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

拟议的项目解决了日益重要的问题，即医院和急性期后提供者如何合作改善患者的体验并减少再次住院。急性后护理，特别是熟练护理机构 (SNF) 的需求出现了巨大增长，同时再住院人数也有所增加。由于医疗保险政策没有对出院后重新入院到 SNF 的患者征收处罚，因此确保跨机构协调护理以防止此类情况发生的组织策略尚未制定，医院对患者出院后护理的责任也有限。我们的提案旨在了解优先将 PAC 患者出院到选定数量的 SNF 的医院是否会减轻因医院及其首选 SNF 投资于协调过渡协议而导致更高的再住院率的因素。 《平价医疗法案》(ACA) 中有一些条款旨在克服医院与 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 合作方式的临时影响，以及对再住院和相关患者结果的影响。基于十年来与 SNF 最低数据集评估相关的国家医疗保险索赔，并使用混合的定量和定性方法，并以交易成本经济学为基础，我们建议：1）开发和测试医院与 SNF“首选提供者”关系的衡量标准； 2) 评估医院与 SNF 的牢固关系对 30 天再住院和疗养院住院治疗风险的影响，控制患者的病情严重程度、患者选择和市场因素； 3) 实证检验医院在多大程度上加强合作伙伴关系（引导出院患者）减少 SNF，以响应 ACA 条款的引入以及加班参与 ACO 和/或捆绑计划； 4) 定性检查医院和 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记，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.