States finding out that the shorter the nursing-home stay following hospitalization, the better for the patient
Policymakers are not only interested in reducing length of stay in hospitals but also nursing homes. An October 2017 report from the AARP Public Policy Institute explains why and how several states are working to reduce the percentage of older adults who receive long-term nursing home care after a hospitalization.
The report, titled “State strategies to reduce the risk of long-term nursing home care after hospitalization,” describes strategies used in four highly ranked or significantly improved states – Connecticut, Maine, Minnesota, and Oregon. The paper also includes a toolkit of resources that can help others learn more and potentially replicate these practices. Following is an edited summary of that report, presented with permission from the AARP Public Policy Institute.
Long-term nursing home residence can be a poor outcome for residents and their families. Few people want to live in a nursing home, and most family caregivers want to do whatever they can to ensure that their family member does not remain in the nursing home any longer than necessary.
People residing in nursing homes also may face much higher out-of-pocket costs than they would for community-based long-term services and supports (LTSS). Long-term nursing home stays may pose a cost problem for states as well, because long-stay residents are likely to spend down their resources and become eligible for assistance from Medicaid.
Nursing home residents who are not discharged to the community within a few months are particularly at risk of a long-term stay. The likelihood of a nursing home resident returning to a community setting declines sharply after 90 days. Because most nursing homes provide both SNF care and long-term custodial care, transitions to long-term residence can be relatively easy.
The good news is, older adults today are less likely to undergo long-term institutionalization after a hospital stay than they were a decade ago. They are more likely to receive supportive services at home or in community settings due to changing expectations about the role of nursing homes, the growing contributions of family caregivers, and the expansion of residential alternatives, such as assisted living.
Better planning shows results
Changes in the post-acute-care landscape – largely driven by changes in Medicare – also may be influencing the trends in long-term nursing home use, according to the AARP Public Policy Institute. In some states and communities, hospitals are giving greater consideration to discharge destinations and outcomes. Accountable care, value-based purchasing, and bundled payment programs are bringing increased attention to the role of post-acute care in helping people transition back into a community setting.
Because nursing facility quality varies widely, hospitals are creating preferred provider networks to improve transitions and avoid preventable readmissions.
State policies can make a difference. The ability of low-income older adults to make a successful transition to community living depends on the availability of personal care assistance services and other home-based supports. States, however, vary widely in how they use Medicaid state plan benefits and waiver programs – as well as state-funded programs – to meet the needs of older adults who are at risk of long-term nursing home stays.
Some states and communities have robust home- and community-based services (HCBS) systems that enable people with LTSS needs to live independently and avoid nursing home placement. In one recent study of nursing home use in Medicaid, nursing home stays were shorter in states with higher HCBS spending and use.
The AARP study describes how state policies in four states – Oregon, Maine, Minnesota and Connecticut – may reduce long-term nursing home care after a hospitalization and ensure timely and effective transitions back to community living.
The first three states – Oregon, Maine, and Minnesota – are among the highest performing on this indicator. They also have relatively low Medicare SNF admissions and low overall nursing home use among older adults. Connecticut had a higher percentage of long stays post-hospitalization in 2012 than the other three states (16.3 percent) and a higher rate of SNF admissions in Medicare (103 admissions per 1,000 enrollees), but its percentage of long stays declined significantly, from 18.2 percent in 2009 to 16.3 percent in 2012.
Minnesota’s Return to Community Initiative
Minnesota’s Return to Community Initiative (RTCI) focuses on nursing home residents who are on Medicare and paying privately for long-term nursing home care (when they no longer qualify for Medicare’s skilled nursing facility benefit) and who may be at risk of spending down to Medicaid.
The RTCI program identifies nursing home residents who fit a community discharge profile, but who remain in the nursing home after 60 days. Community living specialists – who are nurses or social workers employed by local AAAs – inform residents whose names appear on a list (produced weekly) about assistance that can help them plan for a successful transition home.
Nursing home social workers remain responsible for discharge planning, but community living specialists collaborate with them to help residents and their family caregivers identify goals and needs, and plan for care in the community.
The community living specialist assesses needs and helps residents and families understand the community resources that are available to them. Specialists, residents, and family caregivers develop a community living support plan that all agree can enable successful transition to the community that aligns with the resident’s goals and preferences.
A community living specialist follows up with clients who have left the nursing home for their own home, an assisted living facility, or another community setting. The program includes check-ins at specified intervals (a phone call or in-person visit within 72 hours, an in-person visit within 10 days, a 30-day and 60-day check-in, a 90-day check-in, and subsequent check-ins every 90 days for up to five years). This schedule can be modified to fit individual and family needs and preferences.
During these follow-up calls or visits, the specialist assesses how well the plan is working and makes needed changes to enable people to live successfully in the community, and avoid rehospitalization or readmission to the nursing home.
Since RTCI’s launch in April 2010, RTCI-assisted discharges have steadily increased – roughly 390 transitions per year and a total of 4,551 transitions as of May 2017. Most of the roughly 400 nursing homes in Minnesota have some RTCI-assisted discharges, although most facilities had five or fewer. Most of the people who returned to the community with support from the program fit the community discharge profile, that is, they preferred to reside in the community, had entered the nursing home as a post-acute admission, were relatively independent, and were not cognitively impaired or had only mild cognitive impairment.
A year after discharge, half of the RTCI-assisted individuals lived in the community, 36 percent had been readmitted to a nursing home, and 14 percent had died. Only a small percentage (11 percent) had converted to Medicaid.
Maine’s Homeward Bound program
Maine’s Homeward Bound program helps nursing home residents transition to community living through an approach that relies heavily on the state’s private, nonprofit Long-Term Care Ombudsman. The Ombudsman serves residents of nursing facilities and assisted housing programs, including residential care facilities and assisted living facilities, as well as people receiving services at home or in the community, such as adult day service settings.
The Ombudsman is responsible for conducting outreach, initial eligibility screening, and completion of the Homeward Bound application form.
Specifically, an advocate from the Ombudsman Program provides information about transition coordination, so an individual who is seeking services can choose one of the three agencies providing this service. Throughout the transition, Homeward Bound participants receive advocacy support from the Ombudsman.
The Ombudsman Program also makes MDS section Q referrals [which address discharge planning and the resident’s desire to return to the community]. Within a matter of days of receiving a referral, the Ombudsman makes in-person contact and provides general information about community living services and supports. The Ombudsman then makes referrals to the Center for Independent Living (Alpha One) and/or the local Aging and Disability Resource Center.
By the end of 2016, the Homeward Bound program had a total of 92 transitions, in line with the projected number of transitions from the program’s launch. The program had made a total of 406 outreach contacts, exceeding its goal of 308 contacts from the beginning of the program, in 2013.
Connecticut’s ‘Money Follows the Person’
Connecticut’s Money Follows the Person (MFP) demonstration program engages with people who need assistance with housing and services to achieve successful and sustained community living. Many MFP program participants have lived in a nursing home for three years on average.
Since 2008, more than 3,900 people have transitioned from nursing homes to community living through MFP.
Beginning in 2015, nursing homes are required to notify the Connecticut Department of Social Services when a resident is expected to qualify for Medicaid within a 180-day period. MFP program staff may then assess the resident to determine if he or she prefers, and is able, to live in the community; develop a care plan; and help the resident transition to the community. Connecticut strives to reduce the percentage of post-acute care discharges to SNFs. The state’s balancing plan calls for efforts to better inform and train hospital discharge planners about home- and community-based options for post-acute care.
The percentage of Medicaid beneficiaries who were discharged from SNF to a community setting within six months increased from 27 percent in 2009 to 41 percent in 2015. Across all payers, the percentage of people needing supportive services discharged from the hospital to home increased from 47 percent in 2008 to 55 percent in 2016, while hospital discharges to SNFs declined from 53 percent in 2008 to 45 percent in 2016.
Oregon’s quality improvement program
Some highly ranked states, including Oregon, Connecticut, and Minnesota, have incentivized quality improvement in nursing homes (including discharge planning and transitional care services) and have worked with nursing homes to close, downsize, and diversify into community care.
Oregon has among the lowest rates of nursing home use (3.3 percent of people ages 85+ reside in a nursing home) and low use of SNF care in Medicare compared with the national average. A recent initiative focuses on downsizing and diversifying the nursing home industry.
As Oregon has expanded its Medicaid HCBS programs, most recently with the implementation of its 1915(k) Community First Choice waiver program, nursing home caseloads have declined, falling from roughly 5,000 per year on average in 2005-07 to just over 4,000 per year in 2013-15. The resulting drop in nursing home spending offsets some of the increased spending on HCBS. But, unless some nursing homes close, the fixed costs associated with nursing facilities will reduce the savings associated with fewer nursing home residents.
That’s why Oregon has pushed for reductions in nursing home bed capacity and opportunities to expand residential and supported housing alternatives to nursing home care. A 2013 law (Oregon House Bill 2216) provided incentives to the nursing home industry to reduce bed capacity by 1,500 beds by June 30, 2016 – changing the nursing facility rate calculation if the 1,500-bed reduction target is not met.
The Oregon Department of Human Services works with local nursing facility providers that are considering taking advantage of the capacity-reduction initiatives to assess opportunities for more residential and supported housing capacity development.
As of May 2017, the number of nursing home beds had been reduced by 1,210, 80 percent of the 1,500-bed target.
Editor’s note: The AARP Public Policy Institute’s “Long-Term Services and Supports Scorecard Promising Practices: State Strategies to Reduce the Risk of Long-Term Nursing Home Care after Hospitalization,” can be accessed at http://www.longtermscorecard.org/~/media/Microsite/Files/2017/reducingtheriskoflongtermnursinghomecareafterhospitalization.PDF
Nursing homes diversify
Connecticut’s “Strategic Plan to Rebalance Long-Term Services and Supports” describes an agenda to support older adults, people with disabilities, and family caregivers in choosing how and where to receive services and supports. Nursing home diversification is an important part of the plan.
To help nursing home operators diversify, the state created a grant program to help facilities fund new investments: to redesign their business models to accommodate the shift to community living, reduce the number of beds in the state, and reduce the percentage of discharges from hospitals to nursing facilities.
The Connecticut Department of Social Services, in conjunction with the Connecticut Departments of Housing and Public Health, solicited proposals from nursing facilities and awarded $12 million in grants over a two-year period (2014–15). The nursing facilities receiving grant funds have invested in building an infrastructure for community services, including navigators, transition coordinators, affordable adult family living, and adult day services.
Care transitions improved
Minnesota is a national leader in setting policy standards for nursing home quality of life and quality of care. The nursing facility Performance-based Incentive Payment Program (PIPP) is one of many strategies designed to improve quality for people who need long-term services and supports. The program has funded projects designed to improve care transitions, including efforts to reduce hospitalizations and increase successful transitions to the community.
Since 2007, 261 facilities (of the roughly 400 in Minnesota) have participated in the program. SNFs have focused on a wide variety of topics, including clinical quality (87 projects), psychosocial aspects of care (46 projects), organizational change (39 projects), technology (22 projects), and care transitions (20 projects).31
The PIPP projects focused on care transitions reflect the growing consensus that transitional care interventions can improve transfers from nursing homes to home for older adults. Improving care transitions, however, may require significant improvements in nursing home resources, including the availability of nursing and medical staff, diagnostic and pharmacological services, and adequate social services for resident and family engagement and follow-up.