1. Effects of Organizational Relationships on PAC Site of Care Choices Barbara Gage, PhD, Melissa Morley, PhD, Roberta Constantine, PhD, Pamela Spain, PhD, Melvin Ingber, PhD, Justine Allpress, BS, RTI International Funded by ASPE Susan Bogasky, Project Officer Academy Health Annual Research Meeting June, 2008

2. 2 Study Purpose and Primary Analyses Examine the effects of organizational links between acute and post-acute care on the likelihood of post-acute care use, the types of services used, and the number and types of transitions. Geographic analysis of provider availability Episode analysis using 2005 Medicare claims Transfer pattern analysis Utilization, length of stay, and Medicare payments Organizational linkages Regression models

3. 3 Data Sources Medicare claims (CY 2005) Primary source used to build episodes Utilization, payments, patterns of PAC use Online Survey and Certification Reporting System (CY 2006) Facility characteristics Geographic analyses Hospital cost report data (FY 2004-2005) Identify hospital-based sub-providers

4. 4 Methods Defining Organizational Relationships 3 types of mutually-exclusive organizational relationships Acute Discharge to: 1. Hospital-based sub-providers: identified as owned by the HCRIS reports 2. Co-located providers: identified by geographic latitude and longitude coordinates of free-standing providers within 250 yards of each other using GIS 3. Free-standing providers: those not in the other 2 groups

5. 5 Methods Creating Episodes of Care Beneficiary-level episodes of care including all services after the index hospitalization until a 60 day gap in services occurs Episodes include acute hospital stay, long term care hospital, inpatient rehabilitation facility, skilled nursing facility, home health, and hospital outpatient therapy Episodes include hospital readmissions Only live hospital discharges are included in the prediction models

6. 6 SOURCE: RTI Analysis of 2006 POS data. Distribution of Freestanding versus Hospital Based SNFs, IRFs, and HwH LTCHs, 2006

7. 7 Co-located Providers, 2006 SOURCE: RTI Analysis of 2006 POS data.

8. 8 Acute Index Admission LOS and Payment, by Discharge Destination, 2005 SOURCE: RTI Analysis of 2005 Medicare Claims (mmor075b).

9. 9 Proportion of Discharges to First PAC Setting by Organizational Relationship, 2005 SOURCE: RTI analysis of 2005 Medicare Claims (mmor120).

10. 10 Demographics and Severity by Discharge Destination, 2005 SOURCE: RTI Analysis of 2005 Medicare Claims (mmor075b).

11. 11 First Site of Post-Acute Care, by Acute Index Admission DRG, 2005 SOURCE: RTI Analysis of 2005 Medicare Claims (mmor075b).

12. 12 Utilization and Payment * This is a row percent. 1.Note that utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy. 2.APR-DRG level 1 = Minor Severity; APR-DRG level 2 = Moderate Severity; APR-DRG level 3 = Major Severity; APR-DRG level 4 = Extreme Severity.

13. 13 Patterns of Post-Acute Care Use, 2005 NOTES: 1. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF 2. 75 percent of PAC episodes are shown here. SOURCE: RTI analysis of 2005 Medicare claims (mmor167).

14. 14 Regression Results: Predicting Index LOS, PAC Use, and Acute Readmission

15. 15 Regression Results: Predicting First Site of PAC

16. 16 Results Overview: Organizational Relationships Organizational relationships affect choice of PAC setting The presence of a co-located PAC provider (located within 250 yards for the purposes of this analysis) or a PAC subprovider affects discharge patterns to IRF, SNF, LTCH Organizational relationships are not strong predictors of HHA use The odds of PAC use are higher for benes discharged from hospitals with co-located PAC providers or PAC subproviders

17. 17 Results Overview: Supply of PAC Supply of PAC providers does affect use of services Odds of discharges to IRF and LTCH are significantly higher in areas with more beds/1000 beneficiaries

18. 18 Results Overview: Severity of Illness Severity of Illness as measured using APR-DRGs is highly predictive of Index admission LOS Use of any PAC First site of PAC Probability of acute hospital readmission during PAC episode

19. 19 Discussion of Findings Results suggest that site of care choices appear to differ by severity of illness, but Choices are influenced by organizational relationships Substitution is possible, but the presence of a subprovider or co-located provider may influence the relative use of a particular type of PAC provider

20. 20 Limitations Co-location effects are underestimated Certification data limited on satellite providers System membership is not reliably identified Location of co-owned, freestanding providers is not identified-estimated using GIS PECOS data was not complete for this analysis Final Report available at: http://aspe.hhs.gov/health/reports/08/examine/report.html