Weissert W G, Cready C M
Department of Health Policy and Administration, University of North Carolina, Chapel Hill 27599.
Health Serv Res. 1988 Dec;23(5):619-47.
Estimates of hospital-to-nursing home placement delays have always been varied, and given Medicare's new Prospective Payment System (PPS) based on diagnosis-related groups (DRGs), they are likely to have changed again. Theory and previous research suggest that four patient characteristics are the main causes of delays: Medicaid as the patient's nursing home payer source; need for heavy care due to major physical or mental problems; admission to the hospital from a nursing home; and lack of social support. A pilot study of all 1,016 elderly awaiting nursing home placement in two admission cohorts (pre- and post-PPS) from the three largest hospitals in the county surrounding Charlotte, North Carolina--where nursing home beds are in short supply--indicates that other factors are more important. While most placements were delayed, delays were short. Multiple regression results show that Medicaid patients' delays were only about a day longer than those of private-pay patients. Of the many heavy-care conditions studied, only three were associated with delay. Patients without social support and patients admitted from a nursing home, discharged to a hospital-affiliated facility, or placed after PPS had shorter delays. Long delays were found among patients who had applied for Medicaid coverage but had not yet been certified as financially eligible. Nonwhites and males were also delayed. These findings, if replicated in other areas with perceived nursing home bed shortages, appear to have important implications not only for the usefulness of nursing home case-mix reimbursement and subacute levels of nursing home care, but for nursing home bed-need estimates, too, as well as for Medicaid eligibility determination practices and civil rights law enforcement.
对医院至养老院安置延迟的估计一直各不相同，鉴于医疗保险基于诊断相关分组（DRG）的新前瞻性支付系统（PPS），这些估计可能又发生了变化。理论和先前的研究表明，患者的四个特征是延迟的主要原因：医疗补助作为患者养老院支付方来源；因重大身体或精神问题需要重症护理；从养老院入院；以及缺乏社会支持。在北卡罗来纳州夏洛特市周边县的三家最大医院对1016名等待养老院安置的老年人进行的一项试点研究（两个入院队列，PPS实施前后）——该地区养老院床位短缺——表明其他因素更为重要。虽然大多数安置都有延迟，但延迟时间较短。多元回归结果显示，医疗补助患者的延迟仅比自费患者长约一天。在研究的众多重症护理情况中，只有三种与延迟有关。没有社会支持的患者、从养老院入院、出院后进入医院附属设施或在PPS实施后安置的患者延迟时间较短。在申请医疗补助覆盖但尚未被认定符合财务资格的患者中发现了较长的延迟。非白人和男性也有延迟。如果在其他存在养老院床位短缺问题的地区得到验证，这些发现似乎不仅对养老院病例组合报销和养老院亚急性护理水平的实用性具有重要意义，而且对养老院床位需求估计、医疗补助资格判定实践以及民权执法也具有重要意义。
