Skilled Nursing Often Plays Second Fiddle to Acute Care Hospitals

Skilled nursing facilities are less costly for Medicare than long-term acute care (LTAC) facilities, but they can be missed as an option for seniors recovering from hospitalization, according to a new study in JAMA Internal Medicine.

“Essentially what we found was dramatic variation in LTAC use, and only about a half of the variation, the reason why older adults are transferred to LTACs, is how sick they are,” Dr. Anil Makam, assistant professor of internal medicine at UT Southwestern Medical Center, told Skilled Nursing News.

The study used a national sample of Medicare beneficiaries aged 65 and older from 2010 through 2012. Among 65,525 hospitalized older adults transferred to an LTAC or SNF, 3,093 were transferred to an LTAC, which cares for patients who are stable but require ongoing intensive care. The strongest predictors of transfer to such a facility were receiving a tracheostomy and being hospitalized in close proximity to an LTAC.


Following adjustment for case mix, about half of the variation in LTAC use, or 52.1%, was explained by the differences between patients, the researchers found. The rest were attributable to hospital and regional differences. It’s those last two factors that could end up sending patients who could be cared for in SNFs to LTACs.

“There’s about 420 or so unique LTACs across the country and they are not geographically spread evenly,” Makam explained to SNN. “Some have a lot and other areas have very few. Geography in a way is destiny, so if you’re in a region that has few or none [LTACs], there’s going to be very little LTAC use.”

High use of LTACs was particularly concentrated in the South, notably in Louisiana, Oklahoma and Texas, he observed. By contrast, the Pacific Northwest region, the North and the Northeast had less use of LTACs.


SNFs Have Value 

But geography isn’t the whole story in LTAC utilization.

“Within a given region where we know that hospitals might have more access to LTACs, we see a ton of variability in how hospitals are sending patients to LTACs,” Makam said.

This could directly affect SNFs. While patients who are critically ill or need services like mechanical ventilation will need care in an LTAC, the study uncovered gray areas where doctors, hospitals, and others providing care are taking different approaches to the different types of post-acute care.

“We don’t actually know who are the right people to go to an LTAC versus who should be going to a skilled nursing facility,” Makam said.

But skilled nursing facilities have the resources to help people with certain needs recover and can provide adequate nursing care for a lot of patients, he added. Cost is also a factor; LTACs are reimbursed by Medicare between three to 12 times higher than SNFs for the same or comparable types of diagnoses or illnesses, according to Makam.

“I think the focus on partnerships with high-quality skilled nursing facilities will become more pressing, whether skilled nursing facilities can handle patients with a little more complexity than they’re used to,” Makam said. “Are they well staffed, do they have the resources? And, more importantly, do they have the expertise to care for patients that are more complex?”

Written by Maggie Flynn

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