D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2018 . No. 9 THE EFFECT OF WORKFORCE ASSIGNMENT ON PERFORMANCE: EVIDENCE FROM HOME HEALTH CARE Guy David and Kunhee Lucy Kim Journal of Health Economics – May 2018 KEYFINDINGS In this study of more than 43,000 home health episodes following a hospitalization, handoffs between skilled nursing providers—a marker of discontinuity of care—substantially increased hospital readmissions, and were more detrimental for sicker patients. The estimates imply that a single handoff increases the likelihood of 30-day hospital readmission by 16% and that one in four hospitalizations during home health care could be avoided if handoffs were eliminated. THE QUESTION THE FINDINGS Home health is an important and rapidly growing segment of the health Of the more than 43,000 home health patient episodes in this study, 16.6% care system. With the advent of readmission penalties and an emphasis ended with a hospital readmission, and most of the readmissions occurred on population health management, home health has emerged as an within 30 days of hospital discharge. The average home health episode important setting for improving post-acute outcomes and preventing involved six nurse visits over a period of 33 days, with 87% of home health unnecessary readmissions. episodes involving between three and 12 nurse visits. Only 38% of patients were seen by a single nurse throughout their episode of care. Handoffs are Little is known about the optimal way to assign the skilled nursing substantially more likely to occur early in the home health episode and then workforce in home health. Efficient workforce assignment entails sharply decline with more home health days, as shown in Figure 1. matching task and talent, managing planned and unplanned absences, negotiating distances, and allowing flexibility when demand changes. The authors controlled for a rich set of patients’ health risk, demographic, Beyond efficiency, other goals include employee satisfaction and and comorbidity factors, as well as for home health day, number of visits, retention, and delivering higher quality of care. A continuous spacing of visits, episode length, and various caseload and labor supply relationship between a patient and a single health professional can conditions in each office. They find that patients experiencing nurse ensure continuity of care, but may involve a costly deployment of handoffs are 24% more likely to have a hospital readmission, and 21% more resources. Having different nurses visit across one home health care likely to have a hospital readmission within 30 days (the basis for hospital episode may optimize flexibility, but its effect on outcomes is unknown. readmission penalties). Their estimates imply that a single handoff increases Using data from a large, for profit home health agency, the authors the likelihood of 30-day hospital readmission by 16%. sought to answer the question, “Do handoffs between skilled nurses have an effect on hospital readmissions for Medicare patients”? Handoffs were more detrimental to sicker patients. Fragile patients and patients taking multiple medications were 59% and 57% more likely to be readmitted after experiencing handoffs, respectively. The frequency and sequencing of handoffs also affect the likelihood of rehospitalization, with the first handoff having the strongest effect on increasing hospital readmissions. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI Figure 1. Fraction of patient episodes with at least one, two, three, or four expense of flexibility in scheduling, employee satisfaction, and ultimately handoffs by home health day. retention. By quantifying the effect of discontinuous home health care on an important health care outcome, this study can help home health agencies more accurately assess how to balance care continuity with other goals typically achieved through the organization and scheduling of visiting nurses. THE STUDY The authors developed a rich dataset of home health visits, patient health status assessment, and provider work logs. They obtained data on all home health stays for Medicare patients with a prior hospitalization in the past 14 days from a large for-profit freestanding home health company, with 89 offices in 16 states. The study period covers 44 months between January 2012 and August 2015. They excluded episodes consisting of a single visit, as well as patients who had multiple subsequent home health episodes, as these home health stays may have different patterns of visit schedules and provider handoffs. The final sample includes 43,740 unique home health episodes and 1,031,904 patient days under home health. The authors used detailed information from visit logs for all Medicare THE IMPLICATIONS patients, work logs and human resources data for all home health This study is the first to link workforce assignment decisions in the post- providers, as well as all patient demographic and health risks collected acute care setting to hospital readmissions. Most of the research on care as part of the Medicare’s Outcome and Assessment Information Set continuity has focused on transitions of care across settings, especially (OASIS). Home health episodes can end by either a discharge or a on transitions from hospitals to post-acute care facilities. hospitalization. The exact dates of these outcomes for each episode were obtained from OASIS. They merged the patient-day level data Why would handoffs lead to hospital readmissions? It could be a with provider-day level work log data to identify handoffs and link them function of incomplete transmission of information between providers, with hospital readmissions. which could lead to inappropriate care. It could also be because handoffs depreciate the relationship stock built between providers and To uncover the mechanisms underlying the effect of handoffs, they also patients, which has been shown to improve patient outcomes. Finally, examined whether handoffs affect hospital readmissions differently by it could be because patients experiencing a handoff lose access to underlying patient severity and by the frequency and sequencing of providers most familiar with their case. handoffs, and whether handoffs affect time to readmission. In home health care, handoffs can often be avoided through coordinated scheduling, given that providers typically visit patients David G, Kim KL. The effect of workforce assignment on performance: with several days in between. In this study, 38% of patients are seen Evidence from home health care. Journal of health economics. consistently by a single nurse throughout their episode of care. But 2018 May 1;59:26-45. DOI: 10.1016/j.jhealeco.2018.03.003 prioritizing continuity of care may be costly in that it may come at the AUTHORS DR. GUY DAVID DR. KUNHEE LUCY KIM Guy David, PhD is the Gilbert and Shelley Harrison Associate Kunhee Lucy Kim, PhD is a Postdoctoral Training Fellow at the Professor of Health Care Management at Penn’s Wharton Center for Healthcare Innovation and Delivery Science at NYU School. His research on emergency medical services, home Langone Health. Her research focuses on examining health health care, primary care, specialty hospitals, and ambulatory care provider incentives in response to policy, regulations, and surgery centers has yielded insights into how individuals, firms, technological advancement, and investigating their broader and regulators interact across the continuum of care. He is the director of the impacts on managerial strategy, organizational structure, treatment patterns, and doctoral program in Health Care Management and Economics at Wharton, as patient outcomes. Dr. Kim completed her PhD in health care management and well as Director of Education at Penn LDI, where he leads graduate and executive economics at Penn’s Wharton School. education programs. He received his BA and MA in Economics from Tel Aviv University, and his PhD in Business Economics from the University of Chicago.