ALOS complex query

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Steven Littlehale
Steven Littlehale

What do you get when you ask two academics, one geriatrician, one reimbursement specialist, and an analyst to define average length of stay? Five different answers. 

While everyone acknowledges the importance of measuring it, and the current focus on reducing it, universally we have not defined it. In addition, we struggle to understand the variances seen in ALOS. 

There is increased pressure from payers, accountable care organizations and the Bundled Payments for Care Improvement (BPCI) Initiative to reduce ALOS. Yet the sometimes singular focus on DRGs to dictate ALOS increases the likelihood of rehospitalization and other patient safety concerns when key comorbidities and conditions that influence the need for skilled care are ignored. These comorbidities and conditions best explain variations in ALOS.

In a recent study we conducted of Massachusetts facilities, we determined that the commonwealth had lower ALOS than the nation, and both have seen their ALOS decrease over the last few years. This was an anticipated finding due to the high presence of Medicare Managed Care and more recently, Pioneer ACOs. 

We also identified that some residents with congestive heart failure, pneumonia and diabetes had variations in ALOS. Conditions such as bowel and bladder incontinence correlated with longer stays, while cognitive impairment correlated with shorter stays.

What if your resident is going home? His or her SNF Medicare stay will be up to 10 days longer if he or she is incontinent. Cognitively impaired patients transitioning to long-stay in the nursing home will come off Medicare about five days sooner. However, if someone is going home, the impact of dementia on ALOS is less significant.

Why should this matter? If you are “going at risk,” you must anticipate cost. More importantly, if you agree to provide care for the resident, you must be prepared to do so. This may mean advocating — with data — for a certain length of stay prior to admission.