What is the right length of stay?

Post-acute care, post-acute care transitions and utilization of short-term rehabilitation in skilled nursing settings is garnering more and more attention, as regulators, payers and providers attempt to achieve higher levels of efficiency, reducing costs, improving quality outcomes, and increasing patient satisfaction. Value-based payment models such as Accountable Care Organizations, and bundled payments, are emerging, and are of particular interest in their ability to shift the risk from the payers  to the providers. The principle behind value based payment is  that there is sufficient data to predict, on average, the resources that a particular episode of care will require.

For the short stay rehabilitation patients in skilled nursing centers, as the providers consider taking on higher levels of risk, the question becomes, “What is the right length of stay?”

Stackpole & Associates clients include post acute care providers as well as senior living residences of all varieties across the country. It is clear from our interactions with these clients that the average length of stay on short-term care, rehabilitation populations vary widely – from 30+/- days to 6+/- days! Surely, an arthroplasty with no comorbidities shouldn’t experience a 30 day length of stay in Chicago, and 20 day length of stay in Tampa, while a similarly uncomplicated patient post knee or hip replacement has a 6 day length of stay in greater Boston. What’s the difference; what explains the variance?

One possible explanation for the wide degree of variance is the regulatory environment. Massachusetts, with 86% health insurance penetration, has experienced Obamacare-like health reform (we call it Romneycare, although the former presidential candidate was hoisted by his own petard in this regard) since 2006.

Post acute care providers of all kinds, especially skilled nursing centers, which are attracting, and depending upon, high volumes of short stay residents will find this question extremely relevant. Those nursing centers which have enjoyed very high lengths of stay for short-term care residents may not want to have the question discussed, for fear of drawing attention to what may be unnecessarily long lengths of stay.  Other providers who have been squeezed mercilessly by managed care to shorter lengths of stay will be eager to look for some balance.

So the question remains, “What is the right length of stay?” While there can be no single number, there could be developed a risk adjusted range of lengths of stay.  The key variables to answering this question correctly include the patient’s age, health and general status, as well as any comorbidity. But there are other contextual factors as well, such as whether the patient can return safely to his or her residence without risking a fall or an infection. These are risk factors for which adjustments can and should be made either upon admissions to the rehabilitation center, during their stay.

My hope is that we can begin a national dialogue about this question and engage all the stakeholders in a rational discussion.

What do you think is the right length of stay?

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