Establishing Medicaid incentives for liberating nursing home patients from ventilators - PubMed (original) (raw)

. 2022 Jan;70(1):259-268.

doi: 10.1111/jgs.17513. Epub 2021 Oct 19.

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Establishing Medicaid incentives for liberating nursing home patients from ventilators

Laura M Keohane et al. J Am Geriatr Soc. 2022 Jan.

Abstract

Background: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives.

Methods: Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators.

Results: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days.

Conclusions: This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.

Keywords: Medicaid; Medicare; nursing homes; prolonged mechanical ventilation; ventilator liberation.

© 2021 The American Geriatrics Society.

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Figures

Figure 1.

Figure 1.

Number of Medicare and Medicaid members with ventilator or tracheostomy-related service use in Tennessee nursing homes, 2011–2017. Notes: Authors’ analysis of TennCare Medicaid claims (Panel A) and traditional Medicare skilled nursing claims (Panel B). Because patients can receive more than one type of ventilator-related service per year, the number of patients with each type of service sums to more than the total number of unique patients with any services use. Number of nursing homes reports the number of Tennessee nursing homes that had at least two patients in a given year for TennCare chronic ventilator services (Panel A) or for Medicare ventilator and tracheostomy services (Panel B).

Figure 2.

Figure 2.

Distribution of discharge destination among Tennessee inpatients with prolonged mechanical ventilator use while hospitalized, 2010–2017. Notes: Authors’ analysis of the Tennessee Hospital Discharge records database. Inpatient population included patients who had at least a four day inpatient stay and a diagnosis code indicating continuous mechanical ventilator use for at least 96 hours while hospitalized. Hospitals counted according to number of unique national provider identifiers.

Figure 3.

Figure 3.

Percent of all enhanced respiratory care nursing facility patients successfully weaned from ventilator within six months of admission and median days from admission to wean, 2015–2017. Notes: Authors’ analysis of the provider-reported quality data. Study population includes are patients treated for ventilator-related services at nursing homes participating in the ERC program. To be considered a successful wean, a patient must be liberated from a ventilator for at least seven days. To be included in the numerator for percentage of ERC patients successfully weaned within 6 months, patients must have a wean date within 6 months of nursing home admission. Median days from admission to wean includes all ventilator liberation outcomes regardless of timing since admission.

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