Home Alone: Discharge Without Post-Acute Care among Medicare Stroke Patients

Background: In the US, stroke is the fourth leading cause of death and a major cause of functional impairment. After hospitalization, survivors may be discharged without follow-up or receive rehabilitation through an inpatient rehabilitation facility, a skilled nursing facility, or home health services.  We examined post-acute care (PAC) delivery among Medicare beneficiaries.

Methods: We used a 5% sample of Medicare claims to track stroke after-care. We analyzed data on all Medicare stroke beneficiaries (65 years or older) hospitalized on or before August with a principal stroke diagnosis as defined by ICD-9 and DRGs and discharged in 2009 (n=7,763). Exclusion diagnoses were chronic kidney disease, end-stage renal disease, dementia or Alzheimer’s disease.  Rurality was measured at the county level using Urban Influence Codes. We used SAS to conduct descriptive analysis at the 0.05 significance level.  

Results: Discharge home without PAC treatment was the most common outcome (54.6%) across urban and rural residents. African American (45.3%) and other race (49.1%) patients were less likely to be discharged without PAC than white patients (56.3%). Transfer to inpatient rehabilitation facilities was the most frequent disposition status for rural patients (14.5%); home health care for urban patients (14.6%).

Conclusions: More than half of the Medicare beneficiaries in the sample did not receive PAC. The most appropriate PAC service for stroke patients depends on multiple factors and the care continuum for rural stroke patients is particularly complex.  Improved care standardization delivered to Medicare beneficiaries may improve outcomes.