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Postacute Strategies Vary Widely, Lack Standards

   January 21, 2016

Two studies point to the need for a more thoughtful approach to postacute care strategies because readmission rates are simply not improving for some patients.

Hospital and health systems navigating healthcare transformation have no doubt evaluated their approach to postacute care with the hope that its efficient use will help drive down costs. The problem is the lack of standards that exist in the postacute care space.

I've heard concerns from healthcare executives about the variation in quality among skilled nursing facilities, home health agencies, and long-term care hospitals. There is also wide variation in payments to postacute care providers.

Greg Sacks, MD

In last year's report to Congress, the Medicare Payment Advisory Commission (MedPAC) reported that per capita spending on postacute care varied more than any other Medicare-covered service. Yet, it remains one of the fastest-growing areas in healthcare. Between 2001 and 2012, MedPAC reported that it had more than doubled its payments to postacute care providers to $59 billion.

Transitions to Postacute Care

Those combinations of payment and quality variation overshadow the most important part of the postacute care equation—patients. Where is the most appropriate site of postacute care for them?

According to two new studies, it is not at an inpatient facility. UCLA researchers, in a new study published in Medical Care, found that postacute care at an inpatient facility was associated with shorter lengths of stay, but higher 30-day readmission rates.

"It's too big of a leap to say hospitals are sending patients home prematurely, but it points to a pattern," says Greg Sacks, MD, the study's lead investigator.

UCLA researchers analyzed Medicare claims, the local health information, and the American Hospital Association's annual surveys from 2005 to 2008. Out of 112,620 patients spread across 217 hospitals and 39 states, about 40% of patients were discharged to a postacute care setting.

According to the study, 18.6% were sent to inpatient facilities such as skilled nursing, rehab, and longterm care, while 19.9% received home health care.

Richard Iorio, MD

Sacks was surprised by the variability in how hospitals used postacute care. "The extent of the variation was the most surprising," he said. "We adjusted for almost every conceivable variable. We controlled for hospital and patient characteristics, and we looked at the number of postacute care facilities regionally. The most surprising finding was the magnitude of this variation."

Effect on Readmissions
The pattern that UCLA found—higher 30-day readmission rates are associated with postacute care at an inpatient facility—is one that orthopedic surgeons at NYU Langone Medical Center see, too.

"Readmission rates are double for patients who are discharged to postacute facilities rather than home," says Richard Iorio, MD, chief of adult reconstruction and professor of orthopaedic surgery at NYU Langone Medical Center's Hospital for Joint Diseases.

"This difference is seen even when the groups are stratified by medical comorbidities, and has been demonstrated in multiple studies. Going home is best for the patient."

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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