The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

Background: The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood. Objectives: Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic. Research design: Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020. Subjects: Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses. Measures: Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset. Results: During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (−3.9%, CI [−5.2%, −2.7%]) or to home (−2.8% CI [−4.4%, −1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics. Conclusions: Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.