Post-acute care transitions for adults with serious mental illness

Abstract

Approximately 20% of traditional Medicare beneficiaries experience a hospital to SNF transition each year. Despite their frequent occurrence, transitions across levels and locations of care are incredibly error prone, poorly coordinated and communicated, and often result in cyclical patterns of hospital readmission. This is especially true for the most vulnerable and complex patients, including those with serious mental illness (SMI), who represent a growing proportion of U.S. nursing facility residents. This dissertation seeks to enhance current understanding of care transitions across the post-acute continuum for adults with SMI, placing the SNF as a central yet intermediate location of care. In Chapter One, I use Medicare claims data to examine the extent to which observed pathways to hospitals’ high volume SNF partners differ for patients with versus without SMI. I find that patients with SMI experience inequitable access to their originating hospitals’ network of preferred SNF partners. An effect that is significantly moderated by having a condition targeted by the hospital readmission reduction program (HRRP), where patients with both SMI and a HRRP condition are more likely to be admitted to a preferred SNF partner. In Chapter Two, I use data from a nationally representative survey of SNFs and their two top volume hospital partners to examine whether information sharing and retrieval practices differ based on SNF willingness to accept patients with complex mental and behavioral health conditions. I find that SNFs who are more willing to accept these complex patients are significantly more likely to receive complete information on behavioral, social, mental, and functional status. These SNFs are also more likely to use electronically mediated methods of information retrieval. In Chapter Three, I use Medicare claims data to examine SNF discharge patterns for patients with SMI. Specifically, I (a) describe individual, organizational, and county-level geographic factors associated with discharge from the SNF to the home/community, and (b) identify predictors and sources of variation in discharge to the home/community among patients with SMI. I find significant within-group variation among patients with SMI who discharge to the home/community versus another location in terms of key demographic and county structural characteristics. I also find that SNFs who discharge the highest proportion of their SMI patient population to the home/community are more likely to be smaller, non-profit, and more highly rated (overall, quality, and staffing). Findings from this dissertation offer important insights into the ways in which organizational relationships, specifically those between hospitals and SNFs, influence care transitions across the continuum for people with SMI.