Posthospital Nursing Home Utilization and Quality Indicators Among Medicare Beneficiaries in Puerto Rico: Comparison With the United States

Objectives: The purpose of the study is to contribute to the literature regarding post-acute nursing home utilization and quality indicators among Medicare beneficiaries in Puerto Rico compared with the US mainland. Design: Medicare data from 2015 to 2017 was used to identify new discharges to skilled nursing facilities (SNFs) using the Minimum Data Set and the Medicare Provider Analysis and Review. Setting and Participants: Post-acute care patients admitted to SNFs in Puerto Rico and the United States. Methods: Our final cohort included 4,732,222 beneficiaries from Puerto Rico and the United States enrolled in Medicare fee-for-service or Medicare Advantage programs admitted to an SNF (N = 15,197) following an acute hospital stay. We compared demographic, clinical, and facility-level characteristics among patients in Puerto Rico and the United States. We also described 2 quality indicators among these groups: (1) 30-day rehospitalization rates and (2) successful discharge from the facility to the community. Results: Medicare patients in Puerto Rico were physically and cognitively healthier than patients in the United States. Puerto Ricans were also more likely to be admitted to lower quality nursing homes than US patients (2.5 vs 3.4). Finally, Puerto Ricans had higher rates of successful discharge to the community [17.6, 95% confidence interval (CI) 13.0-22.3], but higher 30-day rehospitalization rates compared with US patients (11.2, 95% CI 6.2-16.3). These differences were consistent even when comparing these quality outcomes among Puerto Ricans to US Hispanics only. Conclusions and Implications: SNFs in the United States and Puerto Rico are now receiving financial penalties for high readmission rates. Currently, Medicare does not measure readmission rates for Medicare Advantage patients—even though some states, including Puerto Rico, have a high proportion of Medicare Advantage beneficiaries. As Medicare Advantage enrollment continues to increase, our results highlight the importance of measuring performance among Medicare Advantage patients and assessing disparities in quality of post-acute care among patients in Puerto Rico and the United States.