After hospital discharge, about 40% of Medicare beneficiaries receive post-acute care (PAC) services, such as home health care (HHC), skilled nursing, or inpatient rehabilitation. But do they get the right care at the right time? A recent study found that while sicker patients received more intense levels of PAC services, patients with greater chronic illness were more likely to be rehospitalized in the 30 days after discharge. These findings highlight the importance of assessing patient readiness for discharge and  strengthening care transitions from the hospital to ensure that patients get the appropriate care at the right time.

In the study, Susan Keim, Mary Naylor, and Kathryn Bowles identified predictors of 30-day rehospitalization or return emergency department (ED) use in nearly 3,300 older adult inpatients discharged to home (with or without HHC services) or to a PAC facility (skilled nursing or inpatient rehabilitation). Most patients identified as female (53%) and white (86%). Patients with greater clinical needs (e.g., greater functional decline or fall risk) were more likely to be referred to a PAC facility than discharged to home.

Overall, 15% of patients were rehospitalized within 30 days. Patients discharged to a facility were more likely to be rehospitalized (20%) than patients discharged to home with HHC services (17%) or without (11%).  Most rehospitalizations occurred within 14 days of hospital discharge; many occurred in the first 24 hours. About 40% of all rehospitalizations from home and more than 50% of facility rehospitalizations happened within 7 days after discharge.

Level of PAC services was the strongest predictor of rehospitalizations, with more intense services associated with higher rehospitalization risk. Early rehospitalizations were most frequent among patients discharged to an inpatient rehabilitation facility (IRF), who had less chronic illness burden but much greater functional decline.

Although more acutely ill patients were discharged to a PAC facility, rehospitalized patients (from all discharge locations) had greater chronic illness burden, including more prior hospitalizations and poorer self-rated health. They also had more socioeconomic risk factors, such as being unemployed, single, or lacking a caregiver.

These findings offer several important lessons for hospitals, PAC providers, and regulators. To reduce rehospitalizations, PAC payment models  and care management interventions should target high-risk, high-need patients who are at greatest risk of being rehospitalized. This includes patients with high chronic illness burden and socioeconomic risk, as well as patients in IRFs with significant clinical needs. To prevent early rehospitalizations, regulators should incentivize providers to avoid discharging patients before it is clinically appropriate (i.e., improve their discharge timing), better assess clinical stability at time of discharge, and better match patients’ needs to the appropriate level and quality of PAC services.

Since it is often difficult for discharging providers to assess the quality of the discharge location, providers should use existing care models to improve warm hand-offs and information exchange at the point of care. Hospitals and PAC providers could also be held mutually accountable for patient outcomes and pursue risk reduction approaches, such as collaborative determination of patient discharge readiness or use of decision support tools. As this study was observational in nature, future work should focus on refining risk prediction for patients in PAC settings.

The study, Patient Factors Linked with Return Acute Healthcare Use in Older Adults by Discharge Disposition, was published in the Journal of The American Geriatrics Society in October 2020. Authors include Susan K. Keim, Sarah J. Ratcliffe, Mary D. Naylor, and Kathryn H. Bowles.