Maintaining continuity of care for nursing home residents: effect of states' Medicaid bed-hold policies and reimbursement rates

Abstract

Objective: Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies.

Data sources/study design: Minimum Data Set assessments of long-stay nursing home residents in April-June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics.

Results: Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52-0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer.

Conclusions: Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.

Figure 1

Flow chart of study sample selection and outcomes. Rectangular nodes relate to sample selection, among which those with a darker background represent cases omitted from analyses. Oval nodes represent outcomes. The circular node in the middle represents the final cohort. Of 549,472 long-stay residents of free-standing urban nursing homes, in the second quarter of 2000, 77,955 were hospitalized directly from their original nursing home and entered the study. Of cohort members, 72,158 were discharged back to the original nursing home from the hospital; 4,183 were discharged to another nursing home; and 1,614 were discharged to another institution.