Postacute Strategies Vary Widely, Lack Standards

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.

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.

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."

NYU Langone researchers recently revealed what happened to readmission rates when they changed the medical center's postacute care program for Medicare patients who had surgery for cardiac valve replacement, spinal fusion, or major joint replacement in the lower extremities.

Those three procedures are part of the Medicare bundled payment initiative that NYU Langone began participating in three years ago. Since the medical center would be at risk, it looked to control costs by diverting patients away from receiving postacute care at facilities. The rate of discharge to postacute care facilities decreased across all three categories.

It went from 70.5% to 21.1% among cardiac patients. For the orthopedic patients, the discharge rate decreased from 67.6% to 33.5%, and the spinal fusion patients' discharge rate fell to 29.8% from 40%.

"Our main worry was readmissions would go up," says Leora Horwitz, MD, associate professor of population health and director of the NYU Langone's Center for Healthcare Innovation and Delivery Science. Horwitz co-authored the study, which appears in January's issue of JAMA's Internal Medicine.

Instead, readmission rates remained stable for the patients who had cardiac valve replacement and spinal fusion surgeries; however, readmission rates for the orthopedic patients decreased significantly, from 8% to 5%.

"Joints were our biggest success," says Horwitz. "The orthopedic department took this on as a major project. They have implemented aggressive screening for smokers. They screen everyone for smoking before surgery because recovery is worse if you're a smoker. They won't take a smoker unless they go through smoking cessation program. They (patients) have to try to quit."

Horwitz also says that the orthopedic surgeons promote weight management, as well. The main lesson is that redirecting postacute care to a home-based setting is better for patients and hospitals as long as there is a comprehensive program in place that puts the patients' needs front and center.

"Patients receive postacute care as part of a comprehensive case program based on diagnosis, which in this case is TJR (total joint replacement)," says Joseph Zuckerman, MD, professor and chairman of the department of orthopaedic surgery at NYU Langone's Hospital for Joint Diseases. "This includes pre-op assessment to determine post-op needs so that each patient's needs are individualized."

There has been anecdotal evidence that 30-day readmission rates can fall when the postacute care is at an SNF, but more data points to home-based care as a better alternative.

"There's a lot of cost to the patient not being home," says Horwitz. "This study is important because the rate of postacute care use has skyrocketed and inpatient postacute care may not be as useful as we think it is."