Association of Inpatient Rehabilitation Facilities’ Characteristics and 30–Day Unplanned Hospital Readmissions for Medicare Beneficiaries

PURPOSE: Recent health care reform initiatives have emphasized the importance of value–based payment systems for postacute settings, including inpatient rehabilitation facilities (IRFs), skilled nursing facilities, home health agencies, and long–term acute care hospitals (LTCHs; Medicare Payment Advisory Commission, 2016). IRFs provide the most intensive daily rehabilitation services and have the second highest Medicare spending per beneficiary stay after LTCHs (Centers for Medicare & Medicaid Services [CMS], 2017). However, limited information is available to help consumers and care providers compare quality of services among IRFs. We therefore investigated the effects of six facility-level characteristics of IRFs on 30–day unplanned risk standardized readmission rate (RSRR). The study findings can inform occupational therapists about the optimal discharge IRF location for patients and their caregivers, therefore facilitating the best continuum of postacute care.

METHOD: We used 100% Medicare claims data covering 26,306 discharges from 1,094 IRFs between October 2010 and September 2011. We examined the association between hospital readmission and six facility–level factors (no. of discharges, disproportionate share percentage, profit status, teaching status, freestanding status, and accreditation status). We further compared distributions of organization– and region–level variables by significant facility–level factors.

We followed the methodology published by the National Quality Forum to measure all–cause unplanned readmissions for 30 days postdischarge from IRFs (CMS, 2014). First, we calculated the predicted and expected number of unplanned hospital readmissions using hierarchical generalized linear mixed models after adjusting for patients’ age, gender, disability, comorbidities (in 51 hierarchical condition category groups identified from the prior acute care stay or from all acute care stays in the prior year), case–mix groups, number of acute care stays in the prior year, and covariates associated with the prior acute care stay (including principle diagnosis, surgical procedures, dialysis, length of stay, and days in an intensive care or coronary care unit). Second, we calculated the IRF–wide standardized risk ratio (SRR) by dividing the predicted number of readmissions by the expected number. Lastly, RSRR was computed by multiplying SRR by the overall mean readmission rate, which was 13.19% for all IRF stays.

We examined differences in observed readmission rates and RSRR across categories within each IRF–level variable using analysis of variance or t test. After identifying significant facility–level factors, we further analyzed the organization- and region–level variables that significantly contributed to RSRR.

RESULTS: Profit status was the only facility–level factor significantly associated with unplanned readmissions. For–profit IRFs had significantly higher RSRR (13.26 ± 0.51) than nonprofit IRFs (13.15 ± 0.47; p < .001). Four organization– and region–level characteristics demonstrated statistically significant differences in RSRR between for–profit and nonprofit IRFs: facility size, IRF type, census region, and state location in the *“stroke belt” (southeastern United States; p < .001).

CONCLUSION: Profit status is significantly associated with RSRR. Compared with nonprofits, for–profit IRFs have higher patient volumes and percentage of freestanding facilities and are more likely to be located in the Southern census regions and stroke belt. These findings are in contrast to the notion used for acute care hospitals and SNFs that “higher volume equates to better quality” (Comondore et al., 2009). The RSRR difference between for–profit and nonprofit IRFs may be attributable to the combined effect of organization– and region–level factors. Occupational therapists should recognize the IRF facility–level characteristics associated with RSRR so they can make appropriate recommendations regarding discharge location for patients, therefore helping patients receive optimal postacute care. This study highlighted the importance of facility–, organization–, and region–level factors in patients’ health outcomes. We suggest the consideration of multilevel factors (e.g., personal, environmental, and contextual factors) to maximize patients’ health outcomes. Identifying modifiable and unmodifiable factors related to care process at the organizational and regional levels could potentially improve the care quality of IRFs

References

Centers for Medicare & Medicaid Services. (2014). NQF-endorsed measure #2502 All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (IRFs). Washington, DC: National Quality Forum.Centers for Medicare &Medicaid Services. (2017). Health Care Payment Learning and Action Network. Retrieved from https://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network/

Comondore, V. R., Devereaux, P. J., Zhou, W., Stone, S. B., Busse, J. W., Ravindran, N. C., . . . Guyatt, G. H. (2009). Quality of care in for-profit and not-for-profit nursing homes: Systematic review and meta-analysis. BMJ, 339, b2732. https://doi.org/10.1136/bmj.b2732

Medicare Payment Advisory Commission. (2016). Report to the Congress: Medicare payment policy. Retrieved from http://www.medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf