Preventing Hospitalizations Doesn’t Affect Patient Outcomes — At a Financial Price

As the Centers for Medicare & Medicaid Services continues to crack down on preventable hospitalizations, skilled nursing providers have a keen financial interest in keeping residents out of the acute setting.

Now a new study finds that retaining residents at the skilled nursing facility has no bearing on their mortality rates — with an expensive caveat.

A team from RTI International, a non-profit research group, probed mortality rates among skilled nursing facilities that participated in the Enhanced Care and Coordination Provider (ECCP) program. Under that CMS initiative, facilities received free intervention care from an in-depth team of registered nurses, nurse practitioners, or physicians’ assistants, with the goal of intervening with at-risk patients before they may have been forced to return to the hospital.


RTI found that patients at ECCP skilled nursing facilities were less likely to be re-hospitalized by a factor of 2.2 to 9.3 percentage points in 2015; a RTI also found a drop in avoidable hospitalizations of 17% and a decline in all-cause hospitalizations of 9.5%.

But the RTI researchers, led by senior public health analyst Zhanlian Feng, wanted to know if such an effort had a negative effect on residents’ health: While keeping residents at the nursing home during certain medical episodes might serve to save Medicare money, the move could also hypothetically make nursing home staff less likely to discharge residents in cases where it was really necessary.

“This is a population whose average age is about 84, 85, with many in their late 80s and early 90s — very frail,” Feng said. “A lot of sick people on site — are you able to treat them safely? That’s kind of the question in this research.”


Feng and the team thus compared the outcomes of 23,700 residents of ECCP facilities and 40,600 patients at SNFs that did not participate in the program, focusing on the period between 2014 and 2016. During that time, there was no statistically significant difference in mortality rates among residents at the ECCP sites, where an even greater emphasis was placed on avoiding trips to the hospital.

In other words, nursing home residents had more or less the same risk of dying whether or not their SNF was attempting to cut readmissions with new strategies.

“In nursing facilities, staff members as well as residents and their family members sometimes insist on transferring sick residents to the hospital out of concern that the nursing facility might not be adequately equipped and staffed to manage and treat them,” the RTI team concluded in the study, published in the October issue of the journal Health Affairs. “Such concerns may be alleviated in light of our finding that reductions in hospital transfers can be achieved without adverse impact on mortality rates.”

But Feng and his fellow researchers also note that not every facility has the luxury of the ECCP program, which subsidizes a team of highly skilled employees that could be out of reach for many SNFs operating on tight margins in a changing reimbursement landscape.

“They are hard to keep them,” Feng said of the physician assistants and other professionals involved in ECCP. “They are very expensive. That’s a challenge. In this initiative, CMS gives money to these organizations … These ECCPs are outsiders — they are not part of the nursing home at all.”

Still, Feng noted that overall trends in the nursing home industry show that providers can maintain that level of preventative intervention without the benefit of free labor from CMS.

“Accountable care organizations, bundled payment, and managed care have the effect of encouraging the provision of a higher level of care in nursing facilities,” the team wrote in the study’s conclusion. “In these cases, savings from reduced hospitalizations could finance that care.”

Feng was also upbeat about the general future of the skilled nursing industry, particularly as providers take on higher-acuity patients with more intensive medical care options.

“There’s a place for SNF. Some people will be very sick, and home may not be the ideal place for these people,” he said. “That’s why we need this post-acute setting in the SNF. The question is: How can you better manage that?”

Written by Alex Spanko

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