Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

GENERAL PURPOSE: To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Linking AM-PAC Cognition to PROMIS Cognitive Function.

OBJECTIVE: To link the Activity Measure for Post-Acute Care (AM-PAC) Applied Cognition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function, allowing for a common metric across scales. DESIGN: Cross-sectional survey study. SETTING: Outpatient rehabilitation clinics. PARTICIPANTS: Consecutive sample of 500 participants (N=500) aged ≥18 years presenting for outpatient therapy (physical, occupation, speech). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: AM-PAC Medicare and Generic Cognition short forms and PROMIS Cognitive Function items representing the PROMIS Cognitive Function item bank. RESULTS: The calibration of 25 AM-PAC cognition items with 11 fixed PROMIS cognitive function item parameters using item-response theory indicated that items were measuring the same underlying construct (cognition). Both scales measured a wide range of functioning. The AM-PAC Generic Cognitive assessment showed more reliability with lower levels of cognition, whereas the PROMIS Cognitive Function full-item bank was more reliable across a larger distribution of scores. Data were appropriate for a fixed-anchor item response theory-based crosswalk and AM-PAC Cognition raw scores were mapped onto the PROMIS metric. CONCLUSIONS: The crosswalk developed in this study allows for converting scores from the AM-PAC Applied Cognition to the PROMIS Cognitive Function scale.

Post-COVID-19 Syndrome: Theoretical Basis, Identification, and Management.

As COVID-19 continues to spread, with the United States surpassing 29 million cases, health care workers are beginning to see patients who have been infected with SARS-CoV-2 return seeking treatment for its longer-term physical and mental effects. The term long-haulers is used to identify patients who have not fully recovered from the illness after weeks or months. Although the acute symptoms of COVID-19 have been widely described, the longer-term effects are less well known because of the relatively short history of the pandemic. Symptoms may be due to persistent chronic inflammation (eg, fatigue), sequelae of organ damage (eg, pulmonary fibrosis, chronic kidney disease), and hospitalization and social isolation (eg, muscle wasting, malnutrition). Health care providers are instrumental in developing a comprehensive plan for identifying and managing post-COVID-19 complications. This article addresses the possible etiology of postviral syndromes and describes reported symptoms and suggested management of post-COVID syndrome.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission.

BACKGROUND: Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS: We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS: Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION: Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

The Cost of Implementing and Sustaining the COMprehensive Post-Acute Stroke Services Model.

BACKGROUND: The COMprehensive Post-Acute Stroke Services (COMPASS) model, a transitional care intervention for stroke patients discharged home, was tested against status quo postacute stroke care in a cluster-randomized trial in 40 hospitals in North Carolina. This study examined the hospital-level costs associated with implementing and sustaining COMPASS. METHODS: Using an activity-based costing survey, we estimated hospital-level resource costs spent on COMPASS-related activities during approximately 1 year. We identified hospitals that were actively engaged in COMPASS during the year before the survey and collected resource cost estimates from 22 hospitals. We used median wage data from the Bureau of Labor Statistics and COMPASS enrollment data to estimate the hospital-level costs per COMPASS enrollee. RESULTS: Between November 2017 and March 2019, 1582 patients received the COMPASS intervention across the 22 hospitals included in this analysis. Average annual hospital-level COMPASS costs were $2861 per patient (25th percentile: $735; 75th percentile: $3,475). Having 10% higher stroke patient volume was associated with 5.1% lower COMPASS costs per patient (P=0.016). About half (N=10) of hospitals reported postacute clinic visits as their highest-cost activity, while a third (N=7) reported case ascertainment (ie, identifying eligible patients) as their highest-cost activity. CONCLUSIONS: We found that the costs of implementing COMPASS varied across hospitals. On average, hospitals with higher stroke volume and higher enrollment reported lower costs per patient. Based on average costs of COMPASS and readmissions for stroke patients, COMPASS could lower net costs if the model is able to prevent about 6 readmissions per year.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients.

IMPORTANCE: The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE: To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES: Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS: The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS: The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Combining Items From 3 Federally Mandated Assessments Using Rasch Measurement to Reliably Measure Cognition Across Postacute Care Settings.

OBJECTIVE: To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery. DESIGN: Rasch analysis of data from a prospective, observational cohort study. SETTING: Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies. PARTICIPANTS: Patients (N=147) receiving rehabilitation services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional Independence Measure, MDS 2.0, and the OASIS-B. RESULTS: Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge. CONCLUSIONS: This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Post-Intensive Care Unit Follow-up of Pulmonary Embolism.

The post-intensive care unit follow-up of patients hospitalized with pulmonary embolism is crucial to the comprehensive care of these patients. This article discusses the recommended duration of intensive care unit stay after high-intermediate risk or high-risk pulmonary embolism, duration of anticoagulation after venous thromboembolism event, retrieval of inferior vena cava filters, post-hospitalization follow-up and assessment of right ventricular function, and assessment for chronic thromboembolic pulmonary hypertension, chronic thromboembolic disease, and post-pulmonary embolism syndrome.

Identifying and Bridging the Gaps in Antimicrobial Stewardship in Post-Acute and Long-Term Care.

National organizations have developed guidelines and tools for antimicrobial stewardship (AMS) in post-acute and long-term care (PALTC), but there is a need to effectively translate these into actionable, measurable, and impactful programs. An electronic needs assessment survey was developed and distributed to health care providers and administrators involved with AMS activities in PALTC facilities in Maryland. The results of this survey were used to develop a statewide initiative to improve AMS in nursing facilities. The survey revealed that barriers to implementing AMS include limited access or poor utilization of experts in AMS and infectious disease, adverse event data collection tools, and locally developed protocols and guidelines. Strategies to improve AMS included the provision of free continuing education to a multidisciplinary audience and improved access to individuals with expertise in infectious disease and the development of an adverse drug event tool. Continuing to provide meaningful tools and resources that address the specific needs of nursing facilities should lead to improved compliance with regulations and ultimately improved resident outcomes. [Journal of Gerontological Nursing, 46(1), 8-13.].

Variation in Facility-Level Rates of All-Cause and Potentially Preventable 30-Day Hospital Readmissions Among Medicare Fee-for-Service Beneficiaries After Discharge From Postacute Inpatient Rehabilitation.

Importance: The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries. Objective: To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation. Design, Setting, and Participants: This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019. Main Outcomes and Measures: All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates. Results: Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate. Conclusions and Relevance: This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.

Partnering in postacute darkness? CMS has data that will help.

Health systems will improve postacute outcomes when CMS begins sharing its performance data on nursing facility chains.

Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives.

OBJECTIVE: To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs. METHODS: Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine's THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data. RESULTS: Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs-new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU-former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them-clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician's own understanding of patient experience-there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work-this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes. CONCLUSIONS: The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area.

The Bundled Hospital Elder Life Program-HELP and HELP in Home Care-and Its Association With Clinical Outcomes Among Older Adults Discharged to Home Healthcare.

OBJECTIVES: To describe the Bundled Hospital Elder Life Program (HELP and HELP in Home Care), an adaptation of HELP, and examine the association of 30-day all-cause unplanned hospital readmission risk among older adults discharged to home care with and without Bundled HELP. DESIGN: Matched case-control study. SETTING: Two medical-surgical units within two midwestern rural hospitals and patient homes (home health). PARTICIPANTS: Hospitalized patients, aged 65 years and older, discharged to home healthcare with and without Bundled HELP exposure between January 1, 2015, and September 30, 2017. Each case (Bundled HELP, n = 148) was matched to a control (non-Bundled HELP, n = 148) on Charlson Comorbidity Index, primary hospital diagnosis of orthopedic condition or injury, and cardiovascular disease using propensity score matching. MEASUREMENTS: The primary study outcome was 30-day all-cause unplanned hospital readmission. Additional outcomes measured were 30-day emergency department (ED) visit, hospital length of stay (LOS), and total number of skilled home care visits. RESULTS: Fewer cases (16.8%) than controls (28.4%) had a 30-day all-cause unplanned hospital readmission. The fully adjusted model showed significantly lower risk of 30-day hospital readmission for case (Bundled HELP) patients (0.41; 95% confidence interval = 0.22-0.77; P < .01). The difference between case (10.8%) and control (15.5%) 30-day ED visit was not significant (P = .23). A lower LOS for the case group was shown (P < .01), while the number of skilled home care visits was not significantly different between groups (P = .28). CONCLUSION: HELP protocol implementation during a patient's hospital stay and as a continued component of home care among older adults at risk for cognitive and/or functional decline appears to be associated with favorable outcomes. Our initial evaluation supports continued study of the Bundled HELP. Further research is needed to confirm the initial findings and to evaluate the impact of the adapted model on functional outcomes and delirium incidence in the home. J Am Geriatr Soc 67:1730-1736, 2019.

The Effect of Patient-Controlled Oral Analgesia for Acute Abdominal Pain after Discharge.

BACKGROUND: During hospitalization, patients who were admitted with acute abdominal pain must be prepared to care for themselves at home after discharge to continue established treatment, promote recovery, and avoid readmission. AIMS: Our aim was to investigate the quality of pain management after discharge, when patient-controlled oral analgesia was compared with standard care for patients admitted to hospital with acute abdominal pain. The primary outcome measures were pain intensity and patient perception of care. The secondary outcome measures were pain interference with activity, affective experiences, side effects, and use of analgesics. DESIGN: A questionnaire study measuring the effect of an intervention on patient-controlled oral analgesics. SETTINGS: An emergency department and a surgical department in Denmark. PARTICIPANTS: Patients admitted to hospital with acute abdominal pain. METHODS: A pre- and postintervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected using a Danish modified Revised American Pain Society Patient Outcome Questionnaire with five subscales (scale 0-10) completed in weeks 1 and 4 after discharge. RESULTS: In total, 117 patients were included. The median scores at week 1 and week 4 in the control and intervention groups were, respectively, 2/1 and 1/0 on the pain subscale (p = .11/.16), 3/0 and 3/0 on the activity subscale (p = .19/.80), 1/0 and 0/0 on the emotional subscale (p = .02/.72), 1/0 and 1/0 on the side effect subscale (p = .95/.99), and 8/5 and 7/7 on the patient perception subscale (p = .35/.49). There was no significant difference in the use of analgesics at week 1. CONCLUSIONS: Patient-controlled oral analgesia during the hospital stay did not improve the quality of pain management after discharge.

Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection.

BACKGROUND: Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home. OBJECTIVE: We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection. DESIGN: This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns. SETTINGS: Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals. PATIENTS: Patients undergoing colon and rectal resections were included. MAIN OUTCOME MEASURE: The main outcome measure was hospital use patterns of nonhome discharge. RESULTS: Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045). LIMITATIONS: This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size. CONCLUSIONS: This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Black and Hispanic Patients.

BACKGROUND: Understanding and addressing racial and ethnic disparities in the quality of post-acute care in skilled nursing facilities is an important health policy issue, particularly as the Medicare program initiates value-based payments for these institutions. METHODS: Our final cohort included 649,187 Medicare beneficiaries in either the fee-for-service or Medicare Advantage programs, who were 65 and older and were admitted to a skilled nursing facility following an acute hospital stay, from 8,375 skilled nursing facilities. We examined the quality of care in skilled nursing facilities that disproportionately serve minority patients compared to non-Hispanic whites. Three measures, all calculated at the level of the facility, were used to assess quality of care in skilled nursing facilities: (a) 30-day rehospitalization rate; (b) successful discharge from the facility to the community; and (c) Medicare five-star quality ratings. RESULTS: We found that African American post-acute patients are highly concentrated in a small number of institutions, with 28% of facilities accounting for 80% of all post-acute admissions for African American patients. Similarly, just 20% of facilities accounted for 80% of all admissions for Hispanics. Skilled nursing facilities with higher fractions of African American patients had worse performance for three publicly reported quality measures: rehospitalization, successful discharge to the community, and the star rating indicator. CONCLUSIONS: Efforts to address disparities should focus attention on institutions that disproportionately serve minority patients and monitor unintended consequences of value-based payments to skilled nursing facilities.

The Five-Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations.

OBJECTIVES: To examine characteristics and locations of high- and low-quality skilled nursing facilities (SNFs) and whether certain vulnerable individuals were differentially discharged to facilities with lower quality ratings. DESIGN: Retrospective observational study. SETTING: Medicare-certified SNFs providing postacute care. PARTICIPANTS: SNF stays (N=1,195,166) of Medicare beneficiaries aged 65 and older admitted to 14,033 SNFs within 2 days of hospital discharge. MEASUREMENTS: We used Medicare claims from October 2013 to September 2014 and SNF 5-star ratings published on Nursing Home Compare. We describe the characteristics and populations of facilities according to quality, and the location of low (1 star) and high (5 stars) quality facilities. We used logistic regression models to estimate odds of admission to a low-quality facility after hospital discharge according to race, ethnicity, dual Medicare-Medicaid enrollment, functional status, discharge from a safety-net or low-quality hospital, and residence in a county with more low-quality SNFs. RESULTS: More than one-fifth (22.2%) of the facilities had a 5-star (high quality) rating, and 15.9% had a one-star (low quality) rating. Low-quality facilities were more likely to be in the south (44%), for profit (85%), and larger (>70 beds (86%)). Dual enrollment was the strongest predictor of admission to a 1-star facility (odds ratio (OR) = 1.53, 95% confidence interval (CI) = 1.51-1.55), although racial or ethnic minority status (black: OR = 1.25, 95% CI = 1.22-1.28; Hispanic: OR = 1.10, 95% CI = 1.06-1.14) and geographic prevalence of facilities (for a 10% increase in 1-star beds located in the county of individual's residence: OR = 1.27, 95% CI = 1.26-1.27) were also significant predictors. CONCLUSION: Vulnerable groups are more likely to be discharged to lower-quality facilities for postacute care. Policy-makers should monitor disparities in SNF quality. J Am Geriatr Soc 67:108-114, 2019.