Nursing Homes

Medicare has data on size and location of nursing homes, staffing, and summary comparisons.

Most nursing homes offer limited social structure for residents, with most interactions dominated by staff.

• The Eden network works to expand quality of life in nursing homes by varied and freer social interaction.
• Green Houses are licensed as skilled nursing homes, with home-like layouts for 10 to 12 elders with low staff/elder ratios.
• Board and care homes are similar, without the skilled nursing, and in older buildings.
• Assisted living is a far larger, more professional version of board and care, usually large enough to have many activities, still without skilled nursing. Some have semester-long college courses, like the arts. They can be combined with home health services to avoid or postpone going to a nursing home.
• Village to Village is a network of local groups where volunteers and paid staff help elders at home get transportation, health and wellness programs, home repairs, social and educational activities and trips.
• PACE is a Medicare/Medicaid version of Village to Village, helping people stay at home even if they are eligible for a nursing home, in some states. Also at pace4you.org
• Senior cohousing involves homes clustered around shared facilities, run by the residents.
• Life care communities include a range of care levels, usually independent living, assisted, and skilled nursing, not run by the residents. If prepaid, they act like a long term care insurance policy, with limited reserves for long expensive nursing.
• Living in some kind of group or institution prevents the isolation of many old people at home, when their friends have died or become immobile.
• Private associations include: PioneerNetwork, LeadingAge, formerly Association of Homes and services for the Aging, and Action Pact (consultant).
• Few nursing homes take patients on ventilators or with dementia below age 60, since Medicaid does not pay enough to cover the cost

Medicare plans to pay Accountable Care Organizations to reduce the number of patients who go from hospital to nursing home and back to hospital within 30 days. This penalty discourages doctors both from sending patients back to hospitals and from sending risky patients to nursing homes ('You'll be better at home...").

Medicare's justification repeatedly cites a 2010 article (with 2006 data) by Mor et al. for the statement that 78 percent of re-hospitalizations from nursing homes within 30 days were potentially avoidable. The article made that statement without evidence. It said,

• "Specifically, MedPAC [14] has found that five conditions—congestive heart failure (CHF), respiratory infection, urinary tract infection (UTI), sepsis, and electrolyte imbalance—for which rehospitalization is potentially avoidable account for 78% of all 30-day SNF rehospitalizations."

The MedPAC report cited (2006) said,

• "Kramer and colleagues at UCDHSC identified five conditions for which rehospitalization is potentially avoidable in nursing homes... These five conditions are congestive heart failure (CHF), respiratory infection, urinary tract infection (UTI), sepsis, and electrolyte imbalance. Not all hospitalizations for these conditions are preventable; however, rates of hospitalization for these conditions were significantly lower in facilities with higher nurse’s aide and licensed staff levels as well as in facilities with higher staff retention, after adjusting for facility case mix" (Kramer et al., 2001, emphasis added).

That 2001 study addresses the number of nursing home staff needed to achieve:

• "Quality measures related to hospital transfer for potentially avoidable causes (e.g. urinary tract infections, sepsis, electrolyte imbalance) for a short-stay sample of Medicare SNF admissions."

Medicare does not report how many rehospitalizations could be prevented, though it says 97% of nursing homes do not have enough staff.

Furthermore Medicare gives no hint of how many of the 78% potentially preventable readmissions can actually be prevented, nor why they penalize 100%, when many cannot be prevented.

The article Medicare cites, by Mor et al., focuses on how much states differed in 2006 in the rates of readmission to hospitals, from nursing homes (and other Medicare costs). The article says (again without evidence) the differences depend on "provider norms, practice patterns, bed availability, and presence and willingness to use hospice." They ignore the most direct explanation for variation in readmission rates, which is variation in health. The traditional broadest measure of health is life expectancy, which does explain 34% of the 2006 variation in readmissions from nursing homes. The reasons why some states have short life expectancies include a mix of environmental hazards, poverty, diets and other causes, all of which drive health problems too, and the average readmission rate in those states is higher. Including household income, along with life expectancy, would raise the explanatory power to 40%.

On financial incentives Mor et al. say "skeptics have raised a range of potential issues including the increased incentives for selection of the most profitable patients, withholding of patient care, upcoding and fraud, along with the technical difficulties of case-mix adjustment and quality measurement and monitoring" and they do not address these issues.

Nursing Homes Respond to Harmful Incentives

A 2013 study found that skilled nursing facilities (SNFs) respond to incentives. Starting in 2002 nursing homes were rated on quality of care for patients who stayed over 2 weeks, but not under 2 weeks and not re-hospitalizations, so they sent more of their sickest patients for discretionary re-hospitalizations (before 2 weeks). At the same time they had fewer non-discretionary hospitalizations, which the authors suggest means "that nursing homes were avoiding admitting the sickest patients in the uncertainty of a new policy." (p.348)

• "Selectively discharging patients prior to their 14th day of their SNF stay will bias report card scores; in the extreme, extremely good SNFs that avoid unnecessary readmissions to the hospital may appear to be of low quality, while low-quality SNFs that discharge sicker patients appear to be of high quality. While policymakers have expressed concern that almost half of SNF patients do not stay long enough to have a 14-day assessment and therefore will not be counted (Medicare Payment Advisory Commission, 2006), the manipulation of this margin adds a layer of bias to the problem of an already selected sample (p.350)
• it is uncertain whether the current SNF NHC [Nursing Home Compare] measures can induce broad quality improvement or whether they should be used by consumers to compare quality (p.350)
• Each system has to define a denominator for quality measurement, but there is generally room for gaming the denominator in one way or another (p.350)
• If gaming the denominator is a lower-cost response to the presence of public reporting than true improvements in quality, we should expect gaming of the denominator. (pp.350-1)
  

• Policy makers worry that providers will “game” the system by selecting patients of lower risk to make quality scores look better. If providers game the system, true quality improvement may not occur, and in the worst case net welfare may decrease as sicker individuals face reduced access to care (p.341)
• selecting healthier patients may be used as a lower-cost approach than true improvements in quality in many cases." (p.343)

Will Medicare Place Direct Penalties on Nursing Homes?

Like the penalties for hospitals, Congress penalizes skilled nursing facilities (SNFs) which have above-average rehospitalizations, starting October 2018. A major result will be giving SNFs a strong incentive to decline admission to the frailest patients, who need them most. Starting October 2019, Medicare will stop paying SNFs based on services they provide to patients, but will pay based on how sick the patients are.

Even without the penalty, "Medically complex patients ... can be hard to place" (MedPAC 6/07 p. 208 ). Some SNFs are "selective about the SNF patients they admit" (3/12 p.195) choosing those with "lower severity of illness" (6/07 p.204). 

MedPAC (an arm of Congress) explicitly recommends "hospice use and the presence of advance directives" as methods to decrease rehospitalizations (3/12 p.195). They give an example, "25 facilities undertook early detection ... in-facility treatment ... and improved end-of-life care strategies (such as advance care planning and palliative care) ... savings (from fewer self-reported hospitalizations) range from 17 percent to 24 percent" (3/12 p.196)

MedPAC had recommended the nursing home penalties in their March 2012 Report

• "Congress should direct the Secretary to reduce payments to skilled nursing facilities with relatively high risk-adjusted rates of rehospitalization" (p.199). 
• This will lessen their current "incentive to rehospitalize high-cost patients as a way to shift costs they would otherwise incur onto hospitals" (p.194).

MedPAC reitereated the recommendation in March 2013

• "We have recommended readmission policies for hospitals (now in place) and SNFs [skilled nursing facilities], and we are working on similar policies for home health care and IRFs [inpatient rehabilitation facilities)" (p.153)