The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions

Abstract

Background: Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients.

Objectives: To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions.

Methods: We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions.

Results: ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001).

Conclusions: Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

Figure 1.

SNF NP ACO Outcomes Flowchart 2012–2017 Notes: Final analytic sample included 527,329 Medicare beneficiaries between 2012–2017 with a qualifying SNF stay. This included 102,822 (19.5%) ACO beneficiaries and 424,507 non-ACO beneficiaries. A minority of patients had one or more E&M claims delivered by a nurse practitioner during their SNF stay in either in ACOs or non-ACOs (41.4% with versus 58.6% without for ACOs, and 37.19% with versus 62.81% without for non-ACOs). ACO beneficiaries were more likely to receive any NP E&M service than non-ACO beneficiaries (41.4% ACO vs. 37.19% non-ACO). SNF hospital readmissions were lower when patients received at least some E&M care from nurse practitioners amongst both the ACO attributed (6.5% with versus 7.76% without) and non-ACO attributed (6.54% with versus 8.04% without). Readmission rates for ACO beneficiaries with nurse practitioner E&M care was similar to non-ACO beneficiaries (6.50% versus 6.54%), and slightly lower in the absence of nurse practitioner E&M care (7.76% versus 8.04%) in crude analyses.

Figure 2.

Predicted Probability of SNF Readmission Conditional on No E&M Care (i.e., 0% E&M Care Share), Shared E&M Care (i.e., 1–50% E&M Care Share), and Majority E&M Care (i.e., 51–100% E&M Care Share) Delivered by Nurse Practitioners Notes: Estimates are predicted probabilities of readmission conditional on covariates at their mean values. Statistical significance reflects predicted probabilities being significantly different from 0. Source: Medicare MedPAR claims data (2012–2017), Medicare Carrier/Professional claims data (2012–2017), and Medicare Summary Beneficiary Files (2012–2017)