Each year, roughly three million Medicare beneficiaries are hospitalized for a serious condition and discharged to a postacute setting such as a home health agency or skilled nursing facility. For many of these patients, the transition from hospital to postacute care starts with being asked to decide where and from whom they will receive critical rehabilitative care, just as they are beginning to recover from the preceding health event.
Anyone who has ever had to make this decision or assisted a loved one in choosing a postacute provider has likely asked the question: “Why is this so hard?” Some of this difficulty reflects the fact that it is a challenging process. A lot is at stake at the time of hospital discharge, and there are typically numerous options, spanning a variety of care settings (for example, home health care, skilled nursing facility, or inpatient rehab facility). The decision often needs to be made quickly, with little time to collect quality information or visit potential providers. Part of the challenge of the postacute discharge is also related to the limited nature of the resources that patients and their families have available to assist in this process. Tools do exist, but they are often complicated, incomplete, and potentially misleading.
The Importance Of Postacute Provider Choice
Presently, many Medicare patients are discharged to low-value postacute care settings with comparatively high costs and no measureable improvements in quality outcomes. Several recent policy initiatives, including bundled payments and shared savings programs, have sought to address this issue by incentivizing hospitals to make greater use of high-quality postacute providers. However, Medicare fee-for-service patients must be allowed to choose where they receive care, meaning bundled payment and shared savings programs are not allowed to narrow the choice set or mandate that a patient go to a particular provider. This stipulation makes good consumer decision making essential to postacute care reform efforts. For example, in response to the increased financial risk introduced by bundled payments, hospitals have been creating networks of preferred postacute providers who are believed to provide higher-value post-discharge care to nudge patients toward these settings.
To the extent that hospitals’ and patients’ interests are aligned (for example, demanding high-quality and coordinated clinical care that reduces the risk of needing to be rehospitalized), it is important that providers be able to transparently demonstrate why certain providers are preferred and that patients be able to identify the potential benefits of using these preferred providers. In instances in which the hospitals’ preferences do not match the patients’ (for example, narrow postacute care networks excluding higher-quality and higher-cost providers, restrictions on valuable clinical services without obvious impacts on readmissions or other observed quality indicators, or the absence of specialized providers from the choice set), consumers are in a position to serve as a frontline check against these unintended consequences of payment reforms by “overruling” the suggestions of the acute care facility. Given these dynamics, it is clear that the choices patients and their families make at the time of discharge have significant ramifications for both the individuals directly involved and the health care system at large.
Current Supports For Postacute Care Provider Choice
Although we have given patients this important responsibility, it is unclear whether they have also been given the appropriate tools to make well-informed decisions about where to receive care following a hospital discharge. The Centers for Medicare and Medicaid Services (CMS) produces the Nursing Home and Home Health Compare tools on the Medicare.gov website to facilitate better consumer choice by providing data and summary rankings on the quality of care delivered by all eligible providers. Although these online report cards were designed to facilitate easy comparisons across providers on meaningful characteristics, evidence suggests that they are coming up short. These shortcomings are likely exacerbated for postacute patients due to several design and dissemination issues, particularly with the Nursing Home Compare tool.
One of the biggest challenges consumers face when attempting to use Nursing Home Compare to research postacute providers is that it can be difficult to identify which nursing homes provide this type of care and assess their performance in this specific area. The measures presented on the Nursing Home Compare website are predominantly focused on long-stay residents who receive chronic care, a service that can be quite distinct from the restorative care many short-stay residents require. Prior to July 2016, only three of the 11 quality measures used to generate the Nursing Home Quality Domain five-star ranking were pertinent to short-stay patients. This lack of focus on postacute patients limits the tool’s usefulness for patients and families looking for rehabilitative services. CMS is moving in the right direction in this area; it recently added new measures, resulting in seven of 16 measures relating to short-stay residents. Yet, these improvements disregard the fact that a facility’s performance with respect to short- and long-stay residents is not necessarily similar. Indeed, our analyses of 2017 CMS data indicate that the within-facility correlations for five-star measures that are assessed for both types of patients range from low (0.13) to moderate (0.72) (Exhibit 1), consistent with a previous study that found that the same facility can vary widely in its relative performance across different quality measures. Additionally, users of Nursing Home Compare cannot even determine what proportion of a facility’s patient population is short stay versus long stay, making it difficult to ascertain whether a provider specializes in a particular type of care.
Exhibit 1: Within-Nursing Home Correlation Of Short-Stay (Postacute) And Long-Stay (Chronic) Quality Measures On Nursing Home Compare
Quality domain Correlation coefficient
Pressure ulcers 0.13
Antipsychotic medications 0.32
Flu vaccine 0.50
Pneumonia vaccine 0.72
SOURCE Authors’ calculations using June 2017 Centers for Medicare and Medicaid Services Nursing Home Compare data. NOTES Pairwise within-facility correlation for facilities without censored values in either the short-stay or long-stay measure within the specified quality domain.
The Nursing Home Compare tool also lacks information on many of the provider features that may be of the greatest importance to patients seeking postacute care. For example, the website gives no information about the amenities provided by a facility, the physical setting where care is delivered and a patient resides, the culture and care philosophy of the agency, the ability of the facility to coordinate with acute and primary care providers, and the availability of physicians and nurse practitioners on site. Accessing these “data” in the current environment likely requires an in-person visit to a facility, a time-consuming endeavor that requires a proactive family support system, or a word-of-mouth recommendation from a trusted source without competing incentives, which may not exist.
Beyond shortcomings in the tool itself, more work is needed to actually get this information into the hands of consumers. We know that in its current form, this resource has had limited effects on patients’ actual choices, and available evidence indicates that a considerable portion of this limited impact could stem from a general lack of awareness, on the part of both patients and discharge planners, that the tool even exists. Furthermore, it appears that when hospital staff are aware of the tool and its accompanying quality rankings, they are reluctant to share such information with patients for fear of violating patient choice regulations. Patients and providers alike need to know that help is available, and barriers to accessing these websites during the potentially stressful and hectic time of discharge planning need to be minimized.
Suggestions For Improvement
Moving forward, CMS should take steps to help patients make more informed choices when postacute care is needed. First, quality measures on Nursing Home Compare related to short- and long-stay residents should be separated. This delineation should be clear and presented on the page where search results are shown to easily allow patients to identify the quality metrics most pertinent to their situation. A distinct short-stay five-star summary measure to assist with data interpretation should be created, and CMS should report the proportion of a facility’s patient population that is postacute to provide insight into a provider’s experience with this care.
Second, new information should be added to the Nursing Home Compare website to address a considerable knowledge gap. Specifically, amenity information (for example, availability of private rooms, age of the facility, pictures of the facility and the rooms), clinical services available (for example, onsite physician or nurse practitioner services, types of therapies available), and patient and family reviews or satisfaction rankings would provide data on provider attributes that more closely match consumers’ top concerns. Although some of this information is subjective, consider that even individuals researching hotels have easy access to useful data of this sort. Certainly patients considering where to spend weeks or months of important recovery time are entitled to similar resources, and recent evidence suggests that consumers are already turning to social media platforms such as Facebook to post facility feedback and obtain first-hand perspectives. CMS has an opportunity to facilitate such information exchange in a controlled and transparent manner.
Finally, in light of the apparently limited awareness of this resource, additional efforts are needed to connect consumers with the Home Health and Nursing Home Compare tools. Continued marketing campaigns could be useful at raising awareness, but after 15 years of promoting the tool, it is doubtful that better advertising alone will be sufficient. Instead, CMS might consider requiring that Medicare patients be informed of this resource while discharge planning is occurring. Similarly, efforts to make web-enabled technology (for example, a tablet) available to patients and family members in their hospital room, as recently demonstrated in an experimental setting, might improve use of the tool. Patients could be further nudged to use the tool by asking them to select their preferred postacute care provider through a web portal that integrates Home Health/Nursing Home Compare data and rankings. This approach would mirror the primary way in which US consumers enroll in health insurance plans offered on the Affordable Care Act exchanges.
Selecting the right postacute provider is a complex choice, frequently made under difficult circumstances, with meaningful consequences for the patient and the broader health care system. This complexity will likely increase for patients as reform efforts continue to push integration between acute and postacute providers, possibly creating financial incentives to influence patient choice in ways that may or may not be consistent with their preferences. If consumers are to play an active role in the evolving postacute care choice environment, it is essential that they be well-positioned to make good decisions. Unfortunately, currently available tools have not served consumers well. The changes discussed here would help make patients aware of their provider choices following a hospitalization, allow them to accurately evaluate these options, and facilitate the selection of high-quality providers who can meet their needs and preferences while supporting the overall goals of postacute care payment reform.
David Grabowski serves as a paid consultant to Precision Health Economics and Med1 Healthcare, and he also serves as a paid member of the Scientific Advisory Board at NaviHealth.