Hospital-to-Home Transitions Still Plagued by Lack of Information

In the state of New York alone, patients being discharged from hospitals into a post-acute care (PAC) settings can choose from more than 620 nursing homes, 120 certified home health agencies and 1,400 licensed home care services agencies. A similar breadth of PAC options exist in many other U.S. markets as well.

The emergence of accountable care organizations (ACOs), value-based purchasing and other innovative payment models has gradually broken down silos between the acute and post-acute worlds, but their success is still hindered by a dearth of actionable data and publicly available information to help streamline care transitions for patients.

That’s especially true when it comes to hospital discharges to home health agencies and skilled nursing facilities (SNFs), a new report from the United Hospital Fund suggests.


“We’ve still got some pretty enormous silos between the hospital setting and post-acute care settings,” Lynn Rogut, director of quality measurement and care transformation at the New York City-based United Hospital Fund, told Home Health Care News. “And those silos are still getting in the way of efficient and effective handoffs and transitions.”

Founded in 1879, the United Hospital Fund is an independent, nonprofit organization focused on building health care system efficiency.

In general, when patients and families choose PAC settings and providers that do not match their needs and are not of high quality, they become prone to re-hospitalizations, emergency room visits and declines in physical or psychological function, according to the United Hospital Fund report. Patients who need PAC are among the sickest and most vulnerable, with common chronic conditions such as arthritis, heart failure, stroke, renal failure and chronic obstructive pulmonary disease.


Two of the biggest and most popular resources for patients exploring PAC options are Home Health Compare and Nursing Home Compare.

CMS established the Home Health Compare website in 2012 as a way for consumers to easily look up information on their potential home health care providers, including details on quality of care and location convenience. Home Health Compare now attracts more than 30,000 visitors per month. Nursing Home Compare attracts more than 150,000 visitors per month.

Despite their popularity, Home Health Compare and Nursing Home Compare are both plagued by several shortcomings, according to the United Hospital Fund report.

For example, clinical quality measures continue to be main elements, with less attention given to aspects of quality that patients find meaningful, such as quality of life, care coordination, and communication among staff, patients and family members. Additionally, data typically only reflect a particular point in time rather than the current state of a home health agency or SNF, with information only available in English.

“There’s a disconnect between the information patients and families find useful and the information that’s available on the government websites,” Rogut said. “There has to be a better way of combining all of this information.”

Although both Compare websites are flawed, Home Health Compare is, at least in some ways, more refined than Nursing Home Compare, according to Rogut. The inclusion of Consumer Assessment of Healthcare Providers and Systems (CAHPS) information is one of those ways.

“The better thing about Home Health Compare is that it actually has data on home health CAHPS, which has been very thoroughly vetted and scientifically tested as meaningful to patients and families,” she said. “There’s similar nursing home CAHPS surveys, but they’re not required and not used by CMS for public reporting.”

The United Hospital Fund report — supported by the New York State Health Foundation — was the result of a year-long inquiry into PAC discharge trends and the first part of an ongoing series.

Each year, more than 8 million Americans require PAC following a hospitalization, according to the United Hospital Fund. Traditional Medicare covers most PAC services, with Medicare Advantage (MA) plans, Medicaid and commercial health plans covering the remainder.

In 2016, two of every five hospitalized patients with traditional Medicare were discharged to PAC settings — mostly to SNFs or home health agencies — at a cost to the federal government estimated at more than $60 billion.

Written by Robert Holly

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