Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals

Abstract

Hospitals are now being held at least partly accountable for Medicare patients’ care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities’ quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients’ choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

Since the implementation of the Affordable Care Act, hospitals have had to become more responsible for the care that Medicare patients receive after discharge, so hospitals can cope with rehospitalization penalties and embrace value-based payment models (such as bundled payment and accountable care organizations [ACOs]). Programs based on these models should provide hospitals with incentives to form stronger partnerships with postacute care providers, such as home health agencies and skilled nursing facilities (SNFs).^1–3 Whether or not they create formal relationships with postacute care providers, hospitals might be expected to attempt to steer patients toward higher-quality providers from which patients are less likely to be rehospitalized.^4,5 Indeed, research shows that hospitals that discharge patients to fewer SNFs have lower aggregate rehospitalization rates from SNFs, and hospitals that reduced the number of discharge locations most dramatically over time had the greatest reduction in rehospitalization rates.⁵

These types of changes to hospital referral patterns have important implications for patients’ choice of postacute care facilities. In addition, quality reporting programs of the Centers for Medicare and Medicaid Services (CMS), such as Nursing Home Compare, are intended to stimulate quality-based competition among providers and are predicated on patient choice. Yet little is known about how patients who need postacute care select a facility or the role that hospital staff members play in that selection process.

Most of the existing literature related to nursing facility choice is focused on patients who need long-term care rather than postacute care,^6–12 although the two types of care usually involve very different selection circumstances and have different desired outcomes. Studies focused on facility selection for long-term care reveal that patients and their family members found selecting a facility a hectic and stressful process and that limited information was available to aid them.^6–8,10 Thus, their decisions often rely on word of mouth, the experiences of friends or family members, or the facility’s location or appearance.^10,11

To our knowledge, no studies of nursing facility selection have focused on how hospitalized patients and their advocates choose facilities for postacute care, in spite of the fact that most nursing facility admissions now occur as post-acute care admissions, directly from hospitals.¹³ The choice may have important implications for the patient’s likelihood of successful rehabilitation and return to his or her previous living situation.¹⁴

Postacute care selection usually occurs in the hospital as a part of discharge planning. However, very little is known about the role of hospital discharge planners and case managers in the postacute care placement process. One study that examined the role of case managers in patients’ home health agency selection in Rhode Island found that they simply gave patients a list of agencies and did not attempt to inform them about which were of better quality. Case managers reported that this was primarily because they did not have the information necessary to identify better quality agencies and also because they felt that federal law regarding patient choice prohibited them from doing so.¹⁵

Social Security laws do, in fact, guarantee patients free choice of providers, stating that “any individual entitled to insurance benefits under this title may obtain health services from any institution, agency, or person qualified to participate under this title.”¹⁶ However, this language does not necessarily mean that hospitals cannot assist patients in selecting a better-quality facility or provide them with the information to allow them to do so.¹⁷

Given the lack of research on the selection of nursing facilities for postacute care and the importance of this topic in relation to the changing US health care system, we examined how patients requiring postacute care decide which nursing facility to select and the role that hospital discharge planners and case managers play in the selection process.

Study Data And Methods

We used a multiple case study methodology that included site visits to eight US markets in the period March–October 2015, interviews with staff members of multiple organizations in each market, and interviews with patients admitted to SNFs in five of those markets. Our site visits were conducted as part of a larger study that examined the effect of readmission penalties on hospitals and postacute care providers, the care of frail nursing home residents during a hospitalization, and the role of Medicare Advantage in post-acute care. We selected markets across the United States based on Medicare Advantage penetration rates, choosing four with rates above and four with rates below the national average. These markets were also selected to be representative of all US markets (see Exhibit 1). To protect anonymity, we promised representatives of participating organizations that the markets would not be identified. In each market we recruited one hospital with a low rehospitalization rate and one with a higher rate and at least three SNFs that received referrals from these hospitals. Hospitals ranged in size from 320 to 990 beds; most were nonprofit. SNFs ranged in size from 30 to 310 beds, included multiple ownership types, and varied in the number of stars they received in CMS’s five-star quality rating system (for more details on facility characteristics, see online Appendix A).¹⁸

Exhibit 1.

Characteristics of eight US markets for site visits conducted in March–October 2015

Market	Geographic region	Population (millions)a	White populationa	Patients interviewed
Market 1	Southwest	3.3	76.1%	No
Market 2	South	0.9	61.8	No
Market 3	Midwest	1.2	75.6	Yes
Market 4	Midwest	5.2	65.7	Yes
Market 5	Northwest	0.8	80.2	Yes
Market 6	Northeast	0.9	79.9	Yes
Market 7	South	0.4	58.8	Yes
Market 8	Mid-Atlantic	1.1	66.1	No

SOURCE Authors’ analysis.

^aCounty-level data for 2015 from Census Bureau. QuickFacts [Internet]. Washington (DC): Census Bureau; [cited 2017 Jul 6]. Available from: https://www.census.gov/quickfacts/.

INTERVIEWS

At each hospital we interviewed a network or business development executive, the chief medical officer, a discharge planner, and a hospitalist. At each SNF we interviewed the administrator, an admissions coordinator, and the director of nursing. Interview protocols were pilot-tested in a major hospital system and two nursing facilities in a large city in the Northeast. Our interviews included a wide range of topics, but the ones most salient to the study discussed here were the hospital discharge and SNF admission processes. Sample questions are in Appendix B.¹⁸ All interviews were recorded, with the participant’s consent, and transcribed for data analysis. Interviews averaged forty minutes in length.

In five of the eight markets we also interviewed patients who had recently been admitted to one of the participating SNFs for postacute care. These five markets were selected based on convenience, but they varied in size and geographic location (Exhibit 1). The second author interviewed approximately seven patients in each of fourteen SNFs about one month after our interviews with hospital and SNF staff members.

Our patient interview protocol went through several rounds of pilot-testing, including pilot interviews with twenty-seven postacute care patients in two Northeast states to ensure that patients understood our questions. Our protocol included questions about how patients had selected the SNF, who had been involved in the process, the role of hospital staff members, and the use of data and quality information in the selection (see Appendix B).¹⁸

To recruit patients, we worked with SNF admissions coordinators, who provided the interviewer with a list of potential participants—all of whom were deemed by SNF staff members to be capable of providing informed consent. On a scheduled one-day visit, the interviewer individually recruited patients, prioritizing those who had come from a hospital participating in our study. If a patient was being visited by family members, they were also asked to participate in the study. Respondents were compensated $25 for their participation. Interviews averaged 20–25 minutes in length. All interviews were recorded and transcribed for data analysis. This study was approved by the Brown University Institutional Review Board.

DATA ANALYSIS

Data analysis involved coding the transcripts and identifying emerging patterns and themes across transcripts.^19–21 For both the staff and patient interviews, we developed a preliminary coding scheme based on the questions in the interview guides we developed for the study. We then modified and refined the scheme in an iterative fashion to add codes (when unanticipated material emerged from interviews) and refine code definitions.

For the hospital and SNF staff interviews, all four data analysis team members read all transcripts of interviews from the first site multiple times and individually made notations to code the material. The team included gerontologists, health services researchers, and a medical anthropologist. After forty interviews had been analyzed, the team members had become familiar with the coding scheme. The remaining interviews were coded by subteams of two members: Each subteam member coded the transcripts independently, and the two then met to agree on the final coding. Team members rotated among these subteams, and the entire team convened regularly to discuss and resolve discrepancies.

Analysis of the patient interviews was conducted in a similar fashion by two members of the research team. A coding scheme was iteratively developed as described above. Once inter-rater reliability was ensured, the two coders each coded half of the remaining interviews individually.

Team members met weekly and noted potential emerging themes—that is, patterns of ideas and concepts expressed across interviews. Once coding was completed, the entire team discussed the prevalence of the potential themes across interviews and worked to identify outliers and other disconfirming evidence that would indicate varied experiences on the part of respondents. Themes that had emerged from the analysis of patient interviews were compared to those that had emerged from the staff interviews to identify complementary findings. All coded data were entered into NVivo for data management and organization.

LIMITATIONS

Our study had several limitations. By the standards of qualitative research, the study collected a large amount of data—the results of interviews with 138 hospital and SNF staff members and 98 patients. However, one limitation is that our results might not be generalizable. Although we selected markets, hospitals, and SNFs to be generally representative, participating hospitals, SNFs, and patients might differ from others who did not participate.

A second limitation is that we included only patients capable of providing informed consent—people who may have been healthier and more cognitively intact than other patients. A sample population of sicker patients might have reported different experiences.

A third limitation is that it was beyond the scope of this project to include staff members or patients from postacute care settings other than SNFs, such as long-term care hospitals and inpatient rehabilitation facilities. Nonetheless, our findings were strikingly consistent across eight markets, sixteen hospitals, and twenty-five SNFs.

Study Results

As noted above, we interviewed 138 staff members, who represented sixteen hospitals and twenty-five SNFs. We also interviewed 98 patients recently admitted to one of fourteen of the SNFs. About two-thirds of the patients had been discharged from one of the sixteen hospitals. See Exhibit 2 for characteristics and diagnoses of interviewed patients. Eight of the patients were being visited by family members when our research staff arrived for the interview. In these instances, family members also participated in the interview.

Exhibit 2.

Characteristics and diagnoses of patients interviewed for the study of postacute care

Characteristic	Number
Sex
Female	60
Male	38
Race
White	84
Black	11
Other	3
Type of admission
Emergency hospitalization	78
Falls, accidents, broken bones, concussions	30
Cancer	8
Infection	7
Heart attack or congestive heart failure	6
Stroke	6
Pneumonia	5
Amputation	4
Other	12
Planned hospitalization	19
Joint replacement	9
Back surgery	3
Other	7
Planned stay in a skilled nursing facility	9

SOURCE Authors’ analysis.

NOTE Each patient reported one primary diagnosis.

PATIENTS WERE PROVIDED ONLY WITH LISTS OF FACILITIES

The main theme to emerge from the data was that hospital staff members provided little guidance to patients when they were selecting a facility for postacute care. Across the country, the postacute care patients we interviewed made strikingly similar comments—reporting that hospital discharge planners offered them lists of SNFs containing names and addresses but little else. Patients’ experiences did not vary based on hospital characteristics, bed availability in the market, or the patient’s diagnosis or condition. In the cases where patients were Medicare Advantage beneficiaries, either they were given lists of the managed care organization’s contracted facilities, or the managed care organization staff handled discharge planning.

When we asked patients what information they had been given by hospital staff members to help them select a SNF, only four patients said that they had received any information about SNF quality or instructions about where to find such data. Instead, patients made comments such as this: “I got a two-page list of different facilities that I could go to. It basically was the name, the address, and a phone number.” Several patients in one market reported receiving a list of all SNFs in the region, which contained over 100 such facilities. When asked to describe the list she received, one patient said: “Well, there were—there’s like a hundred of them. It’s all the facilities in the area.”

What we heard from patients was consistent with what we had heard from hospital staff members. Almost all of the discharge planners we interviewed reported providing lists of SNFs to patients, with no qualitative information. Only one discharge planner reported pointing patients and their family members to the Nursing Home Compare website, which provides data to aid consumers in their selection of a postacute care facility. Typical of what we heard from hospital staff members was this comment: “So right now, how it works is everybody gets a list with all of the local SNFs on it, and everybody can choose.” Another discharge planner similarly reported: “We hand them the list. The patients usually do it [choose a SNF] based on location or preference, but we try absolutely not to sway it. In fact, we do have a form that the patients do sign with their choice.”

HOSPITAL STAFF FOCUSED ON PATIENT CHOICE

Interviews indicated that clinical staff members determine which postacute care setting patients will be discharged to before patients become involved. Hospital staff members indicated they believe that they can supply only lists of SNFs to patients (once the SNF setting has been selected), having been instructed that patient choice statutes preclude them from providing any other information. In some cases, these instructions came from top executives. One hospital’s vice president of network development reported that her hospital’s practices were dictated by their legal department: “Our legal experts have said that we’re not able to do that [provide recommendations or data] outside of any sort of Medicare innovation programs, and because…they are very concerned about the requirement for the patient to feel that they have choice in where they go postdischarge.”

This was echoed by a discharge planner in another hospital, who said, “CMS requires patient choice, so we literally had a whole list of everything that’s within whatever the radius is that the family’s looking for…provided to them.”

Hospital staff members reported leaving it to patients and families to discover information about SNF quality themselves. As one discharge planner told us, the hospital does not provide any data to aid in SNF selection “because we’re very, very much into patient choice. You can look it [quality data] up online or you can find that type of information.”

Hospital staff members seemed satisfied with this approach and did not question it. Their comments indicated that they did not use available quality data in their work, nor did they share their opinions of it. Some did report that SNFs attempted to market themselves to hospital staff members. One said: “The facilities come up. They try to come in. They bring you cake and food and things like that. They’re trying to build a relationship.… And that becomes a little bit of a rub because, again, we go back to citing the CMS regulation of patient choice.”

SNF staff members also reported this practice. As one admissions coordinator said, “The social worker is the one that kind of compiles a list for [patients]…[so] you need to have a relationship with those hospital people.” However, we did not hear any reports from patients that this kind of marketing affected the lists they were given.

PATIENTS SELECT THE NEAREST FACILITY

One likely consequence of restricting information about area SNFs to lists of names, addresses, and telephone numbers is that patients tend to select the SNF nearest their home. One patient told us, “They gave me a sheet with about fifty [SNFs] on there, but I looked for ones that were in my area so I wouldn’t have to drive so far, and this is the closest one that had an opening.” This selection process was reported in many patient interviews.

When specifically asked whether they would have been willing to travel farther if a better-quality facility had been recommended, seventy-five of the ninety-eight patients said that they would have been. For example, one patient said, “I would have gone to a different one if it was better than, you know, if I got better rehab.” However, when specifically asked if their clinicians had made a recommendation, the vast majority of patients said that they had not. For example, one said: “No recommendation at all. They say, you go where you wanna go.” In addition, most patients reported that they found the discharge planning process overwhelming and would have appreciated more guidance in selecting a SNF. Few reported being unable to go to their first-choice facility.

ONE HOSPITAL PROVIDED PATIENTS WITH INFORMED CHOICE

Staff members in one hospital that participated in an ACO reported ways in which they subtly steered patients to their network of preferred SNFs, using a colored-coded list of all SNFs in the area. Those at the top of the list, and color-coded green, were the nine in the hospital’s postacute care network that had been selected based on an array of quality measures. So while patients were still provided with a list of all the facilities in the area, additional information was also supplied. As one discharge planner at the hospital told us, “But then I also redirect them to the fact that we do have the postacute care network where at those particular facilities there is more supervision…. The doctors and the nurse practitioners will be seeing the patient on a weekly basis rather than a monthly basis.”

The hospital network development executive said that the hospital selected SNFs using a thorough process that involved questionnaires and site visits. Questionnaires gathered data on a range of topics, including average occupancy, staffing ratios, hospice capabilities, and use of tools to reduce hospitalizations—such as INTERACT, a suite of tools aimed at managing acute changes in patients. Geographic location was also important, as hospital staff reported wanting SNFs to be dispersed across their market. Fewer than half of the SNFs that applied were selected to participate in the network. Interviews with staff at this hospital indicated that they believed their participation in an ACO allowed them to inform patients of their relationship with these preferred SNFs.

Three other hospitals whose representatives we interviewed, which participated in different ACOs, had also formed SNF networks. However, their staff members did not attempt to steer patients to these SNFs. Instead, the hospitals had selected the SNFs based on historical referral patterns and expected patients’ choices to remain consistent over time, so that many patients would continue to select these facilities. A quantitative analysis found that referral patterns for these three hospitals did not change after formation of the SNF networks.²² Surprisingly, this means that despite the formation of SNF networks, the hospitals were still not trying to steer patients to their preferred partners.

Discussion

Despite the fact that hospitals are now held more accountable for the care that patients receive in the postacute care setting, interviews with hospital staff members and patients around the country indicate that concerns about the principle of patient choice paradoxically may undermine hospitals’ ability to respond to that accountability. Furthermore, this undue emphasis on patient choice seems to preclude using the quality data that are available to make an informed choice of skilled nursing facilities. We found that patients are provided only with lists of SNFs and that hospital staff members do not give patients readily available data on quality that could aid them in selecting higher-quality facilities. Most hospital staff members, especially discharge planners, were satisfied with this approach and seemed to be wedded to their interpretation of patient choice. SNF staff members seemed to believe that they could influence patient choice through marketing strategies. Meanwhile, patients expressed frustration with the lack of guidance they received.

Our findings are similar to those of a small study conducted over a decade ago, which also found that hospitals provided patients with lists of facilities and no information about quality. That study concluded that this practice was creating a barrier to informed decision making by consumers.²³

While it is true that Social Security statutes guarantee Medicare patients the right to choose their providers,¹⁶ nothing in these statutes precludes hospitals from helping patients make an informed choice.¹⁷ In fact, while CMS interpretive guidelines say that patients should be provided with a list of facilities near their homes, the guidelines also say that discharge planners may direct patients to the quality data available on the Nursing Home Compare website.²⁴

Proposed changes to Medicare’s conditions of participation for hospitals could help improve this situation. If enacted, these changes would “require that hospitals assist patients, their families, or their caregivers/support persons in selecting a PAC [postacute care] provider by using and sharing data that includes but is not limited to…data on quality measures and data on resource use measures.”²⁵

Previous studies show that it will be important for hospital staff members to provide data that are understandable to patients and their families²⁶ and relevant to patients’ preferences.²⁷ For example, Dana Mukamel and colleagues found that personalized SNF report cards led to greater satisfaction with the discharge planning process and greater likelihood of selecting a high-quality facility,²⁶ and Jennifer Hefele and colleagues found that patients would like information beyond what is currently available on the Nursing Home Compare website.²⁷ In addition, despite efforts by CMS to make Nursing Home Compare data easily understood, multiple studies have found that the website has had limited impact on consumer selection of nursing facilities.^28–30 Consumers are largely unaware of its existence,^31,32 and those who do visit or are shown the website find it difficult to understand and use.^33,34 Thus, an important role of hospital discharge staff members could be to educate patients about quality data and how to interpret it in line with patient preferences.

If the proposed changes to Medicare’s conditions of participation for hospitals are not implemented, CMS could instead clarify what is expected of hospitals in terms of patient choice. This clarification could include providing guidance about both the types of data hospital staff members should share with patients to help in SNF selection and hospitals’ ability to establish networks of preferred providers.

The one hospital in our study whose staff members reported subtly steering patients toward SNFs in the hospital’s preferred network is an interesting illustration of possible ways to address both patient choice and hospital accountability. This hospital had developed a creative way to steer patients toward facilities in its network of preferred SNFs, while still providing patients with the full range of choices in their market. Less strict interpretations of patient choice, such as this, allow patients choice by facilitating a more informed choice. This approach might result in better outcomes for both patients and hospitals, because the hospital is using quality data and a well-designed process to select its partner SNFs. Future research could examine differences in outcomes—such as hospital readmissions, patient satisfaction, and postacute care length-of-stay—between patients who were provided with data to help them make an informed choice and those who did not receive this additional information. Future research could also identify the types of data hospitals could use to select high-quality SNFs for their networks.

Conclusion

Hospital staff members do not appear to provide patients who need care in a skilled nursing facility with data that would allow them to select better-quality facilities. This is in spite of the fact that hospitals are now held at least partly accountable for the postacute care their patients receive, including for rehospitalizations. A system based on quality reporting and competition for patients cannot succeed if patients do not have the data necessary to make an informed choice. Hospitals should provide these data and help patients and their families understand them.