Post-acute care of older adults: the role of skilled nursing facility specialists

项目摘要 在专业护理机构（SNF）进行急性期后护理是常见的，结果较差且多变。来 在过去十年中，SNF一直是在控制支出的同时改善结果的努力的目标，但它是强大的 进展仍然渺茫。我们之前的工作表明，专门从事SNF护理的医生数量 (i.e.,“SNFists”）在过去十年中迅速增长。在这项研究中，我们将研究医生是否 专门从事基于SNF的护理，改善功能结果，减少可能避免的医疗保健 在SNF中接受急性期后护理的患者的利用率（如再次入院）。我们亦会研究 基于价值的SNFist与非SNFist的患者功能结局和医疗保健利用 采购举措。为了实现这些目标，我们将扩展现有的医疗保险索赔数据集， 从急症护理医院出院的Medicare按服务收费受益人的SNF临床评估数据 从2012年到2018年的SNF使用这个数据库，我们将研究医生专业化的趋势 在基于价值的购买的背景下，SNF护理（即，出院医院是否参与 捆绑支付或责任医疗组织）、市场竞争以及其他市场和医生 特色接下来，我们将测量SNF护理中医生专业化对患者结局的影响 以及使用差中差跨时间匹配的潜在可避免的保健利用。最后， 我们将对关键人员进行半结构化访谈（例如，护理主任）， 定量识别不同医生之间的培训、实践策略和护理流程， 专注于SNF护理的人和不专注于SNF护理的人。完成后，这些研究将为实践和政策提供信息， 优化（增加或减少）急性期后护理患者对专门从事基于SNF的医生的访问 在乎

PROJECT SUMMARY Post-acute care in skilled nursing facilities (SNFs) is common, and outcomes are poor and variable. Over the past decade, SNFs have been a target of efforts to improve outcomes while controlling spending, but robust gains remain elusive. Our prior work showed that the number of physicians who specialize in SNF-based care (i.e., “SNFists”) grew rapidly over the past decade. In this study, we will examine whether physicians specializing in SNF-based care improve functional outcomes and reduce potentially avoidable healthcare utilization (such as hospital readmissions) of patients receiving post-acute care in SNFs. We will also examine patient functional outcomes and healthcare utilization of SNFists vs. non-SNFists under value-based purchasing initiatives. To accomplish these goals, we will expand an existing dataset of Medicare claims and SNF clinical assessment data for Medicare fee-for-service beneficiaries discharged from an acute care hospital to a SNF from 2012 through 2018. Using this database, we will examine the trends in physician specialization in SNF care in the context of value-based purchasing (i.e., whether the discharging hospital participated in bundled payments or an Accountable Care Organization), market competition, and other market and physician characteristics. Next, we will measure the impact of physician specialization in SNF care on patient outcomes and potentially avoidable healthcare utilization using difference-in-differences cross-temporal matching. Lastly, we will conduct semi-structured interviews with key personnel (e.g., director of nursing) in SNFs to quantitatively identify training, practice strategies and care processes that differ between physicians who specialize in SNF care and those who do not. When complete, these studies will inform practice and policy to optimize (increase or reduce) post-acute care patients' access to physicians who specialize in SNF-based care.