Are rehospitalization rates increasing for Medicare beneficiaries who were discharged from the hospital to a skilled nursing facility?
Hospital readmission rates for Medicare beneficiaries receiving short-term care in skilled nursing facilities increased from 1999 to 2002 across five potentially preventable conditions.
Why is this important?
Following a hospital stay, some individuals require short-term skilled nursing care or daily rehabilitation services in a skilled nursing facility (SNF) before returning home. Medicare pays for up to 100 days of such "subacute" care for elderly and disabled beneficiaries who have been hospitalized for at least three days.
About 25 percent of Medicare SNF residents are readmitted to the hospital (MedPAC 2006a). Although hospitalizations are often medically necessary, expert evaluation suggests that 28 percent to 40 percent of such admissions might be avoided with high-quality SNF care (MedPAC 2006a; Saliba et al. 2000).
For example, hospitalizations for conditions such as electrolyte imbalance, congestive heart failure, and infections might be avoided through good nursing care to ensure adequate nutrition and fluid intake, preventive measures such as vaccinations and infection control, early identification of the signs and symptoms of medical problems, and timely communication and follow-up with physicians (Kramer and Fish 2001).
Among short-stay Medicare residents in SNFs, rates of hospital readmission increased from 1999 to 2002 for five conditions for which hospitalization might be avoided with good-quality care. The increase ranged from 0.1 to 0.5 percentage points in absolute terms, or 7 percent to 16 percent in relative terms (MedPAC 2006a).
With 2.4 million Medicare beneficiaries admitted to SNFs in 2002, hospitalization rates for the five potentially preventable conditions shown in the chart represent a quality concern with significant cost implications. Furthermore, given the increasing number of Medicare patients receiving SNF care, even small increases in hospitalization rates translates to thousands of additional hospital admissions.
Improvement Ideas and Resources
Research sponsored by the federal government found that hospitalization rates were lower among short-stay patients in SNFs that provided a minimum of 2.4 hours of care by nursing aides and 1.15 hours of care by licensed nurses (including 0.55 hours by registered nurses) per resident per day (Abt Associates 2001). Although increased SNF staffing would not be cost-effective solely to reduce rehospitalizations for these five conditions (except in facilities with high hospitalization rates), it might be justified to support wider improvements in quality of care and residents' quality of life (Ganz et al. 2005).
Case studies suggest that nursing facilities can improve quality of care by addressing other pertinent workforce issues such as staff retention, the allocation of personnel among units and shifts, the level of staff knowledge and training, how staff are supervised, and how SNFs are managed (Abt Associates 2001). In particular, many nursing staff need training to develop skills for recognizing and interpreting patient symptoms that might lead to hospitalization and for effectively interacting with cognitively impaired patients (Louwe and Kramer 2001).
The denominator for each condition includes the total number of Medicare admissions to SNFs during the year indicated. The numerator is the subset of the denominator population admitted to the hospital within 30 days for the condition indicated, which could be listed as either the primary or secondary diagnosis for hospitalization. Rates were adjusted to control for diagnosis and functional severity of patients (Kramer and Fish 2001).
The rates shown in the chart cannot be added because some patients may have been admitted for more than one condition. Other valid measures are needed to assess the quality of subacute care, such as changes in outcomes from SNF admission to discharge and the degree to which staff follow guidelines or best practices in caring for short-stay patients (MedPAC 2006b).
Staff of the Medicare Payment Advisory Commission (MedPAC 2006b) compiled these data from the Medicare skilled nursing facility stay file using methods developed by Kramer and Fish (2001).
* Indicates source of data used in the chart(s).Abt Associates. 2001. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Cambridge, Mass.: Abt Associates for the Centers for Medicare and Medicaid Services.
Feuerberg, M. 2001. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Overview of the Phase II Report: Background, Study Approach, Findings, and Conclusion. Baltimore, Md.: Centers for Medicare and Medicaid Services.
Ganz, D. A., S. F. Simmons, and J. F. Schnelle. 2005. Cost-Effectiveness of Recommended Nurse Staffing Levels for Short-Stay Skilled Nursing Facility Patients. BMC Health Services Research 5 (1): 35.
Kramer, A. M., and R. Fish. 2001. The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care. In Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Cambridge, Mass.: Abt Associates for the Centers and Medicare and Medicaid Services.
Louwe, H., and A. M. Kramer. 2001. Case Studies of Nursing Facility Staffing Issues and Quality of Care. In Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Cambridge, Mass.: Abt Associates for the Centers for Medicare and Medicaid Services.
* MedPAC (Medicare Payment Advisory Commission). 2006a. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Commission.
MedPAC (Medicare Payment Advisory Commission). 2006b. Report to the Congress: Increasing the Value of Medicare. Washington, D.C.: Medicare Payment Advisory Commission.
Saliba, D., R. Kington, J. Buchanan et al. 2000. Appropriateness of the Decision to Transfer Nursing Facility Residents to the Hospital. Journal of the American Geriatrics Society 48 (2): 15463.