Sociodemographic Factors and Characteristics of Caregivers as Determinants of Skilled Nursing Facility Admissions When Modeled Jointly With Functional Limitations

Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries

Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.

Longitudinal Care Network Changes and Associated Healthcare Utilization Among Care Recipients

This study examines caregiver networks, including size, composition, and stability, and their associations with the likelihood of hospitalization and skilled-nursing facility (SNF) admissions. Data from the National Health and Aging Trends Study linked to Center for Medicare and Medicaid Services data were analyzed for 3855 older adults across five survey waves. Generalized estimating equation models assessed the associations. The findings indicate each additional paid caregiver was associated with higher adjusted risk ratios (aRR) for hospitalization (aRR = 1.24, 95% CI 1.10-1.41) and SNF admission (aRR = 1.28, 95% CI 1.06-1.54) among care recipients, a pattern that is also observed with the addition of unpaid caregivers (hospitalization: aRR = 1.13, 95% CI 1.06-1.20; SNF: aRR = 1.12, 95% CI 1.02-1.23). These results suggest that policies and approaches to enhance the quality and coordination of caregivers may be warranted to support improved outcomes for care recipients.

Gatekeepers: The Association of Caregiving Network Characteristics With Emergency Department Use by Persons Living With Dementia

OBJECTIVES

Caregivers are typically enmeshed in networks of family and friends who assist with care, yet this network is largely neglected in research. In light of the fact that caregivers are key medical decision makers and play a critical role in how persons living with dementia (PLwDs) interface with the health care system, this study explores how features of the caregiver network relate to PLwD emergency department (ED) use.

METHODS

Using 2015 National Health and Aging Trends Study data linked with fee-for-service Medicare claims, we examine ED use in a nationally representative sample of community-dwelling persons aged 65 and older with dementia and at least 1 caregiver. We consider aspects of the caregiver network including membership (e.g., daughter in network), network size, hours of care received, and the presence of generalists and specialists (i.e., broad vs narrow functional assistance) as predictors of ED encounters among PLwD.

RESULTS

PLwDs were 81.5 years old on average, 50% were female, and 33% were non-White. Care networks including nonimmediate family members involved in task sharing for mobility and self-care difficulties and those with more generalists had significantly higher odds of an ED visit. Networks that only consisted of specialist caregivers had significantly lower odds of an ED visit.

DISCUSSION

Greater complexity of care networks increases risk of presenting to the ED for care. Better understanding how caregiving networks help PLwD interact with the health care system can inform intervention design and targeting in order to help care networks improve care coordination, management, and shared decision making.

Optimizing the integration of family caregivers in the delivery of person-centered care: evaluation of an educational program for the healthcare workforce

Background

While family caregivers provide 70-90% of care for people living in the community and assist with 10-30% of the care in congregate living, most healthcare providers do not meaningfully involve family caregivers as partners in care. Recent research recommends that the healthcare workforce receive competency-based education to identify, assess, support, and partner with family caregivers across the care trajectory.

Objective

This paper reports a mixed-methods evaluation of a person-centered competency-based education program on Caregiver-Centered Care for the healthcare workforce.

Methods

This foundational education was designed for all healthcare providers and trainees who work with family caregivers and is offered free online (caregivercare.ca). Healthcare providers from five healthcare settings (primary, acute, home, supportive living, long-term care) and trainees in medicine, nursing, and allied health were recruited via email and social media. We used the Kirkpatrick-Barr health workforce training evaluation framework to evaluate the education program, measuring various healthcare providers’ learner satisfaction with the content (Level 1), pre-post changes in knowledge and confidence when working with family caregivers (Level 2), and changes in behaviors in practice (Level 3).

Results

Participants were primarily healthcare employees (68.9%) and trainees (21.7%) and represented 5 healthcare settings. Evaluation of the first 161 learners completing the program indicated that on a 5-point Likert scale, the majority were satisfied with the overall quality of the education (Mean(M) = 4.69; SD = .60). Paired T-tests indicated that out of a score of 50, post-education changes in knowledge and confidence to work with family caregivers was significantly higher than pre-education scores (pre M = 38.90, SD = 6.90; post M = 46.60, SD = 4.10; t(150) = − 16.75, p < .0001). Qualitative results derived from open responses echoed the quantitative findings in satisfaction with the education delivery as well as improvements in learners’ knowledge and confidence.

Conclusion

Health workforce education to provide person-centered care to all family caregivers is an innovative approach to addressing the current inconsistent system of supports for family caregivers. The education program evaluated here was effective at increasing self-reported knowledge and confidence to work with family caregivers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07689-w.

Patterns of Caregiving Among Older Adults With and Without Dementia: A Latent Class Analysis

OBJECTIVES

We identify common patterns of caregiving or "care types" among older adults with and without dementia. Prior research has focused on primary caregivers and on the independent effects of individual caregiving attributes. We examine multiple caregivers of older adults, including the primary caregiver, and how multiple caregiving attributes co-occur to shape caregiving types.

METHODS

We link 2015 care recipient (N = 1,423) and unpaid caregiver data (N = 2,146) from the National Health and Aging Trends Study and the National Study of Caregiving. Latent class analysis of caregiving attributes, representing care intensity and regularity, and various care activities, was used to construct care types. Multinomial logistic regression was used to examine if the recipients' dementia status and caregivers' background characteristics predicted membership in care types.

RESULTS

Five distinguishable care types were identified. Caregivers who were female, adult children, or coresidents, those caring for persons with dementia, and those who had paid help had higher odds of being in the more demanding care types. Conversely, older, White caregivers and those with support for their caregiving activities were less likely to be in a demanding care type.

DISCUSSION

Care types can help us understand sources of heterogeneity in caregiving and effectively target caregiver support services and interventions.

Predictors of Residential Care Admission in Community-Dwelling Older People With Dementia

OBJECTIVES

The objectives of this study were to identify variables associated with dementia and entry into aged residential care (ARC) and derive and validate a risk prediction model for dementia and entry into ARC.

DESIGN

This was an observational study of prospectively collected Home Care International Residential Assessment Instrument (interRAI-HC) assessment data.

SETTING AND PARTICIPANTS

Participants included all people age ≥65 years who had completed an interRAI-HC assessment between July 1, 2012 and June 30, 2018. Exclusion criteria included death or entry into ARC within 30 days of assessment and not living at home at the time of the assessment.

MEASURES

InterRAI data from 94,202 older New Zealanders were evaluated for presence or absence of dementia. A multivariable competing-risks model for entry into ARC with death as the competing event was used to estimate subdistribution hazard ratios (SHR).

RESULTS

In total, there were 18,672 (19.8%) persons with dementia (PWD). PWD were almost twice as likely to enter ARC as persons without dementia [42.8% vs 25.3%; difference 17.5% (95% confidence interval 16.7%‒18.2%)]. PWD at highest risk of entering ARC were those where there was a desire to live elsewhere (SHR 1.44), depression (indicated, SHR 1.15), poor cognitive performance (Cognitive Performance Scale minimal SHR 1.32 and severe plus SHR 1.91), and wandering (SHR 1.19). Factors associated with reduced risks of PWD entering ARC were living with a child or relative, alcohol consumption, and comorbidities.

CONCLUSIONS AND IMPLICATIONS

A desire to live elsewhere, social isolation, independent activities of daily living, and depression were independently associated with entry into ARC. Supporting caregivers may improve outcomes for PWD that delay entry into ARC. Future revisions of the interRAI questionnaire could provide more insight on this matter.

Patients discharged from higher-quality skilled nursing facilities spend more days at home

OBJECTIVE

To evaluate the association of skilled nursing facility (SNF) quality with days spent alive in nonmedical settings ("home time") after SNF discharge to the community.

DATA SOURCES

Secondary data are from Medicare claims for New York State (NYS) Medicare beneficiaries, the Area Health Resources File, and Nursing Home Compare.

STUDY DESIGN

We estimate home time in the 30- and 90-day periods following SNF discharge. Two-part zero-inflated negative binomial regression models characterize the association of SNF quality with home time.

DATA EXTRACTION METHODS

We use Medicare claims data to identify 25 357 NYS fee-for-service Medicare beneficiaries aged 65 years and older with an SNF admission for postacute care who were subsequently discharged to home in 2014.

PRINCIPAL FINDINGS

Following 30 and 90 days after SNF discharge, the average home time is 28.0 (SD = 6.1) and 81.6 (SD = 20.2) days, respectively. A number of patient- and SNF-level factors are associated with home time. In particular, within 30 and 90 days of discharge, respectively, patients discharged from 2- to 5-star SNFs spend 1.2-1.5 (P < .001) and 3.2-4.3 (P < .001) more days at home than those discharged from 1-star (lowest quality) SNFs.

CONCLUSIONS

Improved understanding of what is contributing to differences in home time could help guide efforts into optimizing post-SNF discharge outcomes.