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

拟议的项目解决了医院和急性后提供者如何合作以改善患者体验并减少再次住院的日益重要的问题。急性期后护理有了巨大的增长，特别是对熟练护理设施（SNF），与再住院的增加相吻合。由于医疗保险政策没有对重新接纳出院到SNF的患者进行处罚，因此确保跨环境协调护理以防止他们的组织战略还不发达，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患者出院到选定数量的SNF的医院是否减轻了产生较高再住院的力量，因为医院及其首选SNF投资于协调的过渡协议。《平价医疗法案》（ACA）的一些条款旨在克服医院和SNF之间合作的报销相关障碍。我们建议测试它们对医院和SNF如何合作的临时影响，以及这对再住院和相关患者结局的影响。基于十年来与SNF最小数据集评估相关的国家医疗保险索赔，并使用混合定量和定性方法，并通过交易成本经济学，我们建议：1）开发和测试医院-SNF“首选提供者”关系的测量; 2）评估医院-SNF关系对30天再住院和疗养院住院风险的影响，控制患者的紧急程度、患者选择和市场因素; 3）实证检验医院加强合作伙伴关系的程度（引导出院患者）减少SNF，以应对ACA规定的引入和ACO的参与和/或超时捆绑举措; 4）定性研究医院和SNF之间在行政和临床层面的互动和交流模式，以更好地理解关系强度的标志，作为我们对医院-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.