Association between proportion of provider clinical effort in nursing homes and potentially avoidable hospitalizations and medical costs of nursing home residents

Objectives To assess potential avoidable hospitalizations of nursing home (NH) residents as a function of the percentage of clinical effort their primary care provider (PCP) devotes to NH practice. Design Retrospective cohort study. Setting NHs in Texas. Participants Residents newly admitted to long-term NHs in 2006 to 2008 were identified by linking the Minimum Data Set to 100% Texas Medicare claims data (N = 12,249). Measurements The care that residents received over successive 6-month periods was measured as a time-dependent covariate. Potentially avoidable hospitalizations and Medicare costs were assessed over 6 to 48 months. Results Seventy percent of NH residents had a physician as their major PCP, 25% had an advance practice nurse (APN), and 5% had a physician assistant (PA). Physician PCPs who derived less than 20% of their Medicare billings from NH residents cared for 36% of all NH residents. Most NH residents with APN or PA PCPs had providers with 85% or more of Medicare billings generated in NHs. Residents with PCPs who devoted less than 5% of their clinical effort to NH care were at 52% higher risk of potentially avoidable hospitalization than those whose PCPs devoted 85% or more of their clinical effort to NHs (hazard ratio = 1.52, 95% confidence interval = 1.25-1.83) and had $2,179 higher annual Medicare spending, controlling for PCP discipline. Conclusion The percentage of clinical effort that providers devote to NHs is associated with risk of avoidable hospitalization.