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，即医院和急症后提供者如何合作，以改善患者的体验并减少再次住院。急症后护理，特别是到专业护理机构（SNF）进行护理的人数大幅增加，与此同时，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受SNF出院的患者征收处罚，因此确保跨设置协调护理以防止此类情况的组织战略不发达，医院对出院后患者护理的责任有限。我们的建议旨在了解，由于医院及其首选的医院投资于协调的过渡协议，优先将其PAC患者送到选定数量的snf的医院是否减轻了产生更高再住院率的压力。《负担得起的医疗法案》（ACA）的一些条款旨在克服医院与国家医疗服务机构之间合作中与报销有关的障碍。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国家医疗保险索赔，并使用混合定量和定性方法，根据交易成本经济学，我们建议：1)开发和测试医院-SNF“首选提供者”关系的衡量标准；2)在控制患者敏锐度、患者选择和市场因素的情况下，评估强关系对30天再住院和养老院居住风险的影响；3)实证检验医院加强合作伙伴关系（引导出院患者）以减少snf的程度，以应对ACA条款的引入以及参与ACO和/或捆绑举措；4)在行政和临床层面，定性地检查医院和snf之间的互动和交流模式，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检验。

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.