Abstract
Introduction: China is actively reforming its payment system for hospital service, including implementing Diagnosis-Related Groups (DRG) for acute care and adopting per-diem payment model for post-acute care(PAC).The impact of payment reforms usually extends beyond cost control to influence quality of care.Therefore, it’s important to closely monitor service quality in payment reform. Inspired by the United States' Patient-Driven Payment Model (PDPM) for skilled nursing facilities(SNFs), Jinhua City in eastern China’s Zhejiang Province initiated a per-diem payment reform for post acute hospitalizations in 2021.This reform establishes per-diem payment standards based on comprehensive and standardized patient functional assessment, requiring medical institutions to submit patient functional assessment data upon admission, discharge, and every 30 days.This study aims to utilize patient functional assessment data to evaluate the quality of care in PAC institutions and provide empirical evidence for value-based payment.
Methods: In 2016, The Skilled Nursing Facility Quality Reporting Program (QRP) was established by the Centers for Medicare & Medicaid Services (CMS) of the US to standardize the quality measures of SNFs. This study learns from the framework and indicators of the QRP, and selects seven indicators of patients’ health and functional status for measuring quality of care in post-acute settings of Jinhua City : mobility; activities of daily living; the prevalence of abnormal behavior symptoms; depression; skin integrity (pressure ulcer/injury); urinary catheter and indwelling fistula device placement; control of bowels or bladder. The change of patients in these indicators at discharge compared to admission is calculated as outcome/quality measures.
Results: During October 2021 to December 2022, 18,072 patients from 89 PAC institutions in Jinhua were included, with their assessment data at the point of both admission and discharge. The assessment scores for PAC patients at admission in tertiary hospitals were generally lower than those for patients in secondary and primary institutions, indicating that tertiary hospitals receive patients with more severe conditions.The overall maintenance rate of patients’ functional status(proportion of patients with same or improved functional score at discharge) is 97.6%. The maintenance rate of patients’ functional status is higher in tertiary hospitals compared to secondary and primary institutions, while the primary institutions excel in the improvement rate of patients’ functional status.The most significant improvement was observed in the dimension of activities of daily living,particularly in eating, while the improvement in conditions involving urinary catheters and indwelling fistula device placement was least pronounced.
Discussion and Conclusion: It is found that post-acute patients are more likely to maintain or experience improved conditions in tertiary hospitals in Jinhua City. In the future, attention needs to be paid to improving the quality of services in secondary care and primary care. It should also be noted that patients admitted to primary and secondary institutions exhibit better initial functional status compared to those in tertiary hospitals, indicating that the comparison of quality of care across different institutions should be cautious and take into account the characteristics of the patients admitted. Particular attention should be given to special nursing care, including the care for urinary catheters,fistulas devices, pressure ulcers and the loss of bowels or bladder control.