The Myth of Rehab for Hospitalized Seniors: Forty Percent Never Return Home

Most seniors and senior caregivers believe that discharge from a hospital into a skilled nursing facility (SNF) is just  another natural and obvious step on the road to rehabilitation and recovery, with the hope of heading home on the eventual horizon.  The health care industry actively and intentionally supports this belief in the  information provided to caregivers and patients at the time of discharge.  Even the name of the SNF's sells this hope; a large number of these facilities have the word “rehabilitation” in their name.  A review of a New York’s statewide directory for example, lists 622 facilities, with over half of them having “rehabilitation” in the title. The Ohio Care Planning Council lists 802 facilities, with forty percent (40%) of them having "rehabilitation" in the title. The very name of these  facilities perpetuates a mistaken belief that a hospitalized senior whose Medicare benefit has "run out," will soon return home.

Readers of this blog know, however, that adverse health outcomes inherent to institutional skilled nursing care, and adverse health outcomes endemic, but not inherent, in these facilities, often cause short term rehabilitation to become permanent perpetual skilled care. A significant number of patients entering these facilities experience adverse outcomes, and never make it back home.  A study by the Inspector General of Health and Human Services (HHS), which incidentally only considered patients institutionalized for thirty-five (35) days or less, found that approximately one-third were injured or killed by the very nursing homes that were intended to complete the care necessary to allow them to return home.  Most of these adverse outcomes were preventable.

A 2016 study published in the journal Annals of Surgery paints a bleak picture; forty-one (41%) of patients discharged to a SNF never return home. The study examined the outcomes of patients admitted to SNFs in five states, California, Florida, New York, Texas and Washington. Worse, the researchers found an elevated risk of death with institutional care:

"It is often communicated to patients and families that discharge to an SNF is a step in the process of recovery, and because clinicians have very limited evidence about the natural history of patients discharged to SNFs, patients may be given an unreasonable expectation of return to home. This study demonstrates that a significant proportion (41%) never returns to home, and the 1- and 3-year risk of death is much greater than that in the general population."

The study concluded that "[a]mong all patients discharged to SNFs, 7.8% eventually died in an SNF and overall 1-year mortality was 26.1%." 

Previous studies suggest that health outcomes on discharge to a nursing home do not differ greatly based on the rating, or performance evaluations, of the nursing homes.  In other words, selecting a highly rated facility does not greatly improve your chance of returning home.  The choice between profit and nonprofit facilities is actually more likely to impact health outcomes with for-profit institutions lagging behind the nonprofits. 
   

Families for Better Care ("FBC"), publishes a state-by-state nursing home report card. The following are the grades, rankings, and details for the states included in the study for the  year 2019:

California:  

• California was given an overall garde of "C."
• California’s nursing home ranking plunged to No. 22 overall, that’s down ten spots from its previous report card high.
• The percentage of California nursing homes with one or more deficiencies ticked nearly 3 percent points higher since the last report card, dropping the measure to a failing grade for the first time.
• California’s percentage of nursing homes with severe deficiencies increased a whopping 64 percent since our initial reports, nearly 1 in 5 nursing homes were cited for actual harm or immediate jeopardy to residents.
• While California’s direct care staffing hours remained relatively high at 2 hours and 41 minutes of care per resident daily, the percentage of facilities actually providing above average staffing levels told a very different story; the number of facilities with high levels dropped nearly 40 percent since the last report card.
• A falling percentage of verified ombudsman complaints for the third consecutive report card netted the Golden State its first “A” grade in this quality measure.
• California nursing home care ranked last in nursing home quality for the Pacific Region.

Florida:

• Florida received an overall grade of "B."
• Florida dropped seven spots in its national nursing home ranking to No. 13 overall—marking the lowest overall rank for the Sunshine State in report card history.
• Florida ranks among the best states in three critical nursing home quality indicators: direct staffing hours (No. 7), the percentage of facilities with severe deficiencies (No. 8), and the percentage of verified ombudsman complaints (No. 1).
• While Florida moderately increased direct care staffing hours offered to residents daily, the percentage of nursing homes achieving those higher staffing standards declined considerably, down more than 30 percent since the last reporting period—dropping the state to its lowest level in any report card.
• Inspectors issued one or more deficiencies to nearly every Florida nursing home.
• Fewer Florida nursing homes are scoring above average inspections than ever before.
• Nearly in 1 in 5 Florida nursing homes are on the state’s watch list for dangerous nursing home conditions.
• Florida nursing home care ranks first out of the Southeast Region’s eight states.

New York: 

• New York garnered an overall grade of "C."
• New York surged higher in overall nursing home care, up 20 spots from its dreadfully low No. 45 ranking in the past two report cards.
• New York scored “A” grades in every enforcement measure for the first time.
• Despite New York’s strong showing, the state failed two critical measures: the percentage of facilities with above average professional nursing hours and the percentage of facilities with above average direct care staffing levels, ranking No. 44 and No. 45 respectively.
• New York’s nursing home staffing hours remained woefully stagnant for the third consecutive reporting period, clocking just 2 hours and 20 minutes of direct care per resident daily.
• 4 in 5 New York nursing homes had middling to below direct care nursing staff levels.
• Despite New York achieving its best ombudsman record to date, the advocacy group still verified 3 of 4 ombudsman complaints, indicating widespread concern from residents about their overall quality of care.
• New York nursing home care ranks fourth in the Northeast Region.

Texas:

• Texas recieved a failing "F" grade. Texas is America’s worst nursing home state for the third consecutive report card.
• Texas nursing home care is miserably substandard as the state failed to score even one above average grade in any quality measure—in fact, flunking 5 of 8 statistical categories.
• Despite Texas’s abysmal showing in overall ranking (No. 51) when compared to other states, there was some good news for residents; nursing home direct care staffing hours nominally improved to 2 hours and 16 minutes of care per day, that’s four minutes more care every day since the previous reporting period.
• Although fewer than 30 percent of Texas nursing homes received an above average health inspection rating, that’s still 5 percent better than what was reported in the last report card.
• 1 in 5 Texas nursing homes was cited one or more severe deficiencies. Texas regulators cited 93 percent of the state’s nursing homes for violations of federal or state laws.
• Texas ombudsmen verified nearly every registered complaint for the third consecutive report card, indicating wide-ranging problems being reported by residents and their families about grossly inadequate quality.
• Texas nursing homes struggled to employ enough licensed nursing staff to care for residents; fewer than 10 percent of the state’s nursing homes scored an above average rating in professional nurse staffing, this ranks among the lowest nationwide—only Georgia and Louisiana ranked lower than Texas in this critical safety category.
• Texas nursing homes must do a much better job safeguarding the rights and health of those elderly and disabled adults needing nursing home care—if more money is required for reimbursement to pay for increased costs, then lawmakers must find a way to allocate these needed funds.

Washington:

• Washington continued its nursing home rankings slide, dropping back seven spots to fall to No. 34 overall, plunging the state into below average territory for the first time.
  
• Washington’s nursing home grades show that care is either good or dangerously bad; the state scored above average grades in half of the the quality measures while scoring failing grades in the remaining categories.
• Despite above average grades in every staffing measure, Washington managed to score failing grades in every regulatory and advocacy measure.
• With 65 percent of Washington nursing homes being cited a severe deficiency—the highest percentage nationally—that means more Washington nursing homes had citations for dangerous conditions than did not.
• Less than 3 percent of Washington nursing homes had a deficiency free inspection—one of the nation’s worst rates.
• Washington’s nursing home care ranks last in the Pacific Alaska Region.
• Washington received a near-failing grade of "D."

For more, consider the following:

• One-Third of Nursing Home Residents Injured or Killed In Treatment;
• Are You Really Better Off in a Nursing Home than at Home? SNF Residents with Pre-existing Healthcare Associated Infections Less Likely to be Readmitted to Hospital;
• New Controversial Sign-Off Rule Increases Burdens On Skilled Nursing Facilities- Threatens Transfer To Hospitals;
• Institutional Care: America's Most Vulnerable Seniors Raped and Sexually Abused;
• COPD Patients Discharged to a Skilled Nursing Have Two Times the Risk of Death Within Year Compared to Those Who Go Home;
• Hepatitis Infection Risk in Nursing Homes Up 50%; Infection Risk Across the Board Increases;
• Resident's Death Caused By Nursing Home Failing to Follow Advanced Directives Requesting CPR;
• Nursing Home Involvement in Patient's Death Object Lesson on Aging-in-Place Planning;
• Nursing Home Worker Faces Homicide Charges in Violent Death of Resident;
• Paramedics Often Obstructed, Provided Insufficient Information On Nursing Home Calls;
• Non-Profit Long-Term Care Safer than For-Profit;
• Habits Are Hard to Break: Nursing Homes Habitually Violate Federal Standards Year After Year;
• CDC Reports That SNF Workers Most Likely Among Health Care Workers to Forego Recommended Vaccinations;
• Don't Let Institutions Plan for You: Medicaid-Eligible Nursing Home Resident Stuck With Costs of Private-Pay Room;
• Many Skilled Care Providers Still Unaware of New Medicare Rules Permitting Chronic Condition Care;
• Ohio Ranks Poorly on Long-Term Care Services Scorecard;
• Hospice Costs Medicare Less Notwithstanding that Hospice Patients Live Longer.

Nursing Homes Push Dying Patients Into Unnecessary and Hazardous Rehab

An alarming study contends that Skilled Nursing Facilities (SNFs) may be pushing dying patients into unnecessary and potentially harmful high-intensity rehabilitation services. The study suggests that nursing homes may be sacrificing patient preferences and comfort for profit.  The study is another in a long list of reasons to plan to Age in Place.

University of Rochester Medical Center researchers noted that the number of residents receiving “ultra-high” rehab services in New York state increased by 65% during the three-year period ending in 2015. Most of those services were delivered to individuals in the last seven days of their lives, according to the analysis of data from 647 nursing homes in the Empire State that was published in the Journal of the American Medical Directors Association.

“These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits,” Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study, said in a statement. “It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering.”

Researchers studies residents in the Very High (520 minutes per week) to Ultra-High (720 minutes) groupings of rehab services in the last 30 days of life. Authors speculated that rehab levels for the dying may actually be higher in other states with less regulatory oversight. They also acknowledge that some rehab is needed at the end of life, though more commonly of the low or intermediate variety.

The motive for unnecessary and burdensome rehab is profit. According to the report accompanying the study results, "recent reports from the Office of the Inspector General (OIG), the Centers from Medicare and Medicaid Services, and from popular press suggest that the volume and the intensity of rehabilitation therapy provided to residents in US SNFs may be more extensive than is warranted by the residents' care needs." The OIG report from 2010 found that the proportion of seniors referred to ultrahigh therapy (>720 minutes/wk) increased from 17% to 28% during 2006-2008 while the recipients' age, admitting diagnoses, and proportion of seniors with high functional impairment scores remained largely unchanged. The report also noted that for-profit SNFs were more likely to bill for high-intensity therapy compared to not-for-profits—32% versus 18%, respectively.

A 2015 OIG report showed that SNF billings for higher levels of therapy have continued to increase. Between 2011 and 2013, the percentage of ultrahigh therapy days grew from 49% to 57%, whereas residents' characteristics stayed the same. In 2015, SNFs were reported to make a six times or six hundred percent (600%) higher average daily profit margin from providing ultrahigh compared to low therapy intensity. 

According to the study's author's, "[a]t least as concerning as the evidence suggesting some nursing homes may have exploited the prospective payment system to “optimize their revenues” is the claim by the OIG investigators that SNFs billed for therapy levels that were higher than reasonable or necessary, even among the most vulnerable residents." The OIG cited an example of a hospice patient who “received physical therapy 5 days a week for 5 weeks, even though her medical records indicated that she asked that the therapy be discontinued.” Similarly, a 2016 report appearing in the Wall Street Journal quoted interviews with more than 2 dozen former SNF therapists and rehabilitation directors asserting that “managers often pressure caregivers to reach the 720-minute threshold” (required for ultrahigh therapy billing). 

Although the benefits of rehabilitative therapy in nursing homes are well established, pressures to maximize therapy may be inappropriate or even potentially injurious to some patients and may create obstacles to the provision of palliative and end-of-life (EOL) care in nursing homes.  Numerous previous studies have shown that, despite preferences, many residents are hospitalized in the final weeks of life, and receive burdensome treatments that may have few benefits.  Consider the following:

• Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriatr Soc. 2010; 58: 627–635;
• Site of death among nursing home residents in the United States: Changing patterns, 2003-2007. J Am Med Dir Assoc. 2013; 14: 741–748;
• Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations. J Am Geriatr Soc. 2013; 61: 1900–1908;
• End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011; 365: 1212–1221.

The resident's quality of care may, in such cases, be horrifically impaired. Nursing homes may actually be reluctant to refer their dying residents to hospice so as not to lose the opportunity to maximize a higher Medicare rate by providing rehab.  In other words, preferences and comfort are sacrifices for profit. This conclusion is at least suggested by two separate studies:

• Dying in U.S. nursing homes with advanced dementia: How does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?. J Palliat Med. 2012; 15: 43–50;
• Influence of hospice on nursing home residents with advanced dementia who received medicare-skilled nursing facility care near the end of life. J Am Geriatr Soc. 2012; 60: 2035–2041.

In one study, nearly one-third of Medicare beneficiaries who were hospitalized received SNF-level care in the last 6 months of life and 9.2% died while on a SNF benefit.  Researchers argue that although such care may be appropriate for some, the receipt of SNF services at the end of life is likely to prevent many patients from receiving hospice and/or palliative care that may be more consistent with their wishes and care needs. A recent study reporting on staff experiences with palliative care in nursing homes noted that staff's desire to develop and provide quality palliative care services may conflict with the nursing homes' need to maximize the provision of rehabilitative therapies. In the words of a staff member, “[t]he goal is to get comfort measure people in therapy. They [residents] get the therapy; they [facility] get higher payment [reimbursement].”

Providers defended their practices to McKnight's Long Term Care News, noting that there is a deliberate system in place to regulate rehab levels. "When individuals request admission to a nursing home, they typically come with documentation on the type of care required. And once they’re at the facility, they must be able to maintain those levels of therapy," Nancy Leveille, executive director of the Foundation for Quality Care, part of the New York State Health Facilities Association, told McKnight's reporter Marty Stempniak. "If their condition is such that they cannot maintain, then nursing homes are unable to make a claim for those rehab minutes," Leveille explained.  "Plus, a significant sample of high-level rehab patients are then audited on a regular basis by Medicare or Medicaid, to validate that the services were appropriate," she added.

“There are checks and balances on the system and there are people who come in with terminal diagnoses and are trying to get back on their feet to be able to get back home or back to a different level of functioning for themselves for quality of life,” Leveille said. “But even within that, if they can’t meet the requirements of ultra-high rehab or any level of rehab, they can’t be scored on that.”

In other words, because billings are approved, the care is justifiable.