D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2019 . No. 2 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 Kira L. Ryskina, Yihao Yuan, Shelly Teng, and Robert Burke Health Affairs – published April 1, 2019 KEYFINDINGS 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. THE QUESTION THE FINDINGS SNFs represent an important discharge destination for patients who Over two million Medicare fee-for-service SNF stays occurred between require rehabilitation or skilled nursing after an acute hospital stay. About January 2012 and October 2014. Half of patients who received visits from one in five hospitalized Medicare beneficiaries are discharged to a SNF, a physician or advanced practitioner during their stay were assessed within but little is known about access to timely medical care after this transition. one day of admission. Nearly 80% of patients who received such visits had The authors measure the timing of initial medical assessment by a their initial assessment within four days of admission (Fig. 1). However, physician or advanced practitioner (nurse practitioner or physician 10.4% of patients received no physician or advanced practitioner visit assistant) upon transfer from a hospital to a SNF, and determine how during their entire stay, which had a median duration of 11 days. Patients often this kind of care is missing. Is delayed or missing care more without visits had 30-day hospital readmission rates twice that of patients prevalent in certain patient populations or facility types? Do outcomes with at least one visit (27.9% vs. 14.3%) and twice as many died within 30 differ between patients who receive these visits in a timely manner and days of SNF admission (14.2% vs. 7.2%) as shown in Figure 2. Compared those who do not? 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. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI Figure 1 Percent of stays in skilled nursing facilities (SNFs) after discharge Figure 2 Unadjusted percent of patients in skilled nursing facilities (SNFs) from an acute care hospital with a first postadmission visit by a physician or at risk for a given outcome who experienced it, by whether or not they had advanced practitioner, by number of days since SNF admission, 2012–14 any physician or advanced practitioner visit Source: Authors’ analysis of Medicare Part B claims data from the Carrier File for 2,392,753 SNF stays by fee-for-service beneficiaries with both Part A and Part B coverage in January 2012–October 2014. Courtesy of Health Affairs. THE IMPLICATIONS outcomes and particularly relevant to the promotion of value-based purchasing in postacute care. 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 THE STUDY and at high risk of poor outcomes, with one in four of these patients The authors use Medicare fee-for-service claims data to analyze a group deceased or rehospitalized within thirty days. Results from this study of beneficiaries discharged from acute care hospitals to SNFs between suggest that missing and delayed care from physicians and advanced January 2012 and October 2014. Patients younger than age 65 or not practitioners occurs during this vulnerable time. enrolled in Medicare Parts A and B during hospital and SNF stays were The timing and receipt of visits in the study varied by SNF characteristics excluded from the study. Stays in which patients had visited a SNF in the and geography and, considerably less so, by patient clinical factors, previous year were also excluded, since those patients may have been suggesting that missed care at this transition point depends on local familiar to clinicians and treated differently. practice patterns rather than clinical needs. The authors also find that For each SNF stay, the authors assessed time to and receipt of first patients without physician visits had nearly double the rates of hospital physician or advanced practitioner visit. They analyzed data at the readmissions and death compared to patients who were seen. Although SNF-stay level, with time to and receipt of first visit modeled by patient the authors did not attempt to tease out the effect of missed care on demographic and clinical characteristics, as well as facility size, ownership, readmissions and patient outcomes, this study represents a first step in and location. Comparing patients who did and did not receive a visit, the determining whether a timely medical visit may improve outcomes among authors also measured rates of 7- and 30-day readmissions and deaths, Medicare SNF patients. and successful patient discharges to the community. 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 Ryskina KL, Yuan Y, Teng S, Burke RE. Assessing ‘First Visits’ By within 30 days of SNF admission. Understanding the underlying reasons Physicians To Medicare Patients Discharged To Skilled Nursing Facilities. for, and consequences of, variability in timing and receipt of initial medical Health Affairs. 2019 Apr; 38 (4). DOI: 10.1377/hlthaff.2018.05458 assessment after SNF admission may be important for improving patient LEAD AUTHOR DR. KIRA RYSKINA 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.