Placing Patients in the Right Care Setting Can Impact Outcomes
By Lisa RemingtonPresident and PublisherThe Remington Report
A recent study published in the Journal of the American Geriatrics Society examined the patterns of Medicare beneficiaries post-acute care transitions among assisted living (AL) residents and their outcomes in the first 30 and 60 days after hospital discharge.
The question: How can your organization impact care transitions and outcomes?
(See our recommendations at the end of this article)
The study used data from 2018 national claims and datasets of 104,497 Medicare beneficiaries residing in assisted living.
Referrals were based on hospital discharge status to skilled nursing facilities (SNF), home with home health care (HHC), home without HHC, and other settings.
Outcomes included 30-day and 60-day hospital readmissions, emergency department (ED) visits, long-stay care nursing home placement, and mortality.
The Most Common Care Patient Discharge Settings
- Skilled Nursing Facility (SNF) (40%)
- Home without Home Health Care (28%)
- Home with Home Health Care (17%)
- Other Care Setting (15%)
Discharge Patterns and Impact to Readmissions
Discharge to home without home health care, discharge to SNF had a lower likelihood of ED visits, hospital readmissions, and a higher likelihood of long-stay nursing home placement and mortality.
“Residents’ 30- and 60-day outcomes vary across these settings, depending on multiple characteristics of the individual, the assisted living community, the discharging hospital, and the region.”
Discharges home with home health care was associated with higher likelihood of hospital readmissions, but lower likelihood of long-stay nursing home placement than discharge home without home health care. These results were similar within the first 30 days and 60 days of hospital discharge.
AL residents who are discharged to different post-acute care settings tend to differ in 30-day and 60-day outcomes. At hospital discharge, clinicians and discharge planners should be provided information about the exact type and availability of services at AL to make the most appropriate discharge referrals for AL residents.
What Can We Learn From This Study?
- As the lead author Jinjiao Wang, PhD, RN wrote, “The results highlight the complexity of these post-acute care transitions, which not only must consider assisted living residents’ needs but also available beds.”
- The authors found that residents’ 30-and 60-day outcomes vary across these settings, depending on multiple characteristics of the individual, the assisted living community, the discharging hospital, and the region.
- Wang and colleagues explained hospital clinicians and discharge planners often are unfamiliar with the different services and target populations of assisted living communities and nursing homes
- Authors concluded, “At hospital discharge, clinicians and discharge planners should be provided information about the exact type and availability of services at assisted living to make the most appropriate discharge referrals for [those] residents.”
- Authors said recent reforms may affect post-acute care providers’ ability and willingness to offer certain care to patients.
What Can Your Organization Do to Impact Care Transitions and Outcomes
- Engage in team-based discharge planning.
- Evaluate clinical service lines that can treat higher acuity patients.
- Create/share a care plan at the onset of hospital admit.
- Engage with physicians to discuss best care setting.
- Analyze technology investments to treat higher acuity patients.
Lisa Remington is president and publisher of the Remington Report magazine and President of Remington’s Home Care Leadership Think Tank. She has worked with more than 10,000 organizations in both a consultancy role and an educator. Lisa monitors the complex key trends and forces of change to develop a correct strategic approach to de-risk decision-making and create sustainable futures across the healthcare continuum.