New nursing home patients may wait to see a doctor

(Reuters Health) - - When Medicare patients are discharged from a hospital to a skilled nursing facility, the time it takes for a doctor or advanced-level practitioner to see them for a first evaluation can vary widely, a new study suggests.

About one in six initial medical assessments occur more than four days after nursing home admission, for example, and one in 10 patients never get such an assessment during their nursing home stay, according to the report in Health Affairs.

“Many patients and their caregivers don’t know what to expect when a patient is discharged to a skilled nursing facility,” said lead study author Dr. Kira Ryskina of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

“If seeing a physician (or other prescribing clinicians such as nurse practitioners) soon after transfer is important to them, I would suggest asking about that when selecting the facility,” she told Reuters Health by email.

About one in five patients with insurance through Medicare are discharged from hospitals to skilled nursing facilities, Ryskina and her colleagues note.

The researchers analyzed nearly 2.4 million hospital discharges to skilled nursing facilities under fee-for-service Medicare in 2012-2014. Using codes in Medicare claims, the researchers looked for initial visits by a doctor, nurse practitioner or physician assistant.

About half of first medical assessments happened within a day of admission to the nursing home, and 71 percent occurred within four days. But about 15 percent of assessments happened four to 14 days after the patient arrived, nearly 4 percent were more than 14 days later and 10 percent of patients were never seen at all. The patients who were never seen spent up to 21 days in the nursing facility, with half spending 11 days or more.

“Those patients (without a visit) had almost double the rates of (hospital) readmissions and deaths compared to the patients who had a physician visit,” Ryskina said.

Patients with longer hospital stays or who had been critically ill were slightly more likely to be seen sooner. At the same time, patients who were older or more impaired in daily living activities, such as eating, using the toilet and bed mobility, were more likely to be seen later. Patients with a cognitive impairment were also more likely to be seen later or not at all.

Small and rural facilities tended to have longer delays before a visit occurred.

“Overall, these findings are concerning because they suggest that elderly patients discharged from hospitals to skilled-nursing facilities are not receiving the care they need at a time when they might be particularly at risk for poor outcomes,” Ryskina said.

“Despite the importance of the post-acute-care sector, we still know surprisingly little about how to use post-acute care most effectively,” said Tamara Konetzka, a researcher at the University of Chicago, who wasn’t involved in the study.

Medicare spent more than $60 billion on post-acute care in 2015, Konetzka said, and that number continues to grow. Medicare requires initial doctor visits within 30 days of admission, so future research should focus on the 10 percent of patients who don’t receive a visit and how that can be improved, she said.

“Consumers (and their families) who need care after an acute hospitalization should expect to see a physician or advanced practitioner soon after admission,” she told Reuters Health by email. “Medicare requires it and the visit may play a role in improved outcomes.”

SOURCE: Health Affairs, online April 1, 2019.