The Optimal Outcomes of Post-Hospital Care Under Medicare

Health Services Research, August, 2000 by Robert L. Kane, Qing Chen, Michael Finch, Lynn Blewett, Risa Burns, Mark Moskowitz

Objective. To estimate the differences in functional outcomes attributable to discharge to one of four different venues for post-hospital care for each of five different types of illness associated with post-hospital care: stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fracture, and to estimate the costs and benefits associated with discharge to the type of care that was estimated to produce the greatest improvement.

Study Setting/Data Sources. Consecutive patients with any of the target diagnoses were enrolled from 52 hospitals in three cities. Data sources included interviews with patients or their proxies, medical record reviews, and the Medicare Automated Data Retrieval System.

Analysis. A two-stage regression model looked first at the factors associated with discharge to each type of post-hospital care and then at the outcomes associated with each location. An instrumental variables technique was used to adjust for selection bias. A predictive model was created for each patient to estimate how that person would have fared had she or he been discharged to each type of care. The optimal discharge location was determined as that which produced the greatest improvement in function after adjusting for patients' baseline characteristics. The costs of discharge to the optimal type of care was based on the differences in mean costs for each location.

Data Collection/Extraction Methods. Data were collected from patients or their proxies at discharge from hospital and at three post-discharge follow-up times: six weeks, six months, and one year. In addition, the medical records for each participant were abstracted by trained abstractors, using a modification of the Medisgroups method, and Medicare data were summarized for the years before and after the hospitalization.

Principal Findings. In general, patients discharged to nursing homes fared worst and those sent home with home health care or to rehabilitation did best. Because the cost of rehabilitation is high, greater use of home care could result in improved outcomes at modest or no additional cost.

Conclusions. Better decisions about where to discharge patients could improve the course of many patients. It is possible to save money by making wiser discharge planning decisions. Nursing homes are generally associated with poorer outcomes and higher costs than the other post-hospital care modalities.

Key Words. Home health, nursing home, rehabilitation, cost-effectiveness

The change in Medicare's hospital payment policies to a prospective payment system (PPS) spurred post-acute care activities (Morrisey, Sloan, and Valvona 1988; Neu, Harrison, and Heilbrunn 1989; Neu and Harrison 1988). The resultant earlier discharges from hospitals (Kahn, Rubenstein, Draper, et al. 1990) created a demand for post-acute care services where many of these patients could recuperate and perhaps be rehabilitated. All three major post-acute care entities--home health care agencies, skilled nursing homes, and rehabilitation facilities--experienced substantial growth in the wake of the PPS (DesHarnais, Cheney, and Fleming 1988; Guterman and Dobson 1986; Gornick and Hall 1988; Prospective Payment Assessment Commission 1993), and the acuity levels of nursing home care and home health increased (Shaughnessy and Kramer 1990).

As hospitals moved to discharge patients "quicker and sicker" (Kahn, Rubenstein, Draper, et al. 1990), the question arose about whether patients were discharged to settings sufficient for post-acute care. Hospital discharge planners generally recognize variations in patient characteristics when making their recommendations. Factors considered include the patient's functional ability, availability of caretakers at home, ethnicity, age, sociodemo-graphics, previous hospitals, and dependence on technology (Naylor and Prior 1999). Discharge planners are more likely to send complicated patients for post-hospital care, but the outcomes associated with these different assignments are not clear.

In order to seek more rational discharge planning a number of important questions, such as which post-acute care (PAC) location will give a particular patient the best functional outcomes, need to be answered. This study builds on earlier studies that involve addressing the question and evaluating who should get what kind of care after discharge and the association of functional outcomes with different types of PAC (Kane et al. 1996; Kane, Finch, Blewett, et al. 1996; Kane, Chen, Finch, et al. 1998). The specific focus of these analyses is to determine (1) whether the actual discharge location produces the optimal (greatest) functional improvement, and (2) the extent of the differences between the optimal functional outcomes and the functional outcomes in actual discharge locations. Medicare patients discharged from hospitals were followed for up to one year after discharge to monitor the outcomes attributable to the PAC they received.