Changes in Patient Medical Complexity After Skilled Nursing Facility Payment Reform: A Qualitative Study

The skilled nursing facility (SNF) patient-driven payment model (PDPM) is intended to align payment with patient clinical characteristics to more accurately compensate complex and resource intensive care. However, it is unclear whether and how SNFs shifted their admission practices to align PDPM's financial incentives. This study examined SNF leaders' perspectives on changes in admission practices and patient case mix in order to understand variation in responses to PDPM implementation.

A qualitative study.

A purposive sample of SNF leaders from across the United States [eg, average to high (3-5 stars) and below-average (1-2 stars) care quality].

Ninety-four SNF leaders participated in one-on-one semistructured interviews between January 2021 and December 2022. Thematic analysis examined leaders' perspectives of their organization's response to PDPM, including changes in admission practices and patient case mix, as well as contextual factors contributing to their response. We then examined patterns by SNF quality rating and admission practice changes.

Descriptions of whether and why SNF case mix change differed based on their history of caring for a medically complex patient population. Leaders of SNFs that historically cared for rehabilitation patients frequently described strategic changes in their admission practices (eg, enhanced preadmission screening) after PDPM to prioritize the admission of medically complex patients, including those with higher nursing-related care needs (eg, tracheostomy, wounds, peritoneal dialysis). These leaders tended to represent average or high-quality SNFs, whereas leaders from below-average quality SNFs more frequently reported minimal or no case mix changes, in part reflecting a history of admitting medically complex patients before PDPM.

Results suggest that PDPM's intended effect of shifting SNF admissions to more medically complex patients varied by baseline SNF admission patterns and characteristics. These findings can inform longitudinal national evaluations of organizational responses to PDPM implementation.