Assessing First Visits By Physicians To Medicare Patients Discharged To Skilled Nursing Facilities
Missing and delayed medical care occurs at critical juncture for vulnerable patients
Health Affairs – April 1, 2019
In this study of postacute care, more than 10% of Medicare skilled nursing facility (SNF) stays included no visit from a physician or advanced practitioner. Of stays with visits, about half of initial assessments occurred within a day of admission, and nearly 80% occurred within four days. Patients who did not receive a visit from a physician or advanced practitioner were nearly twice as likely to be readmitted to a hospital (28%) or to die (14%) within 30 days of SNF admission than patients who had an initial visit.
SNFs represent an important discharge destination for patients who require rehabilitation or skilled nursing after an acute hospital stay. About one in five hospitalized Medicare beneficiaries are discharged to a SNF, but little is known about access to timely medical care after this transition.The authors measure the timing of initial medical assessment by a physician or advanced practitioner (nurse practitioner or physician assistant) upon transfer from a hospital to a SNF, and determine how often this kind of care is missing. Is delayed or missing care more prevalent in certain patient populations or facility types? Do outcomes differ between patients who receive these visits in a timely manner and those who do not?
Over two million Medicare fee-for-service SNF stays occurred between January 2012 and October 2014. Half of patients who received visits from a physician or advanced practitioner during their stay were assessed within one day of admission. Nearly 80% of patients who received such visits had their initial assessment within four days of admission (Fig. 1). However, 10.4% of patients received no physician or advanced practitioner visit during their entire stay, which had a median duration of 11 days. Patients without visits had 30-day hospital readmission rates twice that of patients with at least one visit (27.9% vs. 14.3%) and twice as many died within 30 days of SNF admission (14.2% vs. 7.2%) as shown in Figure 2. Compared to stays with at least one visit, those without any visits had a lower rate of successful discharge to the community (51.9% vs. 59.6%). Taking into account a variety of patient and facility-level factors, initial assessments occurred later, or not at all, in SNFs that were small, rural, and in the South or Midwest compared to their larger, urban, suburban and Northeastern counterparts. Patients with cognitive impairment were also more likely not to have a SNF visit and were seen later, on average, than those without cognitive impairment.
As United States health care moves toward value-based payment, hospitals have become accountable for patient outcomes after discharge. Patients transitioning from hospitals to SNFs are often medically complex and at high risk of poor outcomes, with one in four of these patients deceased or rehospitalized within thirty days. Results from this study suggest that missing and delayed care from physicians and advanced practitioners occurs during this vulnerable time. The timing and receipt of visits in the study varied by SNF characteristics and geography and, considerably less so, by patient clinical factors, suggesting that missed care at this transition point depends on local practice patterns rather than clinical needs. The authors also find that patients without physician visits had nearly double the rates of hospital readmissions and death compared to patients who were seen.
Although the authors did not attempt to tease out the effect of missed care on readmissions and patient outcomes, this study represents a first step in determining whether a timely medical visit may improve outcomes among Medicare SNF patients. Current regulatory and payment policies do not incentivize timely physician assessment of patients discharged from hospitals to SNFs. Medicare requires only that a physician complete an initial assessment within 30 days of SNF admission. Understanding the underlying reasons for, and consequences of, variability in timing and receipt of initial medical assessment after SNF admission may be important for improving patient outcomes and particularly relevant to the promotion of value-based purchasing in postacute care.
The authors use Medicare fee-for-service claims data to analyze a group of beneficiaries discharged from acute care hospitals to SNFs between January 2012 and October 2014. Patients younger than age 65 or not enrolled in Medicare Parts A and B during hospital and SNF stays were excluded from the study. Stays in which patients had visited a SNF in the previous year were also excluded, since those patients may have been familiar to clinicians and treated differently. For each SNF stay, the authors assessed time to and receipt of first physician or advanced practitioner visit. They analyzed data at the SNF-stay level, with time to and receipt of first visit modeled by patient demographic and clinical characteristics, as well as facility size, ownership, and location. Comparing patients who did and did not receive a visit, the authors also measured rates of 7- and 30-day readmissions and deaths, and successful patient discharges to the community.
Kira L. Ryskina, MD, MS is an Assistant Professor of Medicine in the Division of General Internal Medicine at the Perelman School of Medicine at the University of Pennsylvania. Her research aims to elucidate non-clinical factors that systematically influence physician practice of high- vs. low-value care. Dr. Ryskina is the recipient of a Career Development Award from the NIA to study physician specialization in nursing home care as a potential mechanism to improve the outcomes of patients receiving post-acute care in nursing homes. She was among the first to describe the emergence of nursing home specialists (“SNFists”) and evaluate its effects on care quality. She treats hospitalized patients at the the University of Pennsylvania Presbyterian Medical Center in Philadelphia.