Frail Medicare Patients Face Primary Care Follow-Up Gaps

TOPLINE:

Vulnerable Medicare beneficiaries with frailty and those needing short-term skilled nursing facility care post-hospitalization were less likely to receive timely primary care follow-up after returning home.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using claims data from Medicare beneficiaries, including 94,248,326 hospital discharges (80.1% aged ≥ 65 years; 55.1% women) between January 2010 and December 2022.
• Patients were discharged from hospitals either directly home (78.5%) or to skilled nursing facilities before returning home (21.5%).
• The primary outcome was the receipt of a primary care follow-up visit within 30 days of returning home.
• Secondary outcomes assessed at 30 days included receipt of a transitional care management (TCM) visit and ambulatory visits with any clinicians, whether primary care clinicians or specialists.
• Researchers also assessed differences in primary care follow-up on the basis of frailty status, which was determined using a claims-based frailty index, and categorized patients into nonfrail (8.9%), prefrail (54.4%), or frail (36.7%) groups according to their scores.

TAKEAWAY:

• From 2010 to 2022, primary care follow-up rates after returning home increased from 51.5% to 57.5% for home discharges and from 24.3% to 28.4% for skilled nursing facility discharges.
• By 2022, TCM visits were received by only 5% of patients discharged to skilled nursing facilities vs 14.3% of those discharged home.
• In 2022, discharge to skilled nursing facilities was associated with an 8.2-percentage-point lower predicted probability of primary care follow-up after returning home than discharge directly to home.
• By 2022, patients with frailty who were discharged to skilled nursing facilities had a 6.1-percentage-point lower predicted probability of primary care follow-up and a 0.9-percentage-point lower predicted probability of receiving TCM services than those without frailty.

IN PRACTICE:

“These findings suggest a need to better target high-risk populations for postdischarge care coordination and policy efforts to support safe transitions from postacute SNF [skilled nursing facility] stays to home,” the authors wrote.

SOURCE:

This study was led by Timothy S. Anderson, of the Division of General Internal Medicine, Department of Medicine, at the University of Pittsburgh, Pittsburgh. It was published online on May 02, 2025, in Journal of the American Geriatrics Society.

LIMITATIONS:

Unbilled care coordination via phone or electronic messaging was not captured in claims data. The increase in the Medicare Advantage enrollment over time may have affected follow-up trends. Follow-up for patients in long-term care nursing homes or those discharged to long-term care hospitals was not examined.

DISCLOSURES:

This study was supported by grants from the National Institute on Aging and the American Heart Association. Few authors disclosed receiving grants from the funding sources and other organizations, and one author reported receiving payments unrelated to this work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.