Patient advocates really, really want to believe that people discharged from a hospital are better off getting additional medical care and rehab at home than in a skilled nursing facility (SNF). But an important new study of 17 million Medicare claims over seven years tells a more ambiguous story.

The study found that post-acute care at home resulted in significantly lower overall costs than SNF-based care. But patients getting care at home were more likely to be readmitted to the hospital within 30 days after discharge. The researchers found there was little difference in the percentage of patients who died. Nor did it matter when it came to improving a beneficiary’s functional abilities, such as walking, cooking, or eating.

Little benefit, some risk

In short, while there is some cost savings to Medicare if patients are discharged from hospital to home, there is little measurable benefit to beneficiaries themselves and there even seems to be some additional risk.

The study, by highly-respected researchers including Rachel Werner and Norma Coe of the University of Pennsylvania and Tamara Konetzka of the University of Chicago, was published on March 11 in JAMA Internal Medicine.

The authors were doing a statistical analysis, not trying to explain the reasons for these outcomes. But they speculate that SNFs can better monitor their patients’ health, intervene before a patient must be readmitted to the hospital, and perhaps provide a higher level of treatment than home care nurses whose visits are likely to be infrequent and for short periods of time.

Home care issues

Other research finds that nursing facilities often send patients back to the hospital at the first sign of a change in condition. However, in recent years, some hospitals and nursing facilities have been working to reverse that trend.

The bigger issue may be at the home care end. Medicare pays visiting nurses and rehab therapists for only limited time with home care patients—perhaps no more than an hour at a time, a few days a week. Patients recovering at home may get additional support from home care aides, but Medicare pays for only a very limited amount of this care. For the vast majority of Medicare beneficiaries, paid, formal care is secondary to the help they get from their families.

And while family members often deliver care with great love, they also do it with limited—or no–skills. That is especially true as hospitals—pressured by Medicare itself—discharge their patients “quicker and sicker.” Family members are responsible for care that once would have been delivered by registered nurses, such as changing dressings on surgical incisions, and managing medications and medical equipment.

In effect, the health care system in general, and Medicare specifically, expects family members to act like nurses with little or no training.

“Worried and unprepared”

So why are we surprised when worried and unprepared family members respond to declines in their loved one’s condition by calling 911, and that emergency department visits lead to preventable hospital admissions?

In reality, we know remarkably little about the quality of family care, either for post-acute support or for long-term care—even though it represents 80 percent or more of all care. Funders are reluctant to pay for the research, perhaps because they are afraid of the answers. And without the funding, researchers can’t research. But if it does nothing else, the JAMA is a call for use to learn more about the quality of home care.

One note on the authors’ methodology: Sorting through all these data is hard, so they used some sophisticated statistical tools to sort out the results. In effect, instead of looking at average Medicare patients discharged from the hospital, they focused on a specific segment of the Medicare population—those they call “marginal patients” for whom either home health or SNF care would be a reasonable choice. By looking where the care setting is a close call, they can tease out the differences in cost, readmissions, and deaths.

Their results won’t be popular among those who favor home care, but they raise important questions about SNF care versus home care. And to my mind the place to search for answers is in the way we structure and pay for home care.