Which is better for stroke patients nursing home or rehab hospital?
Should it depend on who’s paying?
Are your stroke patients likely to be discharged to a nursing home or an acute rehab hospital? Rehab hospitals are clearly more expensive than nursing facilities, but the intensity of care there and shorter lengths of stay significantly alter the cost-effectiveness balance. If you look at readmission rates and expensive long-term complications, you may conclude it costs less to return stroke patients to the community as quickly as possible than to have them remain in an institutionalized environment.
"One way or another, we end up paying for it," says Mark Huang, MD, associate medical director of the Rehabilitation and Research Center of Virginia Commonwealth University at the Medical College of Virginia in Richmond.
Where your stroke patients go following discharge may depend upon their reimbursement arrangements for Medicare. A recent study showed that stroke patients enrolled in Medicare HMOs are less likely to be discharged to rehab facilities than are stroke patients with fee-for-service payer plans.1 About 16% of the managed care patients were discharged to a rehab unit, compared with 23% of the fee-for-service patients. Similarly, the study found nearly 42% of the managed care patients were sent to a nursing home after having a stroke, compared with 28% of the fee-for-service patients.
And what is the likelihood of your stroke patients being rehospitalized following discharge, wherever they’re taken care of? Type and intensity of care typically depends on your patients’ destinations. Stroke patients in a rehab center typically receive three or more hours of intensive therapy each day, while patients in a nursing home might receive only 30 minutes of therapy each day. And studies have shown that intensive care helps some stroke patients return to the community more quickly.
Upfront cost can be misleading
The typical nursing home costs about $300 a day, while an acute rehab hospital is more than three times that. The daily charge considers only the short-term cost of treating a stroke patient, however. Although there have been no clinical studies to compare the two costs, some experts speculate the long-term cost could weigh in favor of the rehabilitation hospital. The higher expense for rehab is mitigated by the fact that stroke patients typically have shorter lengths of stay in rehab hospitals than in nursing homes. One study showed that the length of stay for stroke patients in an acute rehab hospital was 28 days. For comparable stroke patients in a traditional skilled nursing facility, it was 56 days.2 However, that same study showed the short-term cost to be higher for the rehab facility because of the intensity of care.
Joseph Feinglass, PhD, a research associate professor in the division of General Internal Medicine and the Institute for Health Services Research and Policy Studies at Northwestern University Medical School in Chicago, says, although medical care for rehab is more expensive, it helps stroke patients return home and into the community.3 "There is a problem when you use cost-effectiveness guidelines they don’t work very well with elderly patients," Feinglass says.
Huang says returning patients to the community should be considered when managed care payers make their decisions about where to send stroke patients. Traditionally, HMOs consider cost effectiveness in terms of patient mortality, and at least one study has shown no difference in mortality in patients treated in a rehab hospital vs. a nursing home. Critics like Huang argue this comparison should not be the standard for deciding where to send patients for treatment. They insist that short-term cost savings shouldn’t be the main consideration when the patient’s welfare is at stake.
Because rehab facilities provide a better return to the community, in the long term their costs are lower than the skilled nursing setting, says Huang. Patients admitted to rehab hospitals are more likely to return to the community than patients admitted to a nursing home.
"Probably a higher percentage of stroke patients who are sent to a skilled nursing facility will end up staying there," Huang says.
"The problem is," he continues, "after a certain amount of time, managed care companies don’t make nursing home payments, so it costs them less in the long run to send patients there."
Look at the reality
Cynthia Rudder, PhD, director of the Nursing Home Community Coalition of New York State in New York City, says that Medicaid ends up paying for patients who remain in nursing homes after the payer’s money runs out. "Poor medical care costs money in the long run. And if people are being steered to the least expensive setting regardless of their care needs, someone is paying in the long run, and that will be Medicaid," Rudder says. The Nursing Home Community Coalition is a consumer advocacy group.
Huang says the decision of whether to send a patient to a rehab or nursing facility should be based on obtaining the best possible outcome for that patient. The Rehabilitation and Research Center screens stroke patients to see whether an acute rehab setting is appropriate. The patients are assessed for degree of motor paralysis, cognition, bladder incontinence, and other signs that offer clues about their recovery potential.
"If patients have negative diagnostic signs, we may not admit them and recommend that they go into long-term care facilities," Huang says. "We pick patients that we feel will make gains." He says the center sends 87% of its patients back into the community; 12% go into a long-term care facility. "Nationwide, 75% of rehab patients are returned to the community," he says.
Subacute centers offer an alternative
One alternative to an acute rehab center or a nursing home is a subacute center, Rudder suggests. Nursing homes are starting to create subacute centers within their walls where they offer more intensive therapy. Some might even provide nearly as much therapy as rehabilitation hospitals, Rudder and Huang say. The focus of the subacute units is to help people go home.
But as the subacute facility’s therapies increase, so do costs. There doesn’t appear to be a solution that combines low cost in the short term with high outcomes of returning patients to the community, they say.
Cost effectiveness measures determine whether patients are likely to lose months or years off their lives in one medical setting as compared to another. But with elderly patients, Feinglass says, what matters is not so much the quantity of life but quality.
"Look at how many additional years of better quality of life you can give these patients," Feinglass suggests. "If you ration care based on life expectancy, that amounts to age discrimination."
References
1. Retchin SM, Brown RS, Yeh SJ, et al. Outcomes of stroke patients in Medicare fee for service and managed care. JAMA 1997; 278:119-124.
2. Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke: A comparison of rehabilitation settings. JAMA 1997; 277:396-404.
3. Feinglass J, Webster JR. HMO or FFS, physicians must make correct call on discharge. JAMA 1997; 278:161-162.
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