Dual eligibles who move from a long-term care facility to home- and community-based services have a 40% increased risk of a potentially preventable hospital stay, according to recently published research.

Researchers at the University of Minnesota and the University of Hong Kong analyzed Centers for Medicare & Medicaid Services data for seven states, then compared hospitalizations experienced by two groups: dual eligibles who transitioned out of a nursing home between 2003 and 2005, and those who remained in a long-term care facility during that time.

Controlling for demographic and medical factors, the researchers determined that people who transitioned had an elevated risk of being hospitalized and also had their first hospitalization sooner than those living in nursing homes. Including both preventable and non-preventable hospitalizations, 419 people in the transition group were admitted while 297 of the nursing home residents were admitted.

Members of nursing home staff provide round-the-clock care and generally have more training than caregivers in home and community settings, which likely are reasons for these results, said lead researcher Andrea Wysocki, Ph.D., now a post-doctoral fellow at Brown University. This issue could be addressed in part by more “vigilant and effective” treatment of chronic conditions in the home- and community-based settings, the researchers surmised.

Another factor is unaligned reimbursement, Wysocki noted. Medicaid is not incentivized to keep dual eligibles out of the hospital, because Medicare pays for that care. Demonstration projects currently are underway to test payment models that align Medicare and Medicaid, and Wysocki said these could limit hospitalizations of discharged dual eligibles, a group expected to cost $330 billion in 2013.  

Some of these programs for dual eligibles have come under fire for being poorly designed and implemented. But the Affordable Care Act introduced a number of new payment systems that are meant to encourage care coordination and reduce hospitalizations. Hospitals face penalties if they exceed a certain rate of readmissions each year, and this penalty also has been proposed for skilled nursing facilities.

Bundled payment models, such as accountable care organizations, embrace the general idea that providers who achieve good patient outcomes while limiting costs can then share the savings among themselves. These models would reward providers that can transition people out of institutional settings without frequent and unnecessary readmissions. This also is likely to improve patient satisfaction, as studies have shown people prefer to reside at home.