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Influence of Hospital and Nursing Home Quality on Hospital Readmissions
Kali S. Thomas, PhD; Momotazur Rahman, PhD; Vincent Mor, PhD; and Orna Intrator, PhD

Influence of Hospital and Nursing Home Quality on Hospital Readmissions

Kali S. Thomas, PhD; Momotazur Rahman, PhD; Vincent Mor, PhD; and Orna Intrator, PhD
This study examines the joint influence of the quality of the hospital and of the nursing home to which a patient was discharged on the likelihood of re-hospitalization.
While our analysis is limited in that we use linear probability models as opposed to modeling a multinomial outcome, we believe our use of CCREMS is novel and appropriate. The number of fixed and random effects that were estimated with a sample this large is computationally intensive. If we were to ignore the cross-classification of data, our models’ error terms would be misspecified, potentially resulting in biased estimates of covariate effects and spurious conclusions.30,31 With the CCREMS we used, we are unable to capture unobserved, omitted variables that could bias the coefficients, such as characteristics of patients who may self select into certain hospitals and NHs. There might be some strong hospital-NH relationships, but in other cases the patient might choose from several NHs that the hospital recommends and may decide on the basis of geographic convenience and/or bed availability. In addition, hospitals may strategically place their patients in NHs and there may be some selection bias in the types of patients that NHs accept. However, we attempted to control for observable characteristics of the patients, NHs, and hospitals that may be related to their likelihood of rehospitalization. More research is needed to understand the choice set and decision processes of patients, discharge planners, and admission coordinators in order to establish a causal relationship.


We assume that the current policy emphasis on rehospitalizations encourages both hospital and NH providers to manage the transitions between them to avoid penalties. This study highlights the importance of hospitals’ monitoring of the quality of the NHs to which they are discharging patients, and NHs’ monitoring of the quality of hospitals from which they are receiving patients. Therefore, as bundled post acute care and payment becomes a reality and forming preferred provider relationships is important, it is in the best interest of both NHs and hospitals to improve the quality of care they provide to their patients. The goal of improved patient care is the rationale behind the decision to impose penalties, as it is behind accountable care generally. If NHs and hospitals can utilize information—including data and discussion about the importance of the quality of the discharging hospitals and admitting NHs—to reduce 30-day rehospitalization rates, it will be an important step in achieving that goal.

Author Affiliations: Providence VA Medical Center (KST, VM), Providence, RI; Center for Gerontology and Health Care Research, Brown University (KST, VM, MR), Providence, RI; Department of Public Health Services, University of Rochester Medical Center, Rochester, NY, and Geriatrics and Extended Care Data and Analytics Center, Canandaigua VA Medical Center, Canandaigua, NY (OI).

Source of Funding: This work was funded by the National Institute on Aging (Grant No. P01 AG-0277296) and the Agency for Healthcare Research and Quality (Grant No. T32 HS-000011).

Author Disclosure: Dr Thomas reports a pending grant from National Institutes of Health (NIH) and her attendance at an Academy Health conference. Dr Mor is on the board of PointRight Inc and is a consultant to NaviHealth Inc and to hcr-Manorcare; he also owns stock in PointRight Inc and NaviHealth Inc. Dr Mor reports receiving grants from the National Institutes of Health (NIH) and the Robert Wood Johnson Foundation and grants pending from NIH and the Commonwealth Fund. He has received an honorarium from the Alliance for Health Care Quality and attended Academy Health. Drs Rahman and Intrator report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Authorship Information: Concept and design (KST, VM, MR, OI); acquisition of data (VM, OI); analysis and interpretation of data (KST, MR, VM, OI); drafting of the manuscript (KST, MR, OI); critical revision of the manuscript for important intellectual content (KST, VM, OI); statistical analysis (KST, OI); obtaining funding (OI, VM); administrative, technical, or logistic support (VM); supervision (VM, OI).

Address correspondence to: Kali S. Thomas, PhD, Brown University and Providence VA Medical Center, 121 S Main St, Box G121 (6), Providence, RI 01912. E-mail:
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