THE EMERGENCE OF HOSPITAL-SNF LINKAGES AND THEIR IMPACT ON PATIENTS

拟议的项目解决了一个日益重要的问题，即医院和急症后提供者如何合作，以改善患者的体验，减少再次住院。急诊后护理有了巨大的增长，特别是熟练护理设施(SNF)，同时再次住院的人数也在增加。由于医疗保险政策没有对再次接纳出院的患者施加惩罚，确保跨环境协调护理以防止此类情况发生的组织战略欠发达，医院对出院后患者护理的责任也有限。我们的建议旨在了解优先将PAC患者送往选定数量的SNF的医院是否减轻了产生更高再住院率的力量，因为医院及其首选的SNF投资于协调过渡方案。《平价医疗法案》(ACA)中有一些条款旨在克服与报销有关的障碍，阻碍医院与SNF之间的合作。我们建议测试它们对医院和SNF如何合作的临时影响，以及这对再次住院和相关患者结局的影响。基于十年来与SNF最低数据集评估相关的全国医疗保险索赔，并使用定量和定性相结合的方法，在交易成本经济学的指导下，我们建议：1)开发和测试医院-SNF“首选提供者”关系的衡量标准；2)估计牢固的医院-SNF关系对30天再次住院和疗养院住院的风险的影响，控制患者的敏锐度、患者选择和市场因素；3)经验性地测试医院在多大程度上加强其合作伙伴关系(引导他们的出院患者)以应对ACA条款的引入和参与ACO和/或捆绑加班计划；以及4)定性地检查医院和SNF之间在行政和临床层面上的互动和交流模式，以更好地了解关系强度的标志，以此作为我们对医院与SNF联系的定量测量的定性测试。

The proposed project addresses the increasingly important issue of how hospitals and post-acute providers can collaborate to improve their patients' experience and reduce re-hospitalizations. There has been tremendous growth in post-acute care, particularly to Skilled Nursing Facilities (SNF), coinciding with increases in re-hospitalizations. Because Medicare policy has not levied penalties for re-admitting patients discharged to SNF, organizational strategies to ensure coordinated care across settings to prevent them are underdeveloped and hospitals' accountability for their patients' care upon discharge has been limited. Our proposal seeks to understand whether hospitals that preferentially discharge their PAC patients to a select number of SNFs mitigate the forces producing higher re-hospitalization since the hospitals and their preferred SNFs invest in coordinated transition protocols . There are provisions of the Affordable Care Act (ACA) designed to overcome reimbursement related barriers to collaboration between hospital and SNF. We propose to test their provisional effect on how hospitals and SNFs collaborate and the effect this has on re-hospitalization and related patient outcomes. Building upon a decade of national Medicare claims linked to SNF Minimum Data Set assessments and using a mixed quantitative and qualitative methodology, informed by transaction cost economics, we propose to: 1) develop and test a measure of hospital-SNF "preferred provider" relationship; 2) To estimate the effect of strong hospital-SNF relationships on the risk of 30-day re-hospitalization and nursing home residency, controlling for patient acuity, patient selection and market factors; 3) To empirically test the extent to which hospitals strengthen their partnerships (steer their discharged patients) to fewer SNFs in response to the introduction of ACA provisions and participation in ACO's and/or bundling initiatives overtime; and 4) to qualitatively examine the patterns of interaction and exchanges, at the administrative and clinical levels, between hospitals and SNFs to better understand markers of relationship strength as a qualitative test of our quantitative measure of hospital-SNF linkage.