Use of Clinicians Who Focus on Nursing Home Care Among US Nursing Homes and Unplanned Rehospitalization

Abstract

ImportanceThe number of physicians and advanced practitioners who focus their practice in nursing homes (NHs), often referred to as “SNFists” (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the nursing home or skilled nursing facility [SNF] setting) has increased dramatically. Little is known about the association of the NH medical care delivery models that use SNFists with the quality of postacute care.ObjectiveTo quantify the association between NH use of SNFists and facility-level, unplanned 30-day rehospitalization rates for patients receiving postacute care.Design, Setting, and ParticipantsThis cohort study used Medicare fee-for-service claims for all hospitalized beneficiaries discharged to 4482 NHs from January 1, 2012, through December 31, 2019. The study sample comprised NHs that did not have patients under the care of SNFists as of 2012. The treatment group included NHs that adopted at least 1 SNFist by the end of the study period. The control group included NHs that did not have patients under the care of a SNFist during the study period. SNFists were defined as generalist physicians and advanced practitioners with 80% or more of their Medicare Part B services delivered in NHs. Statistical analysis was conducted from January 2022 to April 2023.ExposureNursing home adoption of 1 or more SNFists.Main Outcomes and MeasuresThe main outcome was the NH 30-day unplanned rehospitalization rate. A facility-level analysis was conducted using an event study approach to estimate the association of an NH adopting 1 or more SNFists with its unplanned 30-day rehospitalization rate, adjusting for patient case mix, facility, and market characteristics. Changes in patient case mix were examined in secondary analyses.ResultsIn this study of 4482 NHs, adoption of SNFists increased from 13.5% of facilities (550 of 4063) in 2013 to 52.9% (1935 of 3656) in 2018. Adjusted rehospitalization rates were not statistically different after SNFist adoption compared with before, with an estimated mean treatment effect of 0.05 percentage points (95% CI, −0.43 to 0.53 percentage points; P = .84). The share of Medicare-covered patients increased by 0.60 percentage points (95% CI, 0.21-0.99 percentage points; P = .003) in the year of SNFist adoption and by 0.54 percentage points (95% CI, 0.12-0.95 percentage points; P = .01) 1 year after adoption compared with NHs that did not adopt SNFists. The number of postacute admissions increased by 13.6 (95% CI, 9.7-17.5; P < .001) after SNFist adoption, but there was no statistically significant change in the acuity index.Conclusions and RelevanceThis cohort study suggests that NH adoption of SNFists was associated with an increase in the number of admissions for postacute care but was not associated with a change in rehospitalization rates. This may represent a strategy by NHs to maintain rehospitalization rates while increasing the volume of patients receiving postacute care, which typically results in higher profit margins.