Readmissions Higher With Home Care Compared to SNF Care

The treatment intensity and 24-hour monitoring at skilled nursing facilities could drive lower readmission rates compared to home care.

The rate of readmissions for patients discharged to home health care is 5.6 percentage points higher than for patients discharged to skilled nursing facilities, new research shows.

For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital's readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.

In an article published recently in JAMA Internal Medicine, researchers examined data from more than 17 million hospitalizations, with 61.2% of patients discharged to a skilled nursing facility (SNF) and 38.8% discharged to home with home health care services.

The researchers found that "marginal patients"—individuals who could reasonably be discharged to either home health care or a SNF—had a higher rate of hospital readmission if they were discharged to home health care. The research team speculated that the disparity could be caused by two reasons.

"In providing institutional care, SNFs are able to provide 24-hour monitoring of patients, which may be effective at recognizing complications early and preventing unnecessary readmissions," the researchers wrote.

"Skilled nursing facilities are also able to provide a higher level of treatment intensity compared with home health care visits and can thus effectively treat patients who might require hospitalization if they were at home," they added.

Cost considerations
 

The researchers also found that Medicare reimbursement for home health care was significantly lower than SNF care.

While SNF care may be more effective in limiting readmissions, home health care is less costly for the Medicare program, the researchers wrote.

"The reduction in readmissions comes at a cost for Medicare, as institutional postacute care is associated with higher Medicare payments than is providing postacute care at home. Even after accounting for the lower costs from fewer readmissions from SNFs, the total amount paid by Medicare for hospitalizations and postacute care during the 60-day posthospital period is lower for patients discharged to home compared with those discharged to an SNF."

Medicare reimbursement rules could be a factor in the lower performance of home health care in preventing readmissions, the lead author of the research told HealthLeaders.

"Because of the payment rules for home health by Medicare, it limits the intensity of care that can be provided at home. For example, patients can receive one visit per day at most. More flexibility in the way home health care is delivered would allow more intensive services to be provided in the home, which could help prevent readmissions," said Rachel Werner, associate chief for research in the Division of General Internal Medicine at the University of Pennsylvania in Philadelphia.

Postacute care is a significant element of Medicare spending—pegged at more than $60 billion in 2015.

Reimbursement reforms and policies could be influencing patient discharge decisions.

For example, Medicare's Hospital Readmission Reduction Program, which features financial penalties for readmissions, could be encouraging hospitals to discharge patients to the SNF setting, Werner's research team wrote. "These incentives may push hospitals to favor the use of high-acuity settings such as SNFs, and our results suggest that this strategy may be effective at reducing readmissions."

Other payment models could encourage hospitals to discharge patients to the home health care setting, they wrote. "Alternative payment models such as accountable care organizations and bundled payments hold providers accountable for costs of care across settings and clinicians, an incentive that may push patients toward lower-cost care."