THE ALLIANCE FOR QUALITY NURSING HOME CARE
Rehospitalizations From Skilled Nursing Facilities
A Multifaceted Issue That Calls for Innovative Policy Solutions
Introduction
THERE IS BROAD INTEREST in improving
the quality and efficiency of the health care
system in the United States. Policymakers
are increasingly focused on the rate of
rehospitalizations as an area for potential
improvement.1,2 An estimated one-fifth of
Medicare beneficiaries who are discharged
from the hospital are readmitted within 30
days. Ninety percent of those admissions
are unplanned, and they cost Medicare an
estimated $17.4 billion in 2004.3,4 In addi-
tion to their cost, rehospitalizations appear
to increase the risk of health complications,
Rehospitalizations Have Increased Substantially Over the Past 30 Years
ALMOST ONE-FIFTH of Medicare
beneficiaries are readmitted within 30
days of discharge from a hospital, and
this rate is increasing over time. There
are a number of ways to calculate
rehospitalization rates, but estimates
range from about 17.6 percent to
19.6 percent for Medicare beneficiaries
within 30 days of discharge.6,7 The
share of Medicare beneficiaries who
are rehospitalized within 90 days of
discharge is even greater, at 34 percent.8
Rehospitalizations have become
much more common over the past
JANUARY 2010
resulting in greater functional and cognitive
impairment for patients.5
Nursing facilities are the dominant
provider of Medicare post-acute care
services, and they represent an impor-
tant element of any strategy to reduce
rehospitalizations. A more detailed
exploration of rehospitalizations from
nursing facilities suggests the issue is
complex and driven by the interplay of
several factors. Rehospitalization rates
vary substantially by region, implying
that local practice norms may play an
30 years. The rehospitalization rate
for fee-for-service Medicare beneficiaries
within 60 days of discharge rose from
The rate of Medicare rehospitalization has increased over
the last 3 decades.
Figure 1: Rehospitalization Rate within 60 Days of Hospital Discharge, 1976–78 versus 2003–04.
Rehospitalization Rate
40%
30% 22.5%
20%
10%
0%
1976 to 1978
Source: Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-For-Service Program.
New England Journal of Medicine, 360(14). 2 April 2009.
important role. Specific state and nursing
facility characteristics – such as higher
Medicaid payments and more generous
nurse staffing – also have significant
impacts on rehospitalization. Although
some causes of rehospitalization are
not well understood, the research done
to date suggests that efforts to reduce
reshopitalizations will have the greatest
impact if they reach beyond the Medicare
program and consider nursing facilities’
broader operating and reimbursement
environment.
22.5 percent during the 1976-1978
period to 31.1 percent in the 2003–2004
period.9
31.1%
2003 to 2004
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES

Medicare’s Fragmented Payment Systems May Contribute to Increased

Rehospitalization Rates

SEVERAL FACTORS MAY PLAY A ROLE in
causing higher rates of rehospitalization.
The Centers for Medicare & Medicaid
Services (CMS) uses a prospective pay-
ment system that pays hospitals a fixed
fee for each type of case, providing a
powerful incentive for hospitals to reduce
costs and length of stay.10 In some cases,
efforts by hospitals to transition patients
more quickly to post-acute care or back into
the community may increase the risk of
rehospitalization.11,12
The fragmented nature of the
health care system also contributes
to rehospitalizations as there can be
insufficient communication and
continuity between settings of care.
Medicare reimburses each provider
for the individual services furnished to
its patients. As a result, discharging
and admitting facilities are often focused
on their individual treatment of patients
instead of working together to treat
a patient over the course of an entire
episode of illness. Insufficient coordina-
tion and communication between the
discharging hospital and the community
physician or post-acute care setting
can lead to a whole host of problems,
including poor medication adherence,
lack of a follow-up visit from the physi-
cian, and inadequate understanding
of the warning signs of a worsening
condition. 13,14,15,16
Hospitals and other providers also lack
financial incentives to invest in processes
that would reduce rehospitalization rates.
Medicare does not explicitly reimburse for
services that may reduce rehospitaliza-
tions, such as follow-up calls and other
care management services. In addition,
rehospitalizations usually mean higher rev-
enues for hospitals – there is no financial
penalty for the rehospitalization because
Medicare pays hospitals for both the initial
stay and the rehospitalization, as long as
the rehospitalization occurs more than
24 hours after the initial discharge.17 Both
the House and the Senate health reform
bills would reduce Medicare hospital
payments for certain rehospitalizations.

Rehospitalizations Are Expensive and Increase the Risk of Health Complications

REDUCING THE RATE of rehospitalization serious risk with an estimated 1.7 million facility residents return from the hospital
is important for several reasons. First, HAIs occurring in hospitals each year.21 with other complications, such as new
rehospitalizations are costly. One study In addition to infections, many nursing pressure ulcers.22
estimated that the cost of unplanned
rehospitalizations within 30 days of
hospital discharge accounted for $17.4
Unplanned rehospitalizations represent 17 percent of total
billion of the $102.6 billion in total
Medicare inpatient hospital spending.
Medicare inpatient payments to hospitals
in 2004.18 The $17.4 billion figure includes Figure 2: Unplanned Rehospitalizations as a Share of Total Inpatient Hospital
only unplanned rehospitalizations; the Spending, 2004.
study found that 10 percent of rehospital- Total Hospital Spending: $102.6 Billion
izations were a planned part of a patient’s
course of treatment and did not include Unplanned rehospitalizations
spending, $17.4 billion
them in its estimate.19
Recent research indicates that a sig-
nificant share of unplanned rehospitaliza-
Other hospital spending,
tions are preventable. MedPAC estimates $85.2 billion
that the cost of potentially preventable
hospital readmissions within 30 days of
discharge alone is $12 billion.20
A return trip to the hospital also
increases the risk that a patient will expe- Source: Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-For-Service
Program. New England Journal of Medicine, 360(14). 2 April 2009.
rience a health complication. Healthcare
associated infections (HAI) represent a

2
 JANUARY 2010

Rehospitalizations expose nursing greater functional and cognitive higher risk of developing complications,
facility residents to possible treatment- impairment.23 Those nursing facility such as delirium, when hospitalized.24
related complications, which can lead to residents with dementia have an even

As the Dominant Provider of Medicare Post-Acute Care Services, Nursing Facilities are an
Important Element of any Strategy to Reduce Rehospitalizations

ALTHOUGH REHOSPITALIZATION RATES

are increasing across all provider types,
Nursing facilities are the dominant post-acute care provider for
rehospitalizations from nursing facilities
Medicare patients discharged from hospitals.
are worth examining in more detail
because nursing facilities are the domi- Figure 3: Share of Medicare Hospital Post-Acute Discharges by Provider, 2006.
nant provider of Medicare post-acute
care services. Approximately 40 percent
of Medicare beneficiaries hospitalized in 36.5% 52.0% Nursing facilities
2006 were discharged from the hospital
Long-term care hospitals
to a post-acute care setting.25 Nursing
Inpatient rehabilitation facilities
facilities treated 52 percent of these
Home health care agencies
Medicare beneficiaries.26
In line with national trends, the rate of
rehospitalizations from nursing facilities 8.9%
is increasing. The rehospitalization rate of 2.7%
nursing facility Medicare patients within
Source: Avalere analysis of 2006 Medicare 100 Percent Standard Analytic File (SAF) claims data base
30 days of hospital discharge rose from from the Centers for Medicare & Medicaid Services (CMS).
18.2 percent in 2000 to 23.5 percent in
2006, an increase of 29 percent.27
Nursing facility rehospitalizations are Like other providers, nursing facility rehospitalization rates
also costly. In 2006, the 23.5 percent of are increasing
Medicare beneficiaries in nursing facilities
that returned directly to the hospital within Figure 4: Nursing Facility Rehospitalization Rate, 2000–2006

30 days of discharge accounted for 26%

about $4.3 billion in Medicare spending
24% 23.5%
for rehospitalizations that year.28
Rehospitalization Rate

22%

20%
18.2%
18%

CONSIDER
16%

14%

12%
In 2004, Medicare spent an
2000 2001 2002 2003 2004 2005 2006
estimated $17.4 billion on
unplanned rehospitalizations Source: Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing Facilities, Health Affairs.
January 2010.

3
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES

Hospitalization Rates for Long-Stay Residents Have Increased Along With Rehospitalization
Rates of Short-Stay Residents

NURSING FACILITIES CARE for two
distinct patient populations – short-stay
patients who are recuperating following
an acute episode and long-stay residents
with complex medical needs. Short-stay
patients receive intensive medical
or therapeutic care and rehabilitative
services following a hospitalization, and
their services are generally covered
by Medicare or private payers.29,30
Long-stay patients often have complex
medical conditions and limitations
in activities of daily living (ADLs) or
instrumental activities of daily living
(IADLs), and may, in some instances,
be cognitively impaired.31 Care for
long-stay patients is funded principally
through Medicaid or individual and
family expenditures.
As rates of Medicare rehospitalizations
have increased, so have hospitalizations
of long-stay patients. The average
hospitalization rate for long-stay nursing
facility residents by state increased from
18.9 percent in 2000 to 20.9 percent in
2004, an increase of almost 11 percent.32
Studies suggest that some portion of
nursing home-to-hospital transfers are
unnecessary because the conditions
for which the patient was admitted could
have been safely treated in the nursing
facility.33

Hospitalization and Rehospitalization Rates Vary Significantly by Region

THE CAUSES OF HOSPITALIZATION

AND REHOSPITALIZATION are complex
There is a significant amount of geographic variation in
and multifaceted. For example, there
is significant regional variation in hospi-
rehospitalizations among short-stay nursing facility patients.
talization and rehospitalization rates for Figure 5: Frequency of Rehospitalization of Short-Stay Nursing Home Residents,
nursing facility residents. In 2006, the by State, 2006
rate of rehospitalization for Medicare
nursing facility patients within 30 days WA VT ME
MT ND
of discharge ranged from a low of 15.1 OR
MN NH
WI NY MA
ID SD
percent in Utah to a high of 28.2 percent WY
MI
CT
RI
PA
IA
in Louisiana. The rate was greater than NV
NE
IL IN
OH NJ
DE
UT
WV 15.0% – 16.99%
25 percent in nine states and less than CO KS MO KY
VA MD
D.C.
CA
NC 17.0% – 24.99%
17 percent in nine other states.34 TN
OK SC
AR
For most states, there is a positive AZ NM
MS AL GA 25.0% – 29.99%

correlation between rehospitalization and TX

LA
No information
available
hospitalization rates – states with high FL
AK
rates of rehospitalization tend to have high
HI
rates of hospitalization for long-stay resi-
dents.35 In 2000, the rate of hospitalization
Source: Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing Facilities, Health Affairs.
varied from a low of 8.4 percent in Utah to January 2010.
a high of 24.9 percent in Louisiana, which

IN CONTEXT F
 or most states, there is a positive correlation between nursing facility
rehospitalization and hospitalization rates – states with high rates of rehospitalization
tend to have high rates of hospitalization for long-stay residents.

4
 JANUARY 2010

means long-stay nursing facility residents

in Louisiana were three times more likely
There is a significant amount of geographic variation in
to be hospitalized than their counterparts
hospitalizations among long-stay nursing facility patients.
in Utah.36 These regional trends appear to
be fairly consistent year to year. In 2006, Figure 6: Five-Months Hospitalization Rates of Long-Stay Nursing Home Residents,
for example, Louisiana and Mississippi by State, 2000
had hospitalization rates over 30 percent
WA VT ME
whereas the lowest using states, Oregon, MT ND
MN NH
Utah, and Arizona, had rates below OR
SD WI NY MA
ID RI
MI
10 percent.37 WY
IA
PA CT
NE OH NJ
NV IL IN DE
UT
WV
VA MD 8.4% – 12.1%
CO KS MO
CA KY D.C.
NC 12.2% – 16.0%
TN
OK SC

CONSIDER
AZ NM AR
GA 16.1% – 18.9%
AL
LA
TX 19.0% – 24.9%
FL
Local areas that tend to AK N
 o information
available
use more Medicare services HI
generally are also more
likely to hospitalize nursing Source: Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of States’ Medicaid Payment
facility residents and Bed-Hold Policies. Health Services Research. 2008.

Local Practice Patterns Appear to be an Important Factor in Regional Variation

WHILE THERE ARE REAL REGIONAL

DIFFERENCES in patient demographics,
Hospitalizations in nursing facilities are more prevalent in states
patient acuity, nursing facility utilization,
with elevated inpatient Medicare reimbursements.
and the relative importance of various
payers, these factors do not fully account Figure 7: Post-Acute Rehospitalization Rate and Inpatient Medicare Reimbursements Per
for the variation in rehospitalization across Decedent During Last Two Years of Life
states.38 Another important element is the
30.0
use of other Medicare services, such as
30-day Rehospitalization Rate (%), 2004

physician visits, which is highly correlated 25.0

with hospitalization and rehospitalization
rates, suggesting that local practice 20.0
patterns are an important factor in
explaining regional variation. 15.0
More than 30 percent of the variation
among states in rehospitalization rates for 10.0
nursing facility residents can be explained
by variation in inpatient Medicare reim- 5.0

bursement.39 The number of physician

visits in the last two years of life is also 0.0
$15,000 $20,000 $25,000 $30,000 $35,000 $40,000
strongly correlated with hospitalization
and re-hospitalization rates, further Reimbursement per decedent in last 2 years of life (2001–2005)

suggesting local areas that tend to use Source: Vincent Mor and David Grabowski. Understanding Skilled Nursing Facility Re-Hospitalizations:
more Medicare services generally are Variation by Patient Type and Region. 2008.

also more likely to hospitalize.40

5
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES

Targeted Care Models Can Reduce Rehospitalizations and Health Care Costs

ALTHOUGH SOME COORDINATED CARE

MODELS fail to generate cost savings,41
a number of programs have been able to
reduce hospitalizations and health care
costs by providing additional “care transi-
tion” services that bridge multiple settings
of care. These programs provide patients
and caregivers with tools and coaching to
navigate the transition from acute care to
post-acute care and/or the community.
The interventions typically rely on a
specially trained nurse to coordinate care
and track a patient through the transition.
The nurse educates the patient and her
caregivers about the patient’s condition,
rehabilitation, and medications. This
process promotes proper management
and awareness of “red flags” that indicate
a worsening condition and appropriate
responses to warning signs.42 The program
may provide patients with records they
own and maintain themselves, which facili-
tates the transfer of important information
Patients receiving care transition interventions have lower
rehospitalization rates.
Figure 8: Results from the Care Transitions Model: Rehospitalization Rates by Intervention
and Control Groups, 2002–2003
40% Intervention Group Control Group
Rehospitalization Rate
30.7%
30% 25.6%
22.5%
20% 16.7%
11.9%
10%
8.3%
0%
Within 30 Days Within 90 Days Within 180 Days
Source: Coleman, Eric A., Carla Parry, Sandra Chalmers, and Sung-joon Min. The Care Transitions Intervention.
Archives of Internal Medicine, 166(17). September 2006.
across sites of care. Transition nurses also after release from a hospital and continuing
provide regular follow-up with patients up to one year after discharge.44,45 Savings
to track their progress in rehabilitation.43 from these programs ranged from an
These interventions have lowered estimated $800 to $1,200 per patient
rehospitalization rates for enrollees at each each year.
measured time interval, starting at 30 days

Enhanced Staffing and Higher Medicaid Payments Contribute to Lower Nursing Facility
Hospitalization and Rehospitalization Rates

WITHIN THE NURSING FACILITY SETTING, More generous nurse staffing levels recommended 4.55 hours per resident
higher staffing levels and more generous also appear to significantly lower rates of day and higher proportions of registered
Medicaid payment rates also have a hospitalization. Nurse staffing beyond the nurses to total nurses in a facility have
measurable impact on hospitalization
and rehospitalization.45 The two factors
are interrelated since higher Medicaid
payment rates are associated with more
As Medicaid rates increase, nursing levels rise.
staffing, suggesting that nursing facilities Figure 9: Mean Number of Nurses per 100 Residents, by Medicaid Rate.
staff at higher levels where Medicaid
payments support them.46,47 Medicaid Rate Registered Licensed Practical Nurses’
Staffing characteristics, such as the Nurses (RNs) Nurses (LPNs) Assistants
availability of nurse practitioners (NPs) $65 6.45 13.27 40.73
and physician assistants (PAs) in nursing $75 6.81 13.72 41.86
facilities, appears to significantly reduce $85 7.17 14.16 42.99
rates of initial hospital admissions and $95 7.53 14.60 44.10
rehospitalizations.48,49 NPs and PAs allow $105 7.89 15.04 45.21
some conditions that would otherwise Source: Grabowski, David C. Does an Increase in the Medicaid Reimbursement Rate Improve Nursing
require hospital admission to be managed Home Quality? The Journals of Gerontology. March 2001.

in the nursing facility.50

6

been shown to be effective at reducing
hospital admissions.51 Overall, rates of
hospitalization are lower in facilities that
have higher nurse aide and licensed staff
levels and high staff retention rates.52
Higher Medicaid nursing facility
payment rates are also associated with
lower odds of hospitalization. A $10
increase in the daily Medicaid payment
rate above the state average, for example,
is associated with a 5 percent lower odds
of hospitalization.53 Conversely, reductions
Importance of Aligning Incentives Between Medicare and Medicaid
FOR NURSING FACILITIES in particular,
policies aimed at reducing rehospitaliza-
tion must consider the complex interplay
between Medicare and Medicaid. More
than 88 percent of people in nursing
facilities at any point in time are over age
65. Since nearly all people over 65 are
covered by Medicare, the vast majority
of Medicaid-covered residents in nursing
facilities are dually eligible. Medicare typi-
cally covers acute care services, including
hospitalizations and post-acute care, while
Medicaid pays for long-term care in the
nursing facility and Medicare cost sharing.
Dual eligibles are disproportionately
costly, accounting for 19 percent of total
Key Considerations
Rehospitalizations occur in every post-
acute care setting, including the home.
Efforts to address this issue must take into
consideration the complex factors that
cause rehospitalizations. Policymakers
must also consider the unique challenges
that nursing facilities face as the dominant
provider of post-acute care, the site of
care that is most dramatically affected
by conflicting Medicare and Medicaid
financial incentives, and a care setting
where the frailest population resides for
longer stretches of time. Policy focused on
in Medicaid payments bring additional risk
of hospitalization.54
Varying Medicaid payment rates to
nursing facilities based on case mix also
appears to reduce rates of hospitalization.
Patients in states that adjusted payments
for case mix were 12 percent less likely to
be hospitalized than patients in states that
relied on uniform payment rates.55
On the other hand, one factor that
appears to increase hospitalization rates is
the existence of state bed-hold policies.
Medicare beneficiaries but 31 percent of
total Medicare spending.58
Although Medicare and Medicaid
cover many of the same beneficiaries,
they have conflicting incentives because
saving money in one program may shift
costs to the other program without saving
much money overall. Although higher
Medicaid payments contribute to reduced
hospitalizations, State Medicaid programs
have little financial incentive to increase
payments because the resulting savings
accrue mainly to the Medicare program
(in the form of reduced spending for acute
care episodes) rather than to Medicaid.
Conversely, Medicare-only proposals,
this setting could have a dramatic impact
on the rate of rehospitalizations and
hospitalizations. Key considerations for
policymakers include:
• Do current Medicare proposals to
reduce rehospitalizations promote
interventions, such as coordinated
care models, higher Medicaid rates,
or enhanced staffing that would lead
to lower rates of hospitalization or
rehospitalization?
• Given the relationship between
Medicaid funding, staffing, and
JANUARY 2010
A bed-hold policy reserves a nursing
facility resident’s bed for a specified period
of time while the resident is hospitalized.
Nursing facility residents in states with
bed-hold policies have a 36 percent higher
frequency of hospitalization than residents
in states without them.56 It is not known
if the lower prevalence of hospitalization
reflects more appropriate utilization or
some patients’ refusal to obtain necessary
medical treatment because they fear
losing their bed.57
such as the use of bundled payments, are
unlikely to affect rates of hospitalization
for long-stay patients. The challenge in any
Federal policy effort, therefore, is ensuring
that costs are not simply transferred
from one program to the other.59 Some
researchers suggest that combining
Medicare and Medicaid payments into a
single capitated rate or making the federal
government completely responsible for
providing long-term care to dual eligibles
are worth exploring because they would
promote greater coordination and align
incentives to reduce hospitalizations
across payers and patients.60,61
rehospitalization, should policy
proposals give states an incentive to
maintain adequate Medicaid rates?
• How does regional variation and cor-
relation of nursing facility rehospitaliza-
tions with other Medicare expenditures
inform future policy development?
• Given the interaction of multiple providers
and settings of care in rehospitalizations,
should policy development focus on
promoting system-wide coordination
through, for example, providing support
for electronic health record adoption?
7
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES
ENDNOTES
1 National Quality Forum, Candidate Hospital Care Additional Priorities: 2007
Performance Measure. Washington DC, 2007.
2 Application of Incentives to Reduce Avoidable Readmissions to Hospitals. Federal
Register 2008; 73(84):23673-5.
3 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater
Efficiency in Medicare. June 2007.
4 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009.
5 Ouslander, J.G., A.D. Weinberg, and V. Philips. Inappropriate Hospitalization of
Nursing Facility Residents: A Symptom of a Sick System of Care for Frail Older
People. Journal of American Geriatric Society, 48(2). 2000.
6 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater
Efficiency in Medicare. June 2007.
7 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009.
8 Ibid.
9 Ibid.
10 Michael Morrisey et al. Shifting Medicare Patients out of the Hospital. Health
Affairs. Winter 1988.
11 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater
Efficiency in Medicare. June 2007.
12 Vincent Mor et al. Changes in the Quality of Nursing Homes in the US: A Review
and Data Update. 15 August 2009.
13 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater
Efficiency in Medicare. June 2007.
14 Vincent Mor et al. Changes in the Quality of Nursing Homes in the US: A Review
and Data Update. 15 August 2009.
15 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009.
16 Coleman, Eric A et al. The Care Transitions Intervention. Archives of Internal
Medicine, 166(17). September 2006.
17 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater
Efficiency in Medicare. June 2007.
18 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009.
19 Ibid.
20 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater
Efficiency in Medicare. June 2007.
21 R. Monina Klevens et al. Estimating Health Care-Associated Infections and Deaths
in U.S. Hospitals, 2002. Public Health Reports, 22. March-April 2007.
22 D.D. Tresch et al. Relationship of Long-Term and Acute-Care Facilities: The Problem
of Patient Transfer and Continuity of Care. Journal of the American Geriatrics
Society, 33. 1985.
23 Ouslander, J.G., A.D. Weinberg, and V. Philips. Inappropriate Hospitalization of
Nursing Facility Residents: A Symptom of a Sick System of Care for Frail Older
People. Journal of American Geriatric Society, 48(2). 2000.
24 Cunningham, A.C. Supporting People with Dementia in Acute Hospital Settings.
Nursing Standard, 20. 2006.
25 Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing
Facilities, Health Affairs. January 2010.
26 Avalere analysis of 2006 Medicare 100 Percent Standard Analytic File (SAF)
claims data vase from the Centers for Medicare & Medicaid Services (CMS).
27 Vincent Mor et al. The Revolving Door of Rehospitalization. Health Affairs. January/
February 2010.
28 Ibid.
29 Alecxih, Lisa. Nursing Home Use by Oldest Old Sharply Declines. Presented at
National Press Club, November 21, 2006.
30 Medicare Payment Advisory Commission. Report to the Congress: Medicare
Payment Policy, March 2009.
31 Alecxih, Lisa. Nursing Home Use by Oldest Old Sharply Declines. Presented at
National Press Club, November 21, 2006.
32 Mor, Vincent, and David C. Grabowski. Understanding Skilled Nursing Facility
Rehospitalizations: Variation by Patient Type and Region. December 2008.
33 Grabowski, David, A. James O’Malley, and Nancy R. Barhydt. The Costs and
Potential Savings Associated with Nursing Home Hospitalizations. Health Affairs
26(6). November/December 2007.
Care Context is produced by the Alliance for Quality Nursing Home Care with research and analytic support by Avalere Health.
Alliance for Quality Nursing Home Care
1101 Pennsylvania Ave. NW, Sixth Floor
Washington, DC 20004
202.742.6740
www.aqnhc.org
8
34 Vincent Mor et al. The Revolving Door of Rehospitalization. Health Affairs. January/
February 2010.
35 Mor, Vincent, and David C. Grabowski. Understanding Skilled Nursing Facility
Rehospitalizations: Variation by Patient Type and Region. December 2008.
36 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
37 Mor, Vincent et al. Changes in the Quality of Nursing Homes in the US: A Review
and Data Update. 15 August 2009.
38 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
39 Mor, Vincent, and David C. Grabowski. Understanding Skilled Nursing Facility
Rehospitalizations: Variation by Patient Type and Region. December 2008.
40 Vincent Mor et al. The Revolving Door of Rehospitalization. Health Affairs. January/
February 2010.
41 Peikes D, Chen A, Schore J, and Brown R. Effects of Care Coordination on
Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare
Beneficiaries: 15 Randomized Trials. JAMA 2009; 301:603-618.
42 Eric A. Coleman et al. The Care Transitions Intervention. Archives of Internal
Medicine, 166(17). September 2006.
43 Ibid.
44 Ibid.
45 Bruce Leff et al. Guided Care and the Cost of Complex Healthcare: A Preliminary
Report. The American Journal of Managed Care, 15(8). August 2009.
46 David C. Grabowski. Medicare and Medicaid: Conflicting Incentives for Long-Term
Care. The Milibank Quarterly, 85(4). December 2007.
47 Grabowski, David C. Does an Increase in the Medicaid Reimbursement Rate
Improve Nursing Home Quality? The Journals of Gerontology. March 2001.
48 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
49 Robert L. Kane et al. The Effect of Evercare on Hospital Use. Journal of the
American Geriatrics Society, 51:10. 23 September 2003.
50 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
51 Robert L. Kane et al. The Effect of Evercare on Hospital Use. Journal of the
American Geriatrics Society, 51:10. 23 September 2003.
52 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
53 Kramer, A.M., and R. Fish. The Relationship between Nurse Staffing Levels and
the Quality of Nursing Home Care. Centers for Medicare and Medicaid Services.
In ABT Associates, Appropriateness of Minimum Nurse Staffing Ratios in Nursing
Homes: Phase II final report, December 2001.
54 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
55 Ibid.
56 Intrator, Orna, and Vincent Mor. Effect of State Medicaid Reimbursement Rates on
Hospitalizations from Nursing Homes. Journal of the American Geriatrics Society,
52(3). March 2004.
57 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
58 Ibid.
59 Coughlin, Teresa, Timothy Waidmann, and Molly O’Malley Watts. Where Does
the Burden Lie? Medicaid and Medicare Spending for Dual Eligible Beneficiaries,
Kaiser Commission on the Uninsured, April 2009.
60 Grabowski, David C., A. James O’Malley, and Nancy R. Barhydt. The Costs And
Potential Savings Associated with Nursing Home Hospitalizations, Health Affairs,
November/December 2007.
61 Grabowski, David C. Medicare and Medicaid: Conflicting Incentives for Long-Term
Care. The Milibank Quarterly, 85(4). December 2007.
62 Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing
Facilities, Health Affairs. January/February 2010.
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