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Li R, Geng J, Liu J, Wang G, Hesketh T. Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals-a systematic review and meta-analysis. Age Ageing 2022; 51:6618060. [PMID: 35753767 PMCID: PMC9233979 DOI: 10.1093/ageing/afac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background Quality of aftercare can crucially impact health status of older patients and reduce the extra burden of unplanned healthcare resource utilisation. However, evidence of effectiveness of primary healthcare in supporting aftercare, especially for older patients after discharge are limited. Methods We searched for English articles of randomised controlled trials published between January 2000 and March 2022. All-cause hospital readmission rate and length of hospital stay were pooled using a random-effects model. Subgroup analyses were conducted to identify the relationship between intervention characteristics and the effectiveness on all-cause hospital readmission rate. Results A total of 30 studies with 11,693 older patients were included in the review. Compared with patients in the control group, patients in the intervention group had 32% less risk of hospital readmission within 30 days (RR = 0.68, P < 0.001, 95%CI: 0.56–0.84), and 17% within 6 months (RR = 0.83, P < 0.001, 95%CI: 0.75–0.92). According to the subgroup analysis, continuity of involvement of primary healthcare in aftercare had significant effect with hospital readmission rates (P < 0.001). Economic evaluations from included studies suggested that aftercare intervention was cost-effective due to the reduction in hospital readmission rate and risk of further complications. Conclusion Integrating primary healthcare into aftercare was designed not only to improve the immediate transition that older patients faced but also to provide them with knowledge and skills to manage future health problems. There is a pressing need to introduce interventions at the primary healthcare level to support long-term care.
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Affiliation(s)
- Ran Li
- Center of Global Health, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Global Health, University College London, London, UK
| | - Jiawei Geng
- Center of Global Health, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jibin Liu
- Department of radiotherapy, Affiliated Tumour Hospital of Nantong University, Nantong, China
| | - Gaoren Wang
- Institute of oncology, Affiliated Tumour Hospital of Nantong University, Nantong, China
| | - Therese Hesketh
- Center of Global Health, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Global Health, University College London, London, UK
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2
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Who Visits Relatives in Nursing Homes? Predictors of at Least Weekly Visiting. J Am Med Dir Assoc 2021; 23:1153-1158.e1. [PMID: 34634232 DOI: 10.1016/j.jamda.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/12/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Within the context of a single study, assess the relative importance of the 6 factors identified in a 2019 systematic review as associated with the likelihood that family members will visit nursing home residents. DESIGN Retrospective statistical analysis of an existing survey data set. SETTINGS AND PARTICIPANTS A national survey conducted with 4350 relatives of long-term nursing home residents. METHODS Probit models of the probability of visiting a family member at least once weekly, stratified by age of the visitor, were estimated. To account for possible endogeneity of respondent involvement in the choice of nursing home and visit rate, visit rates were estimated using 2-stage residual inclusion in which the first stage explained involvement in nursing home choice. RESULTS Involvement in nursing home choice has a substantively and statistically significant positive effect on visit probability for all age groups of respondents. Travel time has a substantively and statistically significant negative association on visit probability for all age groups. Younger women are more likely to visit than younger men. For all but the oldest respondents, higher income and full-time employment contribute to involvement in nursing home choice as does being Black or Hispanic. CONCLUSIONS AND IMPLICATIONS As in previous research, travel time is an important determinant of visit rates. The strong association of involvement in nursing home choice with visit probability suggests a strong psychological motivation for visiting. To improve visiting, future research should focus on better understanding of the psychological factors that are associated with it and rely on better data and improved statistical methods. Our findings also suggest that nursing home administrators should consider adopting initiatives to facilitate and empower family members' involvement in nursing home choice, which in turn may lead to increased visitations.
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3
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Kast K, Emmert M, Maier CB. [Public Reporting on long-term Care Facilities in Germany: Current State and Evaluation of Quality Information]. DAS GESUNDHEITSWESEN 2021; 83:809-817. [PMID: 32588407 PMCID: PMC11248030 DOI: 10.1055/a-1160-5720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Little is known about public reporting on long-term care facilities. In this study, we (1) identify the websites that are available for a search on long-term care facilities in Germany, (2) describe them systematically with regard to general information and range of functions, 3) capture the information on quality available on the websites and 4) evaluate the extent to which they can be useful for those in need. METHODS 1) Systematic internet search to identify the websites. 2) Analysis of the websites with regard to defined inclusion and exclusion criteria. 3) Data collection from the included websites. 4) Description of the general content and the range of functions of the websites. 5) Collection of quality-related information on long-term care facilities (structure, process and outcome quality, costs, quality inspections results, user feedback). 6) Evaluation of the usefulness of information by analyzing the information using a catalogue of criteria. RESULTS A total of 24 websites were identified with information on long-term care facilities. Only 4 websites allowed a direct online comparison of several facilities and 17% allowed consumer feedback online. All websites provided information on structural quality, but none on the outcome quality. Across all websites, the usefulness of information for the consumers amounted to 19%. The thematic area on location and accessibility of a facility offered relatively detailed information (79%), while only to 9% was dedicated to the thematic area on care. CONCLUSION There is a large number of websites that can be searched for information on long-term care facilities. They show a range of heterogeneous functions and information. More websites should offer a function of comparison of multiple facilities. With regard to the information available, consumer preferences do not yet seem to be sufficiently taken into account. Further researches should focus on the evaluation of the impact of outcome quality on decision-making and the analysis of the validity of consumer feedback.
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Affiliation(s)
- Kristina Kast
- Lehrstuhl für Gesundheitsmanagement, Friedrich-Alexander-Universität Erlangen-Nürnberg, Fachbereich Wirtschaftswissenschaften, Nürnberg
| | - Martin Emmert
- Lehrstuhl für Gesundheitsmanagement, Friedrich-Alexander-Universität Erlagen-Nürnberg, Fachbereich Wirtschaftswissenschaften, Nürnberg
| | - Claudia Bettina Maier
- Fachgebiet Management im Gesundheitswesen, Technische Universität Berlin, Fakultät Wirtschaft und Management, Berlin
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4
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Groenvynck L, Fakha A, de Boer B, Hamers JPH, van Achterberg T, van Rossum E, Verbeek H. Interventions to Improve the Transition from Home to a Nursing Home: A Scoping Review. THE GERONTOLOGIST 2021; 62:e369-e383. [PMID: 33704485 PMCID: PMC9372886 DOI: 10.1093/geront/gnab036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives The transition from home to a nursing home is a stressful event for both older persons and informal caregivers. Currently, this transition process is often fragmented, which can create a vicious cycle of health care-related events. Knowledge of existing care interventions can prevent or break this cycle. This project aims to summarize existing interventions for improving transitional care, identifying their effectiveness and key components. Research Design and Methods A scoping review was performed within the European TRANS-SENIOR consortium. The databases PubMed, EMBASE (Excerpta Medica Database), PsycINFO, Medline, and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they described interventions designed to improve the transition from home to a nursing home. Results 17 studies were identified, describing 13 interventions. The majority of these interventions focused on nursing home adjustment with 1 study including the entire transition pathway. The study identified 8 multicomponent and 5 single-component interventions. From the multicomponent interventions, 7 main components were identified: education, relationships/communication, improving emotional well-being, personalized care, continuity of care, support provision, and ad hoc counseling. The study outcomes were heterogeneous, making them difficult to compare. The study outcomes varied, with studies often reporting nonsignificant changes for the main outcome measures. Discussion and Implications There is a mismatch between the theory on optimal transitional care and current transitional care interventions, as they often lack a comprehensive approach. This research is the first step toward a uniform definition of optimal transitional care and a tool to improve/develop (future) transitional care initiatives on the pathway from home to a nursing home.
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Affiliation(s)
- Lindsay Groenvynck
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Amal Fakha
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Bram de Boer
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Jan P H Hamers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Theo van Achterberg
- Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Erik van Rossum
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands.,Academy of Nursing, Research Center on Community Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
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5
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Mukamel DB, Saliba D, Weimer DL, Ladd H. Families' and Residents' Perspectives of the Quality of Nursing Home Care: Implications for Composite Quality Measures. J Am Med Dir Assoc 2020; 22:1609-1614.e1. [PMID: 33229306 DOI: 10.1016/j.jamda.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/28/2020] [Accepted: 10/04/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess (1) the relationship of consumers' assessment of overall nursing home quality to their assessment of specific dimensions of quality; and (2) the implications of this relationship for composite quality measures in Nursing Home Compare. DESIGN A survey conducted in 2017 elicited respondents' assessments of the quality of overall care and 13 specific dimensions of care. SETTINGS AND PARTICIPANTS The sample consisted of 4449 respondents who either resided in a nursing home or had a family member who resided in a nursing home during the 6 months before the survey. METHODS We estimated regression models to infer the relationship between consumers' assessments of overall quality and 13 specific dimensions of quality. The regression coefficients, indicating the implicit importance/weight assigned by respondents to each dimension as a component of the consumers' assessment of overall quality, were used to create a prototype composite quality measure. RESULTS For long-stay residents, 8 of the 13 quality dimensions were significantly associated with their overall ratings of quality. Five dimensions achieved significance for short-stay residents. The magnitude of importance weights varied substantially across dimensions of care. CONCLUSIONS AND IMPLICATIONS Our findings suggest that Nursing Home Compare could be improved by augmenting the technical information in the 5-Star composite measure with consumers' assessments of the additional, nontechnical dimensions of quality.
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Affiliation(s)
- Dana B Mukamel
- Division of General Internal Medicine, Department of Medicine, University of California, Irvine, Irvine, CA, USA; iTEQC Research Program, University of California, Irvine, Irvine, CA, USA.
| | - Debra Saliba
- UCLA Borun Center at David Geffen School of Medicine, Los Angeles, CA, USA; Veterans Administration GRECC, Los Angeles, CA, USA; RAND Health, Santa Monica, CA, USA
| | - David L Weimer
- LaFollette School of Public Affairs, University of Wisconsin-Madison, Madison, WI, USA
| | - Heather Ladd
- Division of General Internal Medicine, Department of Medicine, University of California, Irvine, Irvine, CA, USA; iTEQC Research Program, University of California, Irvine, Irvine, CA, USA
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6
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Harrington C, Ross L, Chapman S, Halifax E, Spurlock B, Bakerjian D. Nurse Staffing and Coronavirus Infections in California Nursing Homes. Policy Polit Nurs Pract 2020; 21:174-186. [PMID: 32635838 DOI: 10.1177/1527154420938707] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.
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Affiliation(s)
- Charlene Harrington
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Leslie Ross
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Susan Chapman
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Elizabeth Halifax
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Bruce Spurlock
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Debra Bakerjian
- Department of Social & Behavioral Sciences, University of California, San Francisco
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7
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Tamara Konetzka R, Yan K, Werner RM. Two Decades of Nursing Home Compare: What Have We Learned? Med Care Res Rev 2020; 78:295-310. [PMID: 32538264 DOI: 10.1177/1077558720931652] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.
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Affiliation(s)
| | - Kevin Yan
- The University of Chicago, Chicago, IL, USA
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8
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Halifax E, Bui NM, Hunt LJ, Stephens CE. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care 2020; 36:61-65. [PMID: 32106767 DOI: 10.1177/0825859720904802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Transitioning to a nursing home (NH) is a major life event for 1.4 million NH residents in the United States. Most post-acute NH admissions plan for rehabilitation and discharge home, but with nearly 70% of NH residents being palliative care (PC) eligible, many evolve into long-term placements secondary to poor health and associated decline in function and/or cognition. This article describes the perceptions of NH PC-eligible residents and families transitioning to life in a NH. METHODS Residents at 3 NHs in Northern California (N = 228) were screened for PC eligibility. A convenience sample of PC-eligible residents and their family members (n = 28) participated in qualitative interviews that explored the experience of living as a NH resident with serious illness. Data were analyzed using grounded theory methodology. RESULTS Our study provides insights into the experiences of transitioning to a NH from the perspectives of PC-eligible residents and their families. These data describe how PC-eligible residents and their families experienced disempowerment as they perceived being left out of decisions to go to a NH, loss of autonomy once at the NH, dealt with the realization that they would not be going home, and described perceived barriers to going home. DISCUSSION AND IMPLICATIONS The inclusive and person-centered model of care that PC provides naturally empowers residents and family members. Adequate provision of PC services, together with changes in policy related to NH culture and benefit management, could improve the experience of transitioning to a nursing home.
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Affiliation(s)
- Elizabeth Halifax
- Department of Physiological Nursing, 8785University of California, San Francisco, CA, USA
| | | | - Lauren J Hunt
- Department of Physiological Nursing, 8785University of California, San Francisco, CA, USA.,San Francisco VA Medical Center, San Francisco, CA, USA
| | - Caroline E Stephens
- Department of Community Health Systems Nursing, 8785University of California, San Francisco, CA, USA
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9
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Haeder SF, Weimer DL, Mukamel DB. A Knotty Problem: Consumer Access and the Regulation of Provider Networks. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2019; 44:937-954. [PMID: 31408883 DOI: 10.1215/03616878-7785835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.
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10
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Weimer DL, Saliba D, Ladd H, Shi Y, Mukamel DB. Using contingent valuation to develop consumer-based weights for health quality report cards. Health Serv Res 2019; 54:947-956. [PMID: 31012107 DOI: 10.1111/1475-6773.13155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The current 5-Star composite measure for nursing homes uses expert-driven weights to combine elements of quality into a single score. We assessed the feasibility of using the contingent valuation method (CVM) to derive consumers' preference-based weights for the Nursing Home Compare report card as a potential alternative approach. DATA SOURCES Survey of 4310 adults with nursing home experience (residents or family members of a resident) administered between September 25 and October 9, 2017. STUDY DESIGN Contingent valuation method based on respondents' answers to questions about willingness-to-trade (WTT) visit travel time for better quality in seven quantitative indices included in Nursing Home Compare. We calculated WTT amounts per standard deviation change in quantitative indices to derive weights. DATA COLLECTION METHODS Web-based survey. PRINCIPAL FINDINGS Contingent valuation method results are consistent with respondents making economically rational trade-offs between quality and travel time. Estimates of mean WTT vary across quantitative quality indices. They also vary in terms of respondent status and behavioral factors. Weights based on mean WTT per standard deviation vary substantially across indices, with the largest weights for inspections and staffing. CONCLUSIONS Contingent valuation method has promise as a method for deriving weights for use in summary measures that incorporate consumer preferences.
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Affiliation(s)
- David L Weimer
- LaFollette School of Public Affairs, University of Wisconsin - Madison, Madison, Wisconsin
| | - Debra Saliba
- UCLA Borun Center at David Geffen School of Medicine, Los Angeles, California.,Veterans Administration GRECC, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, California
| | - Yuxi Shi
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, California
| | - Dana B Mukamel
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, California
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11
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Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Post-Acute Care After Joint Replacement in Medicare's Bundled Payments for Care Improvement Initiative. J Am Geriatr Soc 2019; 67:1027-1035. [PMID: 30802938 DOI: 10.1111/jgs.15803] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 11/27/2022]
Abstract
IMPORTANCE Bundled payments, in which services provided around a care episode are linked together, are being tested under Medicare's Bundled Payments for Care Improvement (BPCI) program. Reducing post-acute care (PAC) is critical under bundled payment, but little is known about whether this is done through provider selection or consolidation, and whether particular patterns of changes in PAC are associated with success under the program. OBJECTIVE To characterize patterns of change in PAC under lower-extremity joint replacement episodes in BPCI. DESIGN Retrospective difference-in-differences study. SETTING US Medicare, 2013 to 2015. PARTICIPANTS A total of 264 US hospitals participating in BPCI for lower-extremity joint replacement and matched controls. EXPOSURES Participation in BPCI. MEASUREMENTS Use and duration of institutional PAC (proportion discharged to a skilled nursing facility, an inpatient rehabilitation facility, and a long-term care hospital), dispersion of PAC (proportion of discharges to commonly used providers), and quality of PAC (Star Ratings, readmission rates, length of stay, and nurse staffing); part A Medicare payments. RESULTS BPCI participants decreased the use and duration of institutional PAC compared to controls: overall institutional PAC declined 4.4% in BPCI hospitals vs 2.1% in non-BPCI hospitals (difference = -2.2%; P = .033), and duration decreased by 1.6 days in BPCI hospitals compared to 0.0 days in non-BPCI hospitals (difference in differences = -1.5 days; P < .001). However, BPCI participants did not change their PAC referral patterns to reduce dispersion or refer patients to higher-quality PAC providers. Hospitals that were more successful in reducing Medicare payments started with higher payments and higher use of institutional PAC settings and demonstrated greater drops in use and duration of institutional PAC, but no differences in dispersion or referral to high-quality providers. CONCLUSIONS AND RELEVANCE Reductions in spending under BPCI were driven by a shift from higher- to lower-cost discharge settings, and by shortening the duration of institutional PAC. Hospitals that reduced payments the most had the highest spending at baseline. J Am Geriatr Soc 67:1027-1035, 2019.
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Affiliation(s)
| | - E John Orav
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Arnold M Epstein
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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12
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Miller EA, Gidmark S, Gadbois E, Rudolph JL, Intrator O. Staff Perceptions of Key Factors Guiding Nursing Home Search and Selection Within the Veterans Health Administration. THE GERONTOLOGIST 2018. [PMID: 28641378 DOI: 10.1093/geront/gnx096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Objectives Veterans enter nursing homes (NHs) for short-term postacute, rehabilitation, respite, or end-of-life care. They also enter NHs on a long-term basis due to frailty, disability, functional deficits, and cognitive impairment. Little is known about how a particular NH is chosen once the decision to enter a NH has been made. This study identified VA staff perceptions of the key factors influencing the search and selection of NHs within the Veterans Health Administration (VHA). Research Design and Methods Data derived from 35 semistructured interviews with discharge planning and contracting staff from 12 Veterans Affairs Medical Centers (VAMCs). Results VA staff placed a premium on Veteran and family preferences in the NH selection process, though VA staff knowledge and familiarity with placement options established the general parameters within which NH placement decisions were made. Geographic proximity to Veterans' homes and families was a major factor in NH choice. Other key considerations included Veterans' specialty care needs (psychiatric, postacute, ventilator) and Veteran/facility demographics (age, race/ethnicity, Veteran status). VA staff tried to remain neutral in NH selection, thus instructing families to visit facilities and review publicly available quality data. VA staff report that amenities (private rooms, activities, smoking) and aesthetics (cleanliness, smell, layout, décor) often outweighed objective quality indicators in Veteran and family decision making. Discussion and Implications Findings suggest that VAMCs facilitate Veteran and family decision making around NH selection. They also suggest that VAMCs endeavor to identify and recruit a broader array of higher quality NHs to better match the specific needs of Veterans and families to the choice set available.
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Affiliation(s)
- Edward Alan Miller
- Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | | | - Emily Gadbois
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | - James L Rudolph
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Providence VA Medical Center, Rhode Island
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Orna Intrator
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Canandaigua VA Medical Center, New York
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, New York
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13
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Developing Faculty in Emerging Areas of Interdisciplinary Research. Am J Med 2018; 131:1257-1262. [PMID: 29981720 DOI: 10.1016/j.amjmed.2018.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/22/2018] [Indexed: 01/13/2023]
Abstract
The availability of new techniques and technologies to answer important medical questions is accelerating at a breathtaking pace. In response to these exciting new opportunities, clinical departments, in general, and departments of medicine, in particular, have broadened their research portfolios. Organization of the traditional structures of clinical departments, research infrastructure, training programs, and rewards for faculty has only begun to catalyze emerging research areas such as artificial intelligence, bioinformatics, bioengineering, cell and tissue engineering, cost effectiveness, health services, implementation science, integrative epidemiology, medical informatics, nanomedicine, and quality improvement. Success in these emerging areas of research requires interdisciplinary collaboration on a much larger scale than in the past. The effectiveness of efforts to recruit, develop, mentor, and promote faculty in these exciting areas will be critical to the success of departmental and institutional research programs. We describe examples of initiatives from our 5 departments of medicine designed to develop and promote faculty conducting research in emerging interdisciplinary areas. We focus on core resources, training, organizational structures, and recognition and promotion. Faculty have a compelling opportunity and obligation to pursue emerging research areas that have the potential to further improve the prevention, diagnosis, and treatment of disease. As departments prepare to meet this exciting opportunity in the future, the lessons learned must inform investments in faculty development. Although many of the strategies outlined herein could and should expand beyond any individual department, departments of medicine have a distinct obligation and opportunity to lead this effort.
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Hospital Discharge and Selecting a Skilled Nursing Facility: A Comparison of Experiences and Perspectives of Patients and Their Families. Prof Case Manag 2018; 23:50-59. [PMID: 29381669 DOI: 10.1097/ncm.0000000000000252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY A currently proposed rule by the Centers for Medicare & Medicaid Services would require providers to devote more resources to discharge planning from hospitals to ensure the prioritization of patient preferences and goals in the discharge planning process. Annually, more than 3 million persons enter a nursing home in the United States, with the vast majority of patients coming directly from hospitals. Although early evidence suggests more family involvement than patient involvement in the discharge process, most of this work has relied on retrospective reports of the decision-making process postplacement. This article seeks to examine and compare the experiences and perspectives of patients and others involved in the selection of the nursing home (predominately adult children and spouses). PRIMARY PRACTICE SETTING Large academic medical hospital with patients being discharged to a skilled nursing facility. METHODOLOGY AND SAMPLE A total of 225 patients or their family members and involved others who completed an exit survey assessing their experiences and perspectives in selecting a skilled nursing home and in experiencing the discharge process more generally. RESULTS Patients were the primary decision makers about 23% of the time but were often involved in the decision even when family members/involved others were primarily making decisions in the discharge process. Although patients were involved in the selection of the nursing home to a lesser degree than involved others, their level of satisfaction with the decision to be discharged to a skilled nursing home and their level of satisfaction with their personal level of involvement with the selection of the specific nursing home did not differ from the satisfaction ratings of the involved others. Furthermore, their confidence in the decision and their satisfaction with the decision did not differ from ratings provided by family members/involved others. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Recommendations for case management practice include (1) encouraging patients and their families to take an active role in the discharge process; (2) incorporating technology into the discharge process that promotes this active level of engagement; and (3) facilitating access to data to promote discharge to the highest quality nursing homes available.
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Graham C, Ross L, Bueno EB, Harrington C. Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018800090. [PMID: 30222018 PMCID: PMC6144495 DOI: 10.1177/0046958018800090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.
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Affiliation(s)
- Carrie Graham
- 1 Center for the Advanced Study of Aging Services, Berkeley, CA, USA
| | - Leslie Ross
- 2 University of California, San Francisco, USA
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Nazir A. Understanding the True Quality of Skilled Nursing Facilities: Will Stars Suffice? J Am Med Dir Assoc 2018; 19:816-817. [PMID: 30087030 DOI: 10.1016/j.jamda.2018.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/03/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Arif Nazir
- Department of Family Medicine and Geriatrics, University of Louisville, Louisville, KY; Signature HealthCARE, Louiseville, KY.
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Burke RE, Jones J, Lawrence E, Ladebue A, Ayele R, Leonard C, Lippmann B, Matlock DD, Allyn R, Cumbler E. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med 2018; 33:678-684. [PMID: 29427179 PMCID: PMC5910345 DOI: 10.1007/s11606-017-4298-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 11/06/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. OBJECTIVE We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. DESIGN Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. PARTICIPANTS Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. MAIN MEASURES We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. KEY RESULTS The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. CONCLUSIONS Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.
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Affiliation(s)
- Robert E Burke
- Denver-Seattle Center of Innovation at the Denver VA Medical Center, Denver, CO, USA.
- Hospital Medicine Section, Denver VA Medical Center, Denver, CO, USA.
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | | | - Emily Lawrence
- Denver-Seattle Center of Innovation at the Denver VA Medical Center, Denver, CO, USA
| | - Amy Ladebue
- Denver-Seattle Center of Innovation at the Denver VA Medical Center, Denver, CO, USA
| | - Roman Ayele
- Denver-Seattle Center of Innovation at the Denver VA Medical Center, Denver, CO, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation at the Denver VA Medical Center, Denver, CO, USA
| | - Brandi Lippmann
- Denver-Seattle Center of Innovation at the Denver VA Medical Center, Denver, CO, USA
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Denver, CO, USA
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Rebecca Allyn
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Ethan Cumbler
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Zinn JS, Romano PS. Best of the 2016 AcademyHealth Annual Research Meeting. Health Serv Res 2016; 51:2053-2055. [PMID: 27891604 DOI: 10.1111/1475-6773.12620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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