A new study from researchers at Vanderbilt University Medical Center found that hospitals with a greater local supply of home health agencies were associated with increased readmissions.
One of the reasons readmission rates were higher in those areas may be due to frequent staffing changes and other interruptions in care, according to the study’s lead author.
“Some of this could be that different types of patients are discharged to home health versus other facilities,” Kevin Griffith, assistant professor with the department of health policy at Vanderbilt University Medical Center, told Home Health Care News. “But one thing that has been noted in other research, as well as ours, is that in home health agencies, you’re more likely to have frequent staffing changes.”
Hospital readmissions are regularly viewed as an indicator of the quality of care patients receive. The Centers for Medicare & Medicaid Services (CMS) calculates annual readmission rates, and if those rates are higher than national averages, hospitals are financially penalized.
However, CMS does not take into account whether a patient’s risk for readmission is influenced by the availability of follow-up care after a patient is discharged in their geographical area.
“The quality and the type of care you receive after you leave the hospital depends a lot on where you live,” Griffith said. “If you live in an isolated, rural area, you may have no choice but to return to the emergency room if you’ve experienced complications. Yet the federal government does not currently account for this when they’re deciding what hospitals should receive penalties for excess readmissions.”
Griffith and his co-authors took a closer look at this relationship by pairing county-level data on the health care workforce and infrastructure with the 30-day readmission rates for heart attack, heart failure and pneumonia at hospitals from 2013 to 2019.
On average, a hospital’s surrounding area in the study contained over 620 SNF beds, about 25 primary care physicians, 49 nurse practitioners, 19 licensed nursing home beds and about four home health agencies per 100,000 residents.
The study’s results showed lower 30-day readmission rates at hospitals that operated a palliative care service or had a greater local supply of primary care physicians, skilled nursing facility beds and licensed nursing home beds.
For home health agencies, it was another story.
“Most of the results made sense to us,” Griffith said. “We were kind of surprised that for home health agencies and the supply of nurse practitioners in an area, those were associated with higher hospital readmissions.”
Griffith hypothesized that when dealing with a discontinuity of care — like is common in home health — the chance of rehospitalization increases.
“When you have a patient recovering after a hospital stay, it’s always better if the same person is looking after them with the same team,” Griffith said. “With home health, you’re more likely to have that person swapped out than if you’re at a skilled nursing facility or having your care managed by your primary care physician. That provides a lot of opportunities for the ball to be dropped.”
Another aspect of the higher readmission rates could be the familiarity a caregiver has with a patient once he or she is discharged.
“When you get to know a patient, you are better at discerning what is a potentially worrisome complication versus what’s more normal for that patient,” Griffith said. “We think there’s also a level of risk aversion. If you’re a new nurse being sent out to see a patient for the first time and see something concerning, you might send them to the emergency room. Somebody who has been working with them for a long time might know it’s more normal and not necessarily a cause for concern.”
Ultimately, the study found that CMS may be penalizing or rewarding hospitals in part based on the communities they serve as opposed to the quality of care they provide.
“The results also suggest that hospitals may benefit from work to improve local access to care or hospital-community partnerships to improve continuity of care after a patient’s discharge,” the authors wrote.
For home health agencies, Griffith suggested leaders should better track readmission rates and figure out ways to reduce them.
Like hospitals and skilled nursing facilities, home health agencies might soon see an increase in federal oversight, especially as the sector has grown so much, Griffith said.
Tracking the data themselves could be a key in solving the issue.
“What gets measured gets done,” Griffith said. “If this is something you’re not even tracking, that’s problematic. The results show that maybe the sector could do some digging and ask, ‘What is it about these patients? What could we change about the way home health is delivered that might reduce these unwanted readmissions?’”
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