CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned.

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS: Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

COVID-19 Exacerbated Long-standing Challenges for the Home Care Workforce.

The purpose of this study was to understand staffing challenges faced by home care (including home health) agencies due to the COVID-19 pandemic and the policies and practices put into place by the federal government, state governments, and home care agencies themselves to mitigate these challenges. This study included a review of federal and state policy changes enacted in reaction to the pandemic from March through December 2020, a review of home care agency practices described in media reports, peer-reviewed literature, and gray literature focused on responses to workforce challenges encountered during the pandemic, and interviews with a variety of stakeholders. Some of the challenges encountered were entirely new and resulted directly from the pandemic. In other cases, the pandemic worsened long-standing challenges in the industry. States and the federal government addressed some of these issues through changes to policies, regulations, and guidance. Home care agencies also responded with changes to their own policies and practices.

Reducing Hospitalizations Among Nursing Facility Residents: Policy Environment and Suggestions for the Future in Seven States.

The current study examined the policy and market context existing in the seven states where the Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents took place. Stakeholder organizations with knowledge of the skilled nursing facility environment but who were not directly involved with the CMS Initiative were interviewed to assess the impact of policies and programs affecting transfers to the hospital from long-term care facilities. Focused interviews were used to identify areas of quality improvement as well as market forces that contributed to hospitalization rates. Interviews were qualitatively coded and emerging patterns and themes were identified. Market pressures were similar across states. Few policies were found that may have affected the Initiative, but most states had regional coalitions focused on improving some aspect of care. When asked what else could be done to reduce hospitalizations among nursing facility residents, participants across the stakeholder organizations suggested greater presence of physicians and nurse practitioners in nursing facilities, better training around behavioral health issues for frontline staff, and more advance care planning and education for families regarding end of life. [Journal of Gerontological Nursing, 48(8), 10-16.].

Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City.

BACKGROUND: Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home. PURPOSE: Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems. METHODS: Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems. RESULTS: Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017. CONCLUSION: As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.

Barriers to a Timely Discharge From Short-Term Care in VA Community Living Centers.

This study aimed to identify the barriers to a timely discharge from short-term care in Veterans Health Administration (VHA) Community Living Centers (CLCs). Ninety-nine interviews were conducted with CLC staff in leadership and direct-care positions in eight varied CLCs. Major themes identified through qualitative analysis as barriers to a timely discharge were a lack of patients' financial resources, low social support, and reluctance of some veterans and staff to view a timely veteran discharge as their goal. Staff also perceived that barriers were much more difficult to overcome in regions where community-based long-term services and supports were limited or nonexistent. Because VHA has lagged behind Medicaid more generally in terms of investment in these types of services, additional strategies are warranted to achieve the important policy goal of deinstitutionalizing VHA care and returning veterans to their homes in the community.

Strategy and risk sharing in hospital-postacute care integration.

ISSUE/TREND: Postacute care has been identified as a primary area for cost containment. The continued shift of payment structures from volume to value has often put hospitals at the forefront of addressing postacute care cost containment. However, hospitals continue to struggle with models to manage patients in postacute care institutions, such as skilled nursing facilities or in home health agencies. Recent research has identified postacute care network development as one mechanism to improve outcomes for patients sent to postacute care providers. Many hospitals, though, have not utilized this strategy for fear of not adhering to Centers for Medicare & Medicaid Services requirements that patients are given choice when discharged to postacute care. MANAGERIAL APPROACH: A hospital's approach to postacute care integration will be dictated by environmental uncertainty and the level of embeddedness hospitals have with potential postacute care partners. Hospitals, though, must also consider how and when to extend shared savings to postacute care partners, which will be based on the complexity of the risk-sharing calculation, the ability to maintain network flexibility, and the potential benefits of preserving competition and innovation among the network members. For hospital leaders, postacute care network development should include a robust and transparent data management process, start with an embedded network that maintains network design flexibility, and include a care management approach that includes patient-level coordination. CONCLUSION: The design of care management models could benefit from elevating the role of postacute care providers in the current array of risk-based payment models, and these providers should consider developing deeper relationships with select postacute care providers to achieve cost containment.

Choosing the Best and Scrambling for the Rest: Hospital-Nursing Home Relationships and Admissions to Post-Acute Care.

OBJECTIVE: We explored post-Affordable Care Act hospital and skilled nursing facility (SNF) perspectives in discharge and admission practices. METHOD: Interviews were conducted with 138 administrative personnel in 16 hospitals and 25 SNFs in eight U.S. markets and qualitatively analyzed. RESULTS: Hospitals may use prior referral rates and patients' geographic proximity to SNFs to guide discharges. SNFs with higher hospital referral rates often use licensed nurses to screen patients to admit more preferred patients. While SNFs with lower hospital referral rates use marketing strategies to increase admissions, these patients are often less preferred due to lower reimbursement or complex care needs. CONCLUSION: An unintended consequence of increased hospital-SNF integration may be greater disparity. SNFs with high hospital referral rates may admit well-reimbursed or less medically complex patients than SNFs with lower referral rates. Without policy remediation, SNFs with lower referral rates may thus care for more medically complex long-term care patients.

Staff-perceived Conflict between Resident-centered Care and Quality in the Skilled Nursing Facility: Are Both Possible?

OBJECTIVES: The purpose of this study was to understand if and how Veterans Affairs (VA) nursing home (CLC) staff experience difficulty in providing care that is both resident-centered (RCC) and concordant with quality standards. METHODS: Twelve VA CLCs were selected for site visits, stratified based on rankings on a composite quality measure (calculated from various indicators) and resident-centered care (RCC) progress (based on a culture change tool). Staff were interviewed about efforts and barriers to achieving goals in RCC and quality, and the interview transcripts systematically analyzed for themes. RESULTS: We interviewed 141 participants, including senior leaders, middle managers, and front-line staff. An emergent theme was conflict between RCC and quality, although participants varied in their perceptions of its impact. Participants perceived three conflict types: 1) between resident preferences and medically indicated actions; 2) between resident preferences and the needs or safety of others; and 3) limits of staff time or authority. CONCLUSIONS: CLC staff perceive conflicts between RCC and care consistent with quality imperatives. CLINICAL IMPLICATIONS: Variation in perceived RCC-quality conflicts suggests that policy clarifications and additional training may provide guidance in dealing with such dilemmas. It may be prudent to clearly communicate to what boundaries exist to RCC in the evolving CLC environment.

Collaborative capacity and patient-centered care in the Veterans' Health Administration Community Living Centers.

INTRODUCTION: Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. METHODS: We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. RESULTS: A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration-measured as task interdependence, quality of interactions and collaborative influence-did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. DISCUSSION: Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility.

OBJECTIVE: This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff. DESIGN: We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process. PARTICIPANTS: Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets. APPROACH: Interviews were qualitatively analyzed to identify overarching themes. KEY RESULTS: Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown. CONCLUSIONS: Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

Medicare Advantage control of postacute costs: perspectives from stakeholders.

OBJECTIVES: Medicare Advantage (MA) plans have strong incentives to control costs, including postacute spending; however, to our knowledge, no research has examined the methods that MA plans use to control or reduce postacute costs. This study aimed to understand such MA plan efforts and the possible unintended consequences. STUDY DESIGN: A multiple case study method was used. METHODS: We conducted 154 interviews with administrative and clinical staff working in 10 MA plans, 16 hospitals, and 25 skilled nursing facilities (SNFs) in 8 geographically diverse markets across the United States. RESULTS: Participants discussed how MA plans attempted to reduce postacute care spending by controlling the SNF to which patients are discharged and SNF length of stay (LOS). Plans typically influenced SNF selection by providing patients with a list of facilities in which their care would be covered. To influence LOS, MA plans most commonly authorized patient stays in SNFs for a certain number of days and required that SNFs adhere to this limitation, but they did not provide guidance or assistance in ensuring that the LOS goals were met. Hospital and SNF responses to the largely authorization-based system were frequently negative, and participants expressed concerns about potential unintended consequences. CONCLUSIONS: In their interactions with hospitals and SNFs, MA plans attempted to influence the choice of SNF and LOS to control postacute spending. However, exerting too much influence over hospitals and SNFs, as these results seem to indicate, may have the negative consequences of delayed hospital discharge and SNFs' avoidance of burdensome plans.

The Prevalence of Culture Change Practice in US Nursing Homes: Findings From a 2016/2017 Nationwide Survey.

BACKGROUND AND OBJECTIVES: Given the dynamic nursing home (NH) industry and evolving regulatory environment, depiction of contemporary NH culture-change (person/resident-centered) care practice is of interest. Thus, we aimed to portray the 2016/2017 prevalence of NH culture change-related processes and structures and to identify factors associated with greater practice prevalence. RESEARCH DESIGN AND METHODS: We administered a nationwide survey to 2142 NH Administrators at NHs previously responding to a 2009/2010 survey. Seventy-four percent of administrators (1583) responded (with no detectable nonresponse bias) enabling us to generalize (weighted) findings to US NHs. From responses, we created index scores for practice domains of resident-centered care, staff empowerment, physical environment, leadership, and family and community engagement. Facility-level covariate data came from the survey and the Certification and Survey Provider Enhanced Reporting system. Ordered logistic regression identified the factors associated with higher index scores. RESULTS: Eighty-eight percent of administrators reported some facility-level involvement in NH culture change, with higher reported involvement consistently associated with higher domain index scores. NHs performed the best (82.6/100 weighted points) on the standardized resident-centered care practices index, and had the lowest scores (54.8) on the family and community engagement index. Multivariable results indicate higher index scores in NHs with higher leadership scores and in states having Medicaid pay-for-performance with culture change-related quality measures. CONCLUSIONS: The relatively higher resident-centered care scores (compared with other domain scores) suggest an emphasis on person-centered care in many US NHs. Findings also support pay-for-performance as a potential mechanism to incentivize preferred NH practice.

Hospital-Skilled Nursing Facility Collaboration: A Mixed-Methods Approach to Understanding the Effect of Linkage Strategies.

OBJECTIVE: To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes. DATA SOURCES/STUDY SETTING: Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015. STUDY DESIGN/DATA COLLECTION: Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared. PRINCIPAL FINDINGS: Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals. CONCLUSIONS: Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.

Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

The purpose of this research was to explore and compare common health system factors for 5 Community Living Centers (ie Veterans Health Administration nursing homes) with high performance on both resident-centered care and clinical quality and for 5 Community Living Centers (CLC) with low performance on both resident-centered care and quality. In particular, we were interested in "how" and "why" some Community Living Centers were able to deliver high levels of resident-centered care and high quality of care, whereas others did not demonstrate this ability. Sites were identified based on their rankings on a composite quality measure calculated from 28 Minimum Data Set version 2.0 quality indicators and a resident-centered care summary score calculated from 6 domains of the Artifacts of Culture Change Tool. Data were from fiscal years 2009-2012. We selected high- and low-performing sites on quality and resident-centered care and conducted 12 in-person site visits in 2014-2015. We used systematic content analysis to code interview transcripts for a priori and emergent health system factor domains. We then assessed variations in these domains across high and low performers using cross-site summaries and matrixes. Our final sample included 108 staff members at 10 Veterans Health Administration CLCs. Staff members included senior leaders, middle managers, and frontline employees. Of the health system factors identified, high and low performers varied in 5 domains, including leadership support, organizational culture, teamwork and communication, resident-centered care recognition and awards, and resident-centered care training. Organizations must recognize that making improvements in the factors identified in this article will require dedicated resources from leaders and support from staff throughout the organization.

Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay.

OBJECTIVE: To identify the challenges that reductions in length of stay (LOS) pose for skilled nursing facilities (SNFs) and their postacute care (PAC) patients. DATA SOURCES/SETTING: Seventy interviews with staff in 25 SNFs in eight U.S. cities, LOS data for patients in those SNFs. STUDY DESIGN: Data were qualitatively analyzed, and key themes were identified. Interview data from SNFs with and without reductions in median risk-adjusted LOS were compared and contrasted. DATA COLLECTION/EXTRACTION METHODS: We conducted 70 semistructured interviews. LOS data were derived from minimum dataset (MDS) admission records available for all patients in all U.S. SNFs from 2012 to 2014. PRINCIPAL FINDINGS: Challenges reported regardless of reductions in LOS included frequent and more complicated re-authorization processes, patients becoming responsible for costs, and discharging patients whom staff felt were unsafe at home. Challenges related to reduced LOS included SNFs being pressured to discharge patients within certain time limits. Some SNFs reported instituting programs and processes for following up with patients after discharge. These programs helped alleviate concerns about patients, but they resulted in nonreimbursable costs for facilities. CONCLUSIONS: The push for shorter LOS has resulted in unexpected challenges and costs for SNFs and possible unintended consequences for PAC patients.

Staff Empowerment Practices and CNA Retention: Findings From a Nationally Representative Nursing Home Culture Change Survey.

This article examines whether staff empowerment practices common to nursing home culture change are associated with certified nursing assistant (CNA) retention. Data from 2,034 nursing home administrators from a 2009/2010 national nursing home survey and ordered logistic regression were used. After adjustment for covariates, a greater staff empowerment practice score was positively associated with greater retention. Compared with the low empowerment category, nursing homes with scores in the medium category had a 44% greater likelihood of having higher CNA retention (odds ratio [OR] = 1.44; 95% confidence interval [CI] = [1.15, 1.81], p = .001) and those with high empowerment scores had a 64% greater likelihood of having higher CNA retention (OR = 1.64; 95% CI = [1.34, 2.00], p < 001). Greater opportunities for CNA empowerment are associated with longer CNA retention. This research suggests that staffing empowerment practices on the whole are worthwhile from the CNA staffing stability perspective.

Reducing Hospital Readmissions Through Preferred Networks Of Skilled Nursing Facilities.

Establishing preferred provider networks of skilled nursing facilities (SNFs) is one approach hospital administrators are using to reduce excess thirty-day readmissions and avoid Medicare penalties or to reduce beneficiaries' costs as part of value-based payment models. However, hospitals are also required to provide patients at discharge with a list of Medicare-eligible providers and cannot explicitly restrict patient choice. This requirement complicates the development of a SNF network. Furthermore, there is little evidence about the effectiveness of network development in reducing readmission rates. We used a concurrent mixed-methods approach, combining Medicare claims data for the period 2009-13 with qualitative data gathered from interviews during site visits to hospitals in eight US markets in March-October 2015, to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal SNF networks. Four hospitals had developed formal SNF networks as part of their care management efforts. These hospitals saw a relative reduction from 2009 to 2013 in readmission rates for patients discharged to SNFs that was 4.5 percentage points greater than the reduction for hospitals without formal networks. Interviews revealed that those with networks expanded existing relationships with SNFs, effectively managed patient data, and exercised a looser interpretation of patient choice.

Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals.

Hospitals are now being held at least partly accountable for Medicare patients' care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities' quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients' choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care.

A growing number of healthcare organizations have moved from traditional, institutional nursing home models to ones that emphasize culture change, or resident-centered care (RCC). In 2006, the Department of Veterans Affairs (VA) began implementing a number of changes to VA nursing homes, now called Community Living Centers (CLCs), to provide veterans with a more resident-centered and homelike environment. This study aimed to understand the barriers CLC staff face when delivering RCC. Ten CLCs were included on the basis of their performance levels on RCC and quality of care. Semistructured interviews that focused on facility efforts in RCC and quality were conducted with all levels of staff. Interviews were systematically content coded. We found similarities and differences in barriers reported at high- and low-performing sites. Staff across all performance levels cited 5 main categories of barriers to delivering RCC: staffing, resources, acuity of residents, RCC and quality of care conflicts, and regulations. Staff in high-performing sites reported fewer barriers to RCC, although 1 barrier cited was difficulty coordinating RCC across departments. Staff in low-performing sites reported additional categories of barriers related to administrator turnover/lack of guidance, CLC culture/staff morale, and difficulty working with residents and families. As RCC continues to spread, it is important to anticipate the barriers to implementing these practices. Particular focus on regulatory, leadership, organizational, workforce, and process factors may help organizations avoid or reduce barriers to RCC. Given their training and skill set, mental health providers may be uniquely situated to assist staff in overcoming these barriers. (PsycINFO Database Record