Post-Acute Care Transitions for Older Adult Medicare Beneficiaries with Serious Mental Illness - PROJECT SUMMARY/ABSTRACT Roughly 1.5 million Medicare patients receive care in a skilled nursing facility (SNF) following acute hospitalization each year. Older adults (65+ years) with serious mental illness (SMI) are a large and growing segment of the SNF population, with specific needs that leave these individuals vulnerable to gaps or errors in care. Understanding how older adults with SMI are connected to post-acute SNF care and how they transition out of post-acute SNF care is essential to ensuring access to an appropriate level of services and high-quality care across the continuum. To date, there has been little work characterizing the post-acute care (PAC) trajectory of older adults with SMI. This study proposes two aims. First, I will (1) assess the extent to which SNF placement patterns differ for patients with SMI. This is motivated by the concern that hospitals are known to invest selectively with SNF partners in improved transitional care practices; if these investments are not aligned with where patients with SMI are sent for care, care disparities may persist or worsen over time. To assess SNF placement patterns, I will describe patterns of hospital to SNF discharge for older adults with and without (a) narrow groupings of SMI (schizophrenia, bipolar disorder), and (b) broad groupings of SMI (narrow SMI + major depression, anxiety, compulsive disorders) as compared to conditions targeted by the hospital readmission reduction program (HRRP). Patients with HRRP conditions are a useful comparison group as they represent populations where hospitals are most likely to have invested in high-quality care transitions to reduce the risk of penalties for hospital readmission. I will use a discrete choice model to evaluate patterns of hospital discharge to preferred-SNF partners to determine whether older adults with SMI have equitable access to hospitals’ more preferred SNF partners, and if this is moderated by the presence of HRRP conditions. In my second aim, I will (2) identify patient-, facility-, and county-level characteristics associated with discharge of older adults with SMI to the community within the 100-day post-acute period. Characterizing factors associated with return to community rather than conversion to long-stay (100+ days) is important given that services provided in the home or community are of higher value and in alignment with patient preferences. I will use a three-level mixed effects model to identify factors related to whether an older adult with SMI is discharged to the community following a SNF stay. This research quantifies (1) how older adult patients with SMI sort into SNFs; and (2) patient, facility, and county-level geographic factors associated with community discharge following a SNF stay, an important component of high-quality care. By identifying where older adults with SMI receive SNF care and how this influences their care trajectory, this work will generate key insights meant to guide policymakers and organizational leaders in the evaluation and improvement of payment/incentive structures and regulatory requirements that affect care delivery for this population.
