- This study characterized trends in the use of post-acute care, costs, and patient outcomes for Medicare beneficiaries who were hospitalized with heart failure between 2008 and 2015, with special attention to patients with frailty
- There was a 3.9% increase in patients receiving post-acute services instead of being discharged home without services; the largest increases were concentrated in skilled nursing facilities (2.3%) and home health agencies (1.1%)
- Trends in the use of post-acute care varied by frailty status, but there was increased use of skilled nursing facilities across all frailty groups
- Over time, patients spent more time alive in the community after discharge, especially those classified as mildly or moderately to severely frail, and there seemed to be no negative impact of recent Medicare cost-containment policies on mortality
- Frail patients had high mortality rates, and along with their increased use of post-acute care, this suggests they may benefit from targeted interventions after hospital discharge
Over the past decade, Medicare has enacted policies designed to reduce expenditures for hospitalization, post-acute care (PAC), and hospital readmission. As a group, Medicare beneficiaries with heart failure (HF) have high rates of frailty, hospitalization, and PAC use, and may be affected by this pressure to reduce costs.
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Tamra Keeney, DPT, PhD, a physical therapist and research scientist in the Division of Palliative Care and Geriatric Medicine and the Center for Aging and Serious Illness at Massachusetts General Hospital, and colleagues studied trends in PAC and outcomes for this population between 2008 and 2015. Their report appears in the Journal of the American Geriatrics Society.
The researchers examined data on a random sample of 718,737 patients with traditional Medicare fee-for-service coverage who were hospitalized for HF and discharged alive between January 1, 2008, and September 30, 2015. The cohort was 54% female, 77% white, and had an average age of 78.
The team used the Claims-based Frailty Index, developed and validated for use with Medicare claims data, to assign a frailty score to each patient. 2% were classified as robust, 54% as pre-frail, 37% as mildly frail, and 7% as moderately to severely frail.
A PAC episode was defined as the first PAC setting after hospital discharge, followed by any additional PAC setting until death, return to the community without PAC services, rehospitalization, or transition to a nursing home without skilled nursing care.
Trends in PAC Use and Cost
Between 2008 and 2015, most HF hospitalized patients were discharged to PAC. The first discharge setting was:
- Skilled nursing facility—18% of patients
- Home with home health care—29%
- Inpatient rehabilitation facility—1.5%
- Long-term care hospital—0.8%
- Home with no services—48%
- Inpatient observation—1.8%
- A nursing home without skilled care—0.8%
Use of PAC services increased by 3.9% during the study period, especially with respect to discharge to skilled nursing facilities (2.3%) and home health agencies (1.1%). The use of skilled nursing facilities increased in all frailty groups.
The lengths of stay for the first PAC setting and the entire PAC episode increased with higher levels of frailty. The average Medicare cost of a PAC episode increased slightly by $123, regardless of frailty classification.
Trends in Readmissions
Over the study period, overall readmission rates decreased substantially: −3.4% for 30-day readmissions, −5.5% for 90-day readmissions, and −6.3% for 180-day readmissions.
Readmission rates were especially improved in frail patients; for example, the change in the 30-day rate was −4.4% in the mildly frail group and −5.4% in the moderately to severely frail group.
Still, 48% to 50% of frail patients were readmitted within 90 days, and 62% to 63% were readmitted within 180 days.
Medicare costs for the 180-day post-hospitalization period declined considerably—$3,000 on average—driven by the overall decrease in hospital readmission rates and subsequent PAC use.
Trends in Mortality
After discharge, patients spent more time alive in the community (1.5 days on average overall) with no negative impact on mortality. The number of days in the community was particularly favorable for patients classified as mildly frail (average of 3.2 days) or moderately to severely frail (4.7 days).
Even so, 28% of mildly frail patients and 32% of moderate to severely frail patients died within 180 days.
Opportunities to Improve Care
Despite some encouraging findings, the high PAC use and mortality observed for frail older adults with HF in this study suggest a need to reconceptualize the role and design of PAC for this population. Frailty indexes can be a useful tool to identify individuals at high risk of subsequent hospitalization and death who might benefit from interventions such as specialized home-based programs or palliative care consultation.
Refer a patient to the Division of Palliative Care and Geriatric Medicine