As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long-term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes.

DESIGN

A cross-sectional comparative study.

SETTING

NHs in nine states, from 2001 to 2012.

PARTICIPANTS

A total of 46 918 NH-years accounting for 67 301 admissions by patients with HIV.

MEASUREMENTS

We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models.

RESULTS

After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P < .001), and a 0.4% percentage point higher 30-day rehospitalization rate (P < .01), compared to those with no HIV admissions. NHs with 5% to 50% of admissions with HIV had 7.0 more deficiencies (P < .001), a 0.1 lower star rating (P < .001), and a 1.5 percentage point higher rehospitalization rate (P < .001).

CONCLUSION

Persons with HIV were generally admitted to lower-quality NHs compared to persons without HIV. More efforts are needed to ensure that persons with HIV have access to high-quality NHs. J Am Geriatr Soc 67:2615-2621, 2019.

Barriers to a Timely Discharge From Short-Term Care in VA Community Living Centers

This study aimed to identify the barriers to a timely discharge from short-term care in Veterans Health Administration (VHA) Community Living Centers (CLCs). Ninety-nine interviews were conducted with CLC staff in leadership and direct-care positions in eight varied CLCs. Major themes identified through qualitative analysis as barriers to a timely discharge were a lack of patients' financial resources, low social support, and reluctance of some veterans and staff to view a timely veteran discharge as their goal. Staff also perceived that barriers were much more difficult to overcome in regions where community-based long-term services and supports were limited or nonexistent. Because VHA has lagged behind Medicaid more generally in terms of investment in these types of services, additional strategies are warranted to achieve the important policy goal of deinstitutionalizing VHA care and returning veterans to their homes in the community.

Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries

Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.

Measuring State Medicaid Home Care Participation and Intensity Using Latent Variables

Population aging and policies to redirect long-term care toward home- and community-based services have led to increases in Medicaid home care spending in most states. Changes in state Medicaid home care policy generosity may result from changes in the number of persons served (i.e., Participation) and/or changes in quantities of services covered (i.e., Intensity). This study measures state Medicaid home care Participation and Intensity comprehensively using latent variables, and uses those latent variables to describe changes in Medicaid home care policy generosity over time and across states. Yearly state-level data from the Medicaid Statistical Information System (1999-2012) are analyzed using exploratory and confirmatory factor analyses. Between 1999 and 2012, 29 states expanded both Participation and Intensity, whereas six states reduced both. In the remaining states, a trade-off occurred. Distinguishing between Medicaid home care Participation and Intensity deserves attention, as expansions along these two dimensions represent potentially different implications for beneficiaries.

Regional variation in racial disparities among patients with peripheral artery disease

OBJECTIVE

Prior studies identified significant racial disparities as well as regional variation in outcomes of patients with peripheral artery disease (PAD). We aimed to determine whether regional variation contributes to these racial disparities.

METHODS

We identified all white or black patients who underwent infrainguinal revascularization or amputation in 15 deidentified regions of the Vascular Quality Initiative between 2003 and 2017. We excluded three regions with <100 procedures. We used multivariable linear regression, allowing clustering at the hospital level to calculate the marginal effects of race and region on adjusted 30-day mortality, major adverse limb events (MALEs), and amputation. We compared long-term outcomes between black and white patients within each region and within patients of each race treated in different regions using multivariable Cox regression.

RESULTS

We identified 90,418 patients, 15,527 (17%) of whom were black. Patients underwent 31,263 bypasses, 52,462 endovascular interventions, and 6693 amputations. Black patients were younger and less likely to smoke, to have coronary artery disease, or to have chronic obstructive pulmonary disease, but they were more likely to have diabetes, limb-threatening ischemia, dialysis dependence, and hypertension and to be self-insured or on Medicaid (all P < .05). Adjusted 30-day mortality ranged from 1.2% to 2.1% across regions for white patients and 0% to 3.0% for black patients; adjusted 30-day MALE varied from 4.0% to 8.3% for white patients and 2.4% to 8.1% for black patients; and adjusted 30-day amputation rates varied from 0.3% to 1.2% for white patients and 0% to 2.1% for black patients. Black patients experienced significantly different (both higher and lower) adjusted rates of 30-day mortality and amputation than white patients did in several regions (P < .05) but not MALEs. In addition, within each racial group, we found significant variation in the adjusted rates of all outcomes between regions (all P < .01). In adjusted analyses, compared with white patients, black patients experienced consistently lower long-term mortality (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73-0.88; P < .001) and higher rates of MALEs (HR, 1.15; 95% CI, 1.06-1.25; P < .001) and amputation (HR, 1.33; 95% CI, 1.18-1.51; P < .001), with no statistically significant variation across the regions. However, rates of all long-term outcomes varied within both racial groups across regions.

CONCLUSIONS

Significant racial disparities exist in outcomes after lower extremity procedures in patients with PAD, with regional variation contributing to perioperative but not long-term outcome disparities. Underperforming regions should use these data to generate quality improvement projects, as understanding the etiology of these disparities is critical to improving the care of all patients with PAD.

Racial Disparities in Health Service Utilization Among Medicare Fee-for-Service Beneficiaries Adjusting for Multiple Chronic Conditions

OBJECTIVE

To examine racial disparities in health services utilization in Hawaii among Medicare fee-for-service beneficiaries aged 65 years and above.

METHOD

All-cause utilization of inpatient, outpatient, emergency, home health agency, and skilled nursing facility admissions were investigated using 2012 Medicare data. For each type of service, multivariable logistic regression model was used to investigate racial disparities adjusting for sociodemographic factors and multiple chronic conditions.

RESULTS

Of the 84,212 beneficiaries, 27.8% were White, 27.4% were Asian, 27.3% were Pacific Islanders; 70.3% had two or more chronic conditions and 10.5% had six or more. Compared with Whites, all racial groups experienced underutilization across all types of services. As the number of chronic conditions increased, the utilization of inpatient, home health care, and skilled nursing facility dramatically increased.

DISCUSSION

Disparities persist among Asians and Pacific Islanders who encounter the problem of underutilization of various health services compared with Whites.

The Contribution of Skilled Nursing Facilities to Hospitals' Readmission Rate

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

We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge.

PRINCIPAL FINDINGS

Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR.

CONCLUSIONS

The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture

SUMMARY

This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound.

INTRODUCTION

This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture.

METHODS

This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics.

RESULTS

States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056).

CONCLUSIONS

Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

OBJECTIVES

Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes.

DESIGN

Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003-2009.

SETTING

The MCBS is a nationally representative survey of beneficiaries matched with claims data.

PARTICIPANTS

Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation.

INTERVENTION/EXPOSURE

Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics.

MEASUREMENTS

Hospital readmission during the PAC stay, return to community residence, and all-cause mortality.

RESULTS

Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21-7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39-1.92), and for-profit PAC ownership (1.43, 1.21-1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9% vs 8.6%, P < .001) and 100 days (39.9% vs 14.5%, P < .001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60-2.54; 100 days: OR 3.79, 95% CI 3.13-4.59).

CONCLUSIONS

Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.

Community Discharge of Nursing Home Residents: The Role of Facility Characteristics

OBJECTIVE

Using a socio-ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems.

DATA SOURCE

Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free-standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008.

STUDY DESIGN

Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community.

PRINCIPAL FINDINGS

Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay.

CONCLUSION

Short- and long-stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states.