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Research Study: In skilled nursing, can satisfied residents and families prevent re-hospitalization?

For skilled-nursing facilities (SNFs), a major regulatory change will soon take effect. Starting this October, SNFs will be penalized for residents they send back to the hospital within 30 days of admission.

It’s a move hailed by many and reviled by some. But no one would disagree that it poses critical questions to SNF administrators.

30-day re-hospitalization rates, after all, have proven surprisingly intractable: they’ve hovered around 19.5% for almost a decade. Not only does this indicate a substantial risk to patient safety, but it may disrupt care coordination, as hospitals and SNFs scramble to communicate effectively with each other.

Aside from quality issues, re-hospitalization is also extremely expensive. Sending skilled-nursing residents back to the hospital costs Medicare about $14 billion each year. Patients may experience an uptick in their healthcare bills as a result, as well. And starting this fall, re-hospitalizations could deprive SNFs of crucial incentive payments from CMS.

Administrators should at least consider every possible means to reduce re-hospitalization rates. A recent study from NRC Health shed light on one potentially effective approach.

Read below for a summary of the findings.

Study Design

This study was conducted on skilled-nursing facilities in a northeastern state, and set out to determine whether resident/family satisfaction scores correlated with re-hospitalization rates.

Researchers examined “observed” (as opposed to “risk-standardized”) re-hospitalization rates from July 2015 to June 2016, for 70 different SNFs across the state. They then compared these rates with each facility’s top-box resident and family satisfaction scores, unearthing some intriguing trends that should give SNF administrators food for thought.

First Finding: Family Trumps Resident

It may not surprise anyone to learn that facilities with higher satisfaction ratings have lower rates of re-hospitalization. Data has shown, after all, that satisfaction scores correlate very well with overall quality.

But a closer look into the details turns up something unexpected. When evaluating whose feedback is most important, this study found that the family’s opinions had more correlative power than the resident’s. High family-member approval was the best predictor of low rates of re-hospitalization.

Two satisfaction items, the “Would Recommend” and “Rate as a Place to Live” questions, revealed this phenomenon:

From this information, it appears that family satisfaction can be an early indicator of re-hospitalization rates.

Second Finding: A Wide Spread in Quality

Nor is the difference a trivial one. In fact, compared with their high-rated peers, SNFs in the bottom quartile for satisfaction saw re-hospitalization rates that were 9 percentage points higher. These low-performers re-hospitalized 27% of their residents, while those at the top re-hospitalized only 18%.

But satisfaction rates don’t have to differ dramatically to show this benefit; even incremental improvements matter. For every 10-point increase in ratings from family members, SNFs saw a 2% reduction in re-hospitalizations.

Third Finding: Targets for Improvement

One of the advantages of the satisfaction data-set is that it can point the way toward specific interventions. In this case, the data showed where SNFs should direct their efforts in order to target those factors that have the strongest relationship with re-hospitalization.

For residents, the best areas to focus on are:

  • Coordination of care—SNF staff should try not to make residents repeat themselves or give information again that they already gave to the hospital.
  • Information and education—Post-hospitalization can be a disorienting time. SNFs should make sure residents understand how they should manage their care.

For families, meanwhile, SNFs should consider:

  • Information and education—Concerned family members want to make sure they’re properly caring for their family members. SNFs should give them the tools they need to do that.
  • Respect for preferences—Asking about how family members prefer to be treated (in terms of, e.g., mode of contact or degree of involvement) will go a long way toward helping them feel comfortable leaving a loved one in an SNF’s care.
  • Emotional support—Empathy works wonders. SNF staff should strive to be attentive to the unique emotional stresses of post-hospitalization, and give family members the support they need.

Fourth Finding: Participation Rates

The final revealing statistic from the study has to do with how well SNFs drummed up feedback from residents and family members. On the whole, SNFs who saw high participation rates on surveys also tended to have low rates of re-hospitalization.

Though it’s difficult to draw conclusions from this observation, it may be that SNFs with strong feedback operations show strong efforts elsewhere in their work. Their diligence in surveying, in other words, may translate to clinical diligence as well.

A Point to Remember

It’s important to point out that this might not be true for all of the statistics observed above. Markers of family and resident satisfaction correlate to low re-hospitalization rates. They don’t cause low re-hospitalization rates.

However, that doesn’t mean that they’re unimportant. These indicators of customer satisfaction can be an effective proxy for quality. Residents and their family members are, unsurprisingly, excellent judges of the care they or their loved ones receive; efforts taken to ensure their satisfaction will likely improve quality across the board.

The key, as always, is to understand exactly what residents and family members want to see from skilled-nursing facilities—and to strive every day to