Nursing Home Characteristics and Potentially Preventable Hospitalizations of Long-Stay Residents

Cost of care pathways before and after appropriate and inappropriate transfers to the emergency department among nursing home residents: results from the FINE study

BACKGROUND

Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate).

METHODS

This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant.

RESULTS

Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€.

CONCLUSIONS

Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02677272.

Interprofessional relationships and their impact on resident hospitalizations in nursing homes: A qualitative study

AIM

The aim of this study is to explore experiences and perspectives of nurses and providers (e.g., physicians, medical directors, fellows, and nurse practitioners) on reducing preventable hospitalizations of nursing home (NH) residents in relation to interprofessional relationship and hospitalization decision-making process.

BACKGROUND

Preventable NH resident hospitalization continues to be a pressing public health issue. Studies show that improved interprofessional relationship may help reduce hospitalization, yet research on communication processes and interactions among different NH staff remains limited.

METHODS

This is a qualitative descriptive study. Two focus groups were held with fourteen nurses and thirteen in-depth, qualitative interviews were conducted with providers from two Chicagoland NHs. Focus group sessions and interviews were transcribed, coded, and analyzed for common themes based on qualitative description method.

RESULTS

All study participants agreed that providers have the ultimate responsibility for hospitalization decisions. However, nurses believed they could influence those decisions, depending on provider characteristics, trust, and resident conditions. Nurses and providers differed in the way they experienced and conveyed emotions, and differed in key elements affecting hospitalization decisions such as structural or environmental factors (e.g., lacking staff and equipment at the facility, poor communication between the NH and hospitals) and interpersonal factors (e.g., characteristics of effective nurses or providers and the effective interactions between them).

CONCLUSIONS

Interpersonal factors, including perceived competence, respect, and trust, may influence NH hospitalization decisions and be targeted for reducing preventable hospitalizations of residents.

Nurse Practitioner Employment in Relation to Nursing Staff Turnover and Resident Care Outcomes in US Nursing Homes

OBJECTIVES

A growing number of nurse practitioners (NPs) are employed in nursing homes (NHs) through various NP staffing mechanisms. The purpose of this study was to examine if having NH-employed NPs was associated with nursing staff turnover and resident care outcomes measured as hospital utilization, infection control citations, and substantiated complaints in NHs in 2021-2022.

DESIGN

A cross-sectional, retrospective study.

SETTING AND PARTICIPANTS

A total of 13,966 NHs from payroll-based journal (PBJ) and claim-based quality measures published by the Centers for Medicare and Medicaid Services in 2021-2022.

METHODS

Facilities were identified as having NH-employed NPs if at least 1 employed NP with paid working hours ≥10 per week was reported through the PBJ. We examined if having NH-employed NPs was associated with nursing staff turnover rates, unplanned hospital utilization, infection control citations, and substantiated complaints using doubly robust estimation that combined inverse probability weight representing the NH's likelihood of employing NPs and outcome regression.

RESULTS

Approximately, 2.8% of NHs had employed NPs. Facilities with NH-employed NPs tended to be larger, hospital affiliated, and not for profit with greater medical and nursing staff availability. In addition, a significantly higher proportion of facilities with NH-employed NPs were in metropolitan areas or states with full NP practice independence. We found that facilities with NH-employed NPs had significantly lower registered nurse (adjusted β, -5.40; 95% CI, -9.50 to -1.30) and certified nursing assistant turnover rates (adjusted β, -3.35; 95% CI, -6.29 to -0.40). Facilities with NH-employed NPs also had significantly fewer long-stay resident hospitalizations, infection control citations, and substantial complaints compared with those with no NH-employed NPs.

CONCLUSIONS AND IMPLICATIONS

This study highlights the value of NH-employed NPs to improve registered nurse and certified nursing assistant staff retention and NH resident outcomes. NH stakeholders and policymakers may consider various strategies to incentivize NP employment in NHs such as removing regulatory barriers to NP practice.

Facility staffing associated with potentially avoidable hospitalizations in nursing home residents in Japan: a retrospective cohort study

BACKGROUND

Wide variations in facility staffing may lead to differences in care, and consequently, adverse outcomes such as hospitalizations. However, few studies focused on types of occupations. Therefore, we aimed to examine the association between a wide variety of facility staffing and potentially avoidable hospitalizations of nursing home residents in Japan.

METHODS

In this retrospective cohort study using long-term care and medical insurance claims data in Ibaraki Prefecture from April 2018 to March 2019, we identified individuals aged 65 years and above who were newly admitted to nursing homes. In addition, facility characteristic data were obtained from the long-term care insurance service disclosure system. Subsequently, we conducted a multivariable Cox regression analysis and evaluated the association between facility staffing and potentially avoidable hospitalizations.

RESULTS

A total of 2909 residents from 235 nursing homes were included. The cumulative incidence of potentially avoidable hospitalizations at 180 days was 14.2% (95% confidence interval [CI] 12.7-15.8). Facilities with full-time physicians (adjusted hazard ratio [HR]: 0.59, 95% CI: 0.37-0.94) and a higher number of dietitians (HR: 0.72, 95% CI: 0.54-0.97) were significantly associated with a lower likelihood of potentially avoidable hospitalizations. In contrast, having nurses or trained caregivers during the night shift (HR: 1.72, 95% CI: 1.25-2.36) and a higher number of care managers (HR: 1.37, 95% CI: 1.03-1.83) were significantly associated with a high probability of potentially avoidable hospitalizations.

CONCLUSIONS

We revealed that variations in facility staffing were associated with potentially avoidable hospitalizations. The results suggest that optimal allocation of human resources, such as dietitians and physicians, may be essential to reduce potentially avoidable hospitalizations. To provide appropriate care to nursing home residents, it is necessary to establish a system to effectively allocate limited resources. Further research is warranted on the causal relationship between staff allocation and unnecessary hospitalizations, considering the confounding factors.

Factors associated with avoidable hospital transfers among residents in Swiss nursing homes

Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.

Physician Practice Characteristics Influencing Nurse Practitioner and Physician Assistant Care in Nursing Homes: A Scoping Review

OBJECTIVES

Physicians, nurse practitioners (NPs), and physician assistants (PAs) are key to the effective delivery of medical care in nursing homes (NHs). Although several studies have reported on the relationship between the care delivered by a given discipline and specific clinical outcomes, the mediating effect of physician practice characteristics is unknown. A scoping review was conducted to determine whether studies examining the impact of NP and PA care in NHs have accounted for both the collaborative relationship between themselves and physicians as well as physician practice size and type.

DESIGN

Scoping review.

SETTINGS AND PARTICIPANTS

NH and NH residents.

METHODS

Papers eligible for review included peer-reviewed studies written in English and that were quantitative in nature. Inclusion criteria required that more than 1 NH and more than a single NP or PA be included for the analysis. Further, the size of the NH studied must have equaled or exceeded 100 residents and more than 1 clinical outcome reported. Databases searched included Ovid MEDLINE, Cochrane Library, Web of Science; CINAHL, and AgeLine.

RESULTS

A total of 1878 studies underwent abstract review of which 1719 were excluded. A full-text review of the remaining articles was completed (n = 157, as 2 articles could not be retrieved), of which 16 met eligibility criteria. The study designs were generally retrospective and quasi-experimental in nature. No randomized controlled studies were identified. Physician practice variables such as number of physicians, total practice case load, case mix, and the nature of the collaborative practice between NP/PA and MD were infrequently specified. In no reports was the type of physician practice characterized and no physician practice variables were adjusted for with regard to outcomes.

CONCLUSIONS

None of the studies included in the review were found to have incorporated any physician variables into their outcome analyses. Before purporting equivalency between medical provider disciplines in NHs, future studies must, at the very least, consider the mediating effect of physician practice characteristics.

[Inappropriate admissions of Ehpad residents to emergency departments]

After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone.

CONTEXT

In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).

METHODS

Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.

FINDINGS

Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.

CONCLUSIONS

Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

Do mobile hospital teams in residential aged care facilities increase health care efficiency: an evaluation of French residential care policy

CONTEXT

Patients in residential aged care facilities (RACF) are frequently admitted to hospital since the RACF often lack adequate medical resources. Different economic agents, whose missions and funding may conflict, provide care for RACF residents: residential facility, primary care physicians, and hospital. In this article, I estimate the economic impact of employing a mobile hospital team (MHT) in RACF, which modifies the relationship between these three agents by providing care directly in RACF.

METHOD

A national, patient level database on RACF from 2014 to 2017 is used to calculate RACF outcome indicators. I analyse the difference between RACFs, that use MHT for the first time during the period (treatment group), and those that did not use MHT at all in the same period using a difference in difference (DID) model.

RESULTS

The MHT had a significant impact on health care quality in treated RACFs and reduced the number of patients transferred to hospital and the number of emergency department visits, and increased palliative care utilisation at the end-of-life, without increasing total hospital expenditure.

CONCLUSION

MHT appear improve care quality in RACFs by filling the gap in care needs including better end of life care, without increasing health expenditure. Given the high number of hospital transfers especially towards the end of life, securing the right level and mix of social and medical resources in RACFs is essential. Transferring some competencies of MHT teams to residential facilities may improve the quality of life of residents while improving allocative efficiency of public resources.

Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation

INTRODUCTION

This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD).

METHODS

We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models.

RESULTS

The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness.

DISCUSSION/CONCLUSION

Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.

'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers

Background

care home staff play a crucial role in managing residents’ health and responding to deteriorations. When deciding whether to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. Previous studies have identified factors that influence staff decision-making, yet few have moved beyond description to produce a conceptual model of the decision-making process.

Objectives

to develop a conceptual model to describe care home staff’s decision-making when faced with a resident who potentially requires a transfer to the hospital.

Methods

data collection occurred in England between May 2018 and November 2019, consisting of 28 semi-structured interviews with 30 members of care home staff across six care home sites and 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, visiting families, friends and healthcare professionals) at three of these sites.

Results

a conceptual model of care home staff’s decision-making is presented. Except in situations that staff perceived to be urgent enough to require an immediate transfer, resident transfers tended to occur following a series of escalations. Care home staff made complex decisions in which they sought to balance a number of potential benefits and risks to: residents; staff (as decision-makers); social relationships; care home organisations and wider health and social care services.

Conclusions

during transfer decisions, care home staff make complex decisions in which they weigh up several forms of risk. The model presented offers a theoretical basis for interventions to support deteriorating care home residents and the staff responsible for their care.

Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review

The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.

Hospital transfer rates and advance care planning following a nursing home-targeted video-conference education series (Project ECHO): a prospective cohort study

Purpose

Nursing home staff manage increasingly complex patients yet struggle to access education. This study measured the impact of a novel education programme on emergency transfers from nursing homes.

Methods

In this prospective experimental cohort study, ten interactive sessions were provided to 20 nursing homes, using teleconferencing technology through the “Project ECHO” (Extension for Community Healthcare Outcomes) model. Details of all emergency hospital transfers were submitted by participating nursing homes 6 months before and 6 months from commencement of ECHO.

Results

Of 20 nursing homes, 13 submitted sufficient data for inclusion. In these 13, there were 260 emergency transfers over a year. There was no significant difference in the number of transfers before and after ECHO (137/260 pre-ECHO vs 123/260 post-ECHO, p = 0.62). Post-ECHO, it was 50% more likely that transfer wishes were discussed in advance of transfer (62 of 137 (45%) transferred pre-ECHO vs 82 of 123 (67%) post-ECHO, p < 0.001). There was a significant increase in compliance with resident wishes post-ECHO in that transferred residents were less likely to have a documented “Not for Transfer” wish (29/137 pre-ECHO (21%) vs 10/123 post-ECHO (8%), p < 0.001). Point prevalence surveys of residents demonstrated significant increases in “Do Not Resuscitate” orders; 286/589 (49%) residents pre-ECHO vs 386/594 (65%) post-ECHO, p < 0.001. Post-ECHO, pain was less frequently the primary cause for transfer (11/137 (8%) pre-ECHO vs 1/123 (0.8%) post-ECHO, p = 0.006).

Conclusion

ECHO did not affect rates of emergency hospital transfers but did increase advance care planning discussions ahead of hospital transfer by 50% and compliance with the results of those discussions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00624-6.

Aim

What effect does a novel education programme have on emergency hospital transfers of, and advance care planning decisions among, nursing home residents?

Findings

This education programme did not affect overall rates of emergency hospital transfer. It did increase advance care planning discussions, increase compliance with the results of these discussions and increase “DNR” orders among nursing home residents.

Message

Novel tele-education programmes have the potential to improve advance care planning discussions in nursing homes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00624-6.

Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations

Background: Hospitalizations of nursing home residents are associated with various health risks. Previous research indicates that, to some extent, hospitalizations of this vulnerable population may be inappropriate and even avoidable. This study aimed to develop a consensus list of hospital discharge diagnoses considered to be nursing home-sensitive, i.e., avoidable. Methods: The study combined analyses of routine data from six statutory health insurance companies in Germany and a two-stage Delphi panel, enhanced by expert workshop discussions, to identify and corroborate relevant diagnoses. Experts from four different disciplines estimated the proportion of hospitalizations that could potentially have been prevented under optimal conditions.   Results: We analyzed frequencies and costs of data for hospital admissions from 242,236 nursing home residents provided by statutory health insurance companies. We identified 117 hospital discharge diagnoses, which had a frequency of at least 0.1%. We recruited experts (primary care physicians, hospital specialists, nursing home professionals and researchers) to estimate the proportion of potentially avoidable hospitalizations for the 117 diagnoses deemed avoidable in two Delphi rounds (n=107 in Delphi Round 1 and n=96 in Delphi Round 2, effective response rate=91%). A total of 35 diagnoses with high and consistent estimates of the proportion of potentially avoidable hospitalizations were identified as nursing home-sensitive. In an expert workshop (n=16), a further 25 diagnoses were discussed that had not reached the criteria, of which another 23 were consented to be nursing home-sensitive conditions. Extrapolating the frequency and mean costs of these 58 diagnoses to the national German context yielded total potentially avoidable care costs of €768,304,547, associated with 219,955 nursing home-sensitive hospital admissions. Conclusion: A total of 58 nursing home-relevant diagnoses (ICD-10-GM three-digit level) were classified as nursing home-sensitive using an adapted Delphi procedure. Interventions should be developed to avoid hospital admission from nursing homes for these diagnoses.

Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations

Background: Hospitalizations of nursing home residents are associated with various health risks. Previous research indicates that, to some extent, hospitalizations of this vulnerable population may be inappropriate and even avoidable. This study aimed to develop a consensus list of hospital discharge diagnoses considered to be nursing home-sensitive, i.e., avoidable. Methods: The study combined analyses of routine data from six statutory health insurance companies in Germany and a two-stage Delphi panel, enhanced by expert workshop discussions, to identify and corroborate relevant diagnoses. Experts from four different disciplines estimated the proportion of hospitalizations that could potentially have been prevented under optimal conditions.  Results: We analyzed frequencies and costs of data for hospital admissions from 242,236 nursing home residents provided by statutory health insurance companies. We identified 117 hospital discharge diagnoses, which had a frequency of at least 0.1%. We recruited experts (primary care physicians, hospital specialists, nursing home professionals and researchers) to estimate the proportion of potentially avoidable hospitalizations for the 117 diagnoses deemed avoidable in two Delphi rounds (n=107 in Delphi Round 1 and n=96 in Delphi Round 2, effective response rate=91%). A total of 35 diagnoses with high and consistent estimates of the proportion of potentially avoidable hospitalizations were identified as nursing home-sensitive. In an expert workshop (n=16), a further 25 diagnoses were discussed that had not reached the criteria, of which another 23 were consented to be nursing home-sensitive conditions. Extrapolating the frequency and mean costs of these 58 diagnoses to the national German context yielded total potentially avoidable care costs of €768,304,547, associated with 219,955 nursing home-sensitive hospital admissions. Conclusion: A total of 58 nursing home-relevant diagnoses (ICD-10-GM three-digit level) were classified as nursing home-sensitive using an adapted Delphi procedure. Interventions should be developed to avoid hospital admission from nursing homes for these diagnoses.

Characteristics associated with hospitalization within 30 days of geriatric intermediate care facility admission

AIM

To identify facility-level characteristics associated with hospitalization within 30 days after admission to a geriatric intermediate care facility (GICF) (30-day hospitalization) in Japan.

METHODS

This retrospective cohort study used nationwide long-term care insurance claims data and a national survey of long-term geriatric care facilities. The study population was residents admitted to GICFs between October 2016 and February 2018. The outcome variable was 30-day hospitalization. The independent variables were facility-level characteristics such as level of healthcare professionals.

RESULTS

The final sample for analysis comprised 282 991 residents of mean age ± SD, 85.8 ± 7.2 years, of whom 12 814 (4.5%) experienced 30-day hospitalization. In a multivariable logistic generalized estimating equation model adjusted for facility- and resident-level characteristics, and clustering GICFs, the odds of 30-day hospitalization were 0.906 times lower (95% confidence interval [CI] 0.857-0.958) among residents in a GICF with dental hygienist than in those in a facility without. Furthermore, the risk of 30-day hospitalization was lower among residents who had been admitted to a GICF with higher staffing levels of pharmacists (adjusted odds ratio [aOR] 0.941, 95% CI 0.899-0.985), registered nurses (aOR 0.931, 95% CI 0.880-0.986), care workers (aOR 0.920, 95% CI 0.879-0.964) and speech-language pathologists (aOR 0.926, 95% CI 0.874-0.982) than in those who had been admitted to a GICF with fewer of these healthcare professionals.

CONCLUSIONS

Transitional care including dental hygienist or higher staffing levels of pharmacists, registered nurses, care workers and speech-language pathologists may be a more effective way to prevent 30-day hospitalization. Geriatr Gerontol Int 2021; 21: 1010-1017.

Hospitalization Trajectories in Home- and Community-Based Services Recipients: The Influence of Physician and Social Care Density

OBJECTIVES

Repeated hospitalizations among older adults receiving Home- and Community-Based Services (HCBS) may indicate unmet medical and social needs. This study examined all-cause hospitalization trajectories and the association between area-level resource density for medical and social care and the trajectory group membership.

METHODS

The study participants included 11,223 adults aged 60 years or older who were enrolled in public HCBS programs in Michigan between 2008 and 2012. Data sources included the Michigan interRAI-Home Care, Dartmouth Atlas of Health Care Data, the American Community Survey, and the County Business Patterns from the Census Bureau. The group-based trajectory modeling was used to identify trajectories of hospitalization over 15 months. Correlates of the trajectories were examined using multinomial logistic regression.

RESULTS

Four distinct hospitalization trajectory groups emerged: "never" (43.1%)-individuals who were rarely hospitalized during the study period, "increasing" (19.9%)-individuals who experienced an increased risk of hospitalization, "decreasing" (21.6%)-individuals with a decreased risk, and "frequent" (15.8%)-individuals with frequent hospitalizations. Older adults living in areas with a higher number of social service organizations for older adults and persons with disability were less likely to be on the "frequent" trajectory relative to the "decreasing" trajectory. The density of primary care physicians was not associated with the trajectory group membership.

DISCUSSION

Area-level social care resource density contributes to changes in 15-month hospitalization risks among older adult recipients of HCBS.

Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project

BACKGROUND

Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model.

METHODS

This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics.

RESULTS

The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1).

CONCLUSIONS

Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.

Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents

OBJECTIVES

To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately.

DESIGN

Multicenter, observational, case-control study.

SETTING AND PARTICIPANTS

17 hospitals in France, 1037 NH residents.

MEASURES

All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer.

RESULTS

A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs.

CONCLUSIONS AND IMPLICATIONS

Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02677272.

Characterizing Emergency Department Use in Assisted Living

OBJECTIVES

Little is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL.

DESIGN

Observational retrospective cohort study.

SETTING AND PARTICIPANTS

We identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds).

METHODS

With Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions.

RESULTS

Risk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina.

CONCLUSIONS AND IMPLICATIONS

We observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED.

Nursing Home Transfers for Behavioral Concerns: Findings from the OPTIMISTIC Demonstration Project

OBJECTIVES

To characterize pretransfer on-site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long-stay residents transferred for behavioral concerns.

DESIGN

This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns.

SETTING

NHs in central Indiana were utilized (N = 19).

PARTICIPANTS

This study included long-stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers).

MEASUREMENTS

The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on-site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses.

RESULTS

Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia-related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses.

CONCLUSION

Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns.

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis

BACKGROUND

Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.

OBJECTIVES

To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents.

RESEARCH DESIGN

We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors.

SUBJECTS

Privately owned, free-standing NHs in the United States (N=13,260).

RESULTS

Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED.

CONCLUSIONS

Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

Diagnostic Testing in Long-Term Care and Resident Emergency Department Visits: A Retrospective Cohort Study

OBJECTIVES

To investigate the association between rapid access to radiographs, blood tests, urine cultures, and intravenous (IV) therapy in a long-term care (LTC) home with resident transfers to the emergency department (ED).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

21,811 residents living in 162 LTC homes in Ontario, Canada.

METHODS

We administered a survey to LTC homes to collect wait times for radiographs, basic blood tests, urine culture, and IV therapy. Rapid availability was defined as typically receiving test results within 1 or 2 days, or same-day IV therapy. We linked the survey results to administrative data and defined a cohort of residents living in survey-respondent homes between January and May 2017. We followed residents in the linked administrative databases for 6 months, until discharge, or death. Two physicians identified diagnostic codes for ED visits that were potentially preventable with rapid availability of each of the 4 resources. Multilevel logistic regression models estimated associations between potentially preventable ED visits and rapid diagnostic tests and intravenous access while controlling for demographic characteristics, illness severity, LTC home size, chain status, and physician availability.

RESULTS

Rapid blood tests, radiographs, urine culture, and IV therapy were available in 55%, 47%, 34%, and 45% of LTC homes, respectively. LTC homes that were part of multihome chains were less likely to have rapid access to the 4 resources. Of the 4736 residents (27%) who visited an ED during follow-up, individuals from homes with rapid access to radiographs (odds ratio 0.79, 95% confidence interval 0.66-0.97), urine culture (0.88, 0.72-1.08), blood tests (0.83, 0.69-1.00), and IV therapy (0.93, 0.70-1.23) tended to have fewer potentially preventable ED visits.

CONCLUSIONS AND IMPLICATIONS

Rapid access to diagnostic testing and IV therapy in LTC reduced ED visits. Improving access to these resources may prevent ED visits and allow residents to stay home.

Racial and ethnic patterns and differences in health care expenditures among Medicare beneficiaries with and without cognitive deficits or Alzheimer's disease and related dementias

BACKGROUND

Numerous studies have documented racial and ethnic differences in the prevalence and incidence of Alzheimer's disease and related dementias (ADRD). Less is known, however, about racial and ethnic differences in health care expenditures among older adults at risk for ADRD (cognitive deficits without ADRD) or with ADRD. In particular, there is limited evidence that racial and ethnic differences in health care expenditures change over the trajectory of ADRD or differ by types of service.

METHODS

We examined racial and ethnic patterns and differences in health care expenditures (total health care expenditures, out-of-pocket expenditures, and six service-specific expenditures) among Medicare beneficiaries without cognitive deficits, those with cognitive deficits without ADRD, and those with ADRD. Using the 1996-2017 Medical Expenditure Panel Survey, we performed multivariable regression models to estimate expenditure differences among racial and ethnic groups without cognitive deficits, those with cognitive deficits without ADRD, and those with ADRD. Models accounted for survey weights and adjusted for various demographic, socioeconomic, and health characteristics.

RESULTS

Black, Asians, and Latinos without cognitive deficits had lower total health care expenditures than whites without cognitive deficits ($10,236, $9497, $9597, and $11,541, respectively). There were no racial and ethnic differences in total health care expenditures among those with cognitive deficits without ADRD and those with ADRD. Across all three groups, however, Blacks, Asians, and Latinos consistently had lower out-of-pocket expenditures than whites (except for Asians with cognitive deficits without ADRD). Furthermore, service-specific health care expenditures varied by racial and ethnic groups.

CONCLUSIONS

Our study did not find significant racial and ethnic differences in total health care expenditures among Medicare beneficiaries with cognitive deficits and/or ADRD. However, we documented significant differences in out-of-pocket expenditures and service-specific expenditures. We speculated that the differences may be attributable to racial and ethnic differences in access to care and/or preferences based on family structure and cultural/economic factors. Particularly, heterogeneous patterns of service-specific expenditures by racial and ethnic groups underscore the importance of future research in identifying determinants leading to variations in service-specific expenditures among racial and ethnic groups.

Exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and manager's in nursing homes in England and Sweden: a survey protocol

INTRODUCTION

In order to avoid unnecessary hospital admission and associated complications, there is an urgent need to improve the early detection of infection in nursing home residents. Monitoring signs and symptoms with checklists or aids called decision support tools may help nursing home staff to detect infection in residents, particularly during the current COVID-19 pandemic.We plan to conduct a survey exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes in England and Sweden.

METHODS AND ANALYSIS

An international cross-sectional descriptive survey, using a pretested questionnaire, will be used to explore nurses, care workers and managers views and experiences of how infections are detected and managed in practice in nursing homes. Data will be analysed descriptively and univariate associations between personal and organisational factors explored. This will help identify important factors related to awareness, knowledge, attitudes, belief and skills likely to affect future implementation of a decision support tool for the early detection of infection in nursing home residents.

ETHICS AND DISSEMINATION

This study was approved using the self-certification process at the University of Surrey and Linköping University ethics committee (Approval 2018/514-32) in 2018. Study findings will be disseminated through community/stakeholder/service user engagement events in each country, publication in academic peer-reviewed journals and conference presentations. A LAY summary will be provided to participants who indicate they would like to receive this information.This is the first stage of a plan of work to revise and evaluate the Early Detection of Infection Scale (EDIS) tool and its effect on managing infections and reducing unplanned hospital admissions in nursing home residents. Implementation of the EDIS tool may have important implications for the healthcare economy; this will be explored in cost-benefit analyses as the work progresses.

Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study

OBJECTIVE

Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016.

MEASURES

Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors.

RESULTS

The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29-1.38) and nonprofit (adjHR 1.37; 95% CI 1.32-1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36-1.48) and nonprofit (adjHR 1.38, 95% CI 1.33-1.44).

CONCLUSIONS AND IMPLICATIONS

This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.

Sex-Specific Differences in Hospital Transfers of Nursing Home Residents: Results from the HOspitalizations and eMERgency Department Visits of Nursing Home Residents (HOMERN) Project

Nursing home (NH) residents are often transferred to hospital (emergency department (ED) visits or hospital admissions) and this occurs more frequently in males. However, respective reasons are rather unclear. We conducted a multicenter prospective study in 14 northwest German NHs with 802 residents in which NH staff recorded anonymized data between March 2018 and July 2019 for each hospital transfer. Measures were analyzed using descriptive statistics and compared between sexes via univariate logistic regression analyses using mixed models with random effects. Eighty-eight planned transfers (53.5% hospital admissions, 46.5% ED visits) occurred as well as 535 unplanned transfers (63.1% hospital admissions, 36.9% ED visits). The two most common causes for unplanned transfers were deteriorations of health status (35.1%) and falls/accidents/injuries (33.5%). Male transferred residents were younger, more often married; their advance directives were more commonly not considered correctly and the NH staff identified more males nearing the end of life than females (52.9% vs. 38.2%). Only 9.2% of transfers were rated avoidable. For advance directive availability and NH staff’s perceptions on transfer conditions, we found marked inter-facility differences. There might be sociocultural factors influencing hospital transfer decisions of male and female nursing home residents and facility characteristics that may affect transfer policy.

Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study

Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.

Comparing quality of care in medical specialties between nurse practitioners and physicians

BACKGROUND

The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings.

OBJECTIVE

This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction.

DATA SOURCES

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review.

CONCLUSIONS

Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction.

IMPLICATIONS FOR PRACTICE

Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.

Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias

Importance

Compared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality.

Objective

To determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD.

Design, Setting, and Participants

A cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019.

Exposures

Enrollment in MA.

Main Outcomes and Measures

Self-reported health care utilization, care satisfaction, and health status.

Results

The sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD.

Conclusions and Relevance

Compared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.

Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial

IMPORTANCE

Dementia is often underdiagnosed in nursing homes (NHs). This potentially results in inappropriate care, and high rates of emergency department (ED) transfers in particular.

OBJECTIVE

To assess whether systematic dementia screening of NH residents combined with multidisciplinary team meetings resulted in a lower rate of ED transfer at 12 months compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster randomized trial with NHs as the unit of randomization. The IDEM (Impact of Systematic Tracking of Dementia Cases on the Rate of Hospitalization in Emergency Care Units) trial took place at 64 public and private NHs in France. Recruitment started on May 1, 2010, and was completed on March 31, 2012. Residents who were aged 60 years or older, had no diagnosed or documented dementia, were not bedridden, had lived in the NH for at least 1 month at inclusion, and had a life expectancy greater than 12 months were included. The residents were followed up for 18 months. The main study analyses were completed on October 14, 2016.

INTERVENTION

Two parallel groups were compared: an intervention group consisting of NHs that set up 2 multidisciplinary team meetings to identify residents with dementia and to discuss an appropriate care plan, and a control group consisting of NHs that continued their usual practice. During the inclusion period of 23 months, all residents of participating NHs who met eligibility criteria were included in the study.

MAIN OUTCOMES AND MEASURES

The primary end point (ED transfer) was analyzed at 12 months, but the residents included were followed up for 18 months.

RESULTS

A total of 64 NHs participated in the study and enrolled 1428 residents (mean [SD] age, 84.7 [8.1] years; 1019 [71.3%] female): 599 in the intervention group (32 NHs) and 829 in the control group (32 NHs). The final study visit was completed by 1042 residents (73.0%). The main reason for early discontinuation was death (318 residents [22.7%]). The intervention did not reduce the risk of ED transfers during the 12-month follow-up: the proportion of residents transferred at least once to an ED during the 12-month follow-up was 16.2% in the intervention group vs 12.8% in the control group (odds ratio, 1.32; 95% CI, 0.83-2.09; P = .24).

CONCLUSIONS AND RELEVANCE

This study failed to demonstrate that systematic screening for dementia in NHs resulted in fewer ED transfers. The findings do not support implementation of multidisciplinary team meetings for systematic dementia screening of all NH residents, beyond the national recommendations for dementia diagnosis, to reduce ED transfers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01569997.

Does older adults' use of social care influence their healthcare utilisation? A systematic review of international evidence

Improving our understanding of the complex relationship between health and social care utilisation is vital as populations age. This systematic review aimed to synthesise evidence on the relationship between older adults' use of social care and their healthcare utilisation. Ten databases were searched for international literature on social care (exposure), healthcare use (outcome) and older adults (population). Searches were carried out in October 2016, and updated May 2018. Studies were eligible if they were published after 2000 in a high income country, examined the relationship between use of social care and healthcare utilisation by older adults (aged ≥60 years), and controlled for an indicator of need. Study quality and bias were rated using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Study data were extracted and a narrative synthesis was conducted. Data were not suitable for quantitative synthesis. Thirteen studies were identified from 12,065 citations. Overall, the quality and volume of evidence was low. There was limited evidence to suggest that longer lengths of stay in care homes were associated with a lower risk of inpatient admissions. Residents of care homes with onsite nursing had fewer than expected admissions to hospital, compared to people in care homes without nursing, and adjusting for need. Evidence for other healthcare use outcomes was even more limited and heterogeneous, with notable gaps in primary care. We conclude that older adults' use of care homes may moderate inpatient admissions. In particular, the presence of registered nurses in care homes may reduce the need to transfer residents to hospital. However, further evidence is needed to add weight to this conclusion. Future research should build on this evidence and address gaps regarding the influence of community based social care on older adults' healthcare use. A greater focus on primary care outcomes is imperative.

Care workers' view on factors leading to unplanned hospitalizations of nursing home residents: A cross-sectional multicenter study

Nursing home residents have a high risk of adverse events during hospitalizations. Since up to two-thirds of hospitalizations of nursing home residents are rated as potentially preventable, this study aimed to describe factors related to unplanned hospitalizations and to describe rates of unplanned hospitalizations, comparing differences between high- and low-hospitalization nursing homes. This cross-sectional multicenter study was conducted in 19 Swiss nursing homes and used questionnaire surveys of ward supervisors (n = 33) and nursing staff (n = 146) and retrospectively assessed hospitalization data. The study revealed several issues regarding unplanned hospitalizations, mostly concerning limitations regarding physicians' availability, lack of acquaintance of on-call physicians with the residents, and health professionals' lack of knowledge about the residents' wishes concerning therapeutic decisions. Our findings suggest that standardizing advance care planning processes and better physician availability might further reduce hospitalizations and improve quality of care in nursing homes.

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

OBJECTIVES

To investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.

METHODS

We administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death. We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.

RESULTS

Fifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED. The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.

CONCLUSIONS AND IMPLICATIONS

Residents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.

Global Long-Term Care Research: A Scientometric Review

Since the early 1960s, long-term care (LTC) has attracted a broad range of attention from public health practitioners and researchers worldwide and produced a large volume of literature. We conducted a comprehensive scientometric review based on 14,019 LTC articles retrieved from the Web of Science Core Collection database from 1963 to 2018, to explore the status and trends of global LTC research. Using CiteSpace software, we conducted collaboration analysis, document co-citation analysis, and keyword co-occurrence analysis. The results showed a rapid increase in annual LTC publications, while the annual citation counts exhibited an inverted U-shaped relationship with years. The most productive LTC research institutions and authors are located primarily in North American and European countries. A simultaneous analysis of both references and keywords revealed that common LTC hot topics include dementia care, quality of care, prevalence and risk factors, mortality, and randomized controlled trial. In addition, LTC research trends have shifted from the demand side to the supply side, and from basic studies to practical applications. The new research frontiers are frailty in elderly people and dementia care. This study provides an in-depth understanding of the current state, popular themes, trends, and future directions of LTC research worldwide.

Reducing Avoidable Facility Transfers (RAFT): Outcomes of a Team Model to Minimize Unwarranted Emergency Care at Skilled Nursing Facilities

BACKGROUND

Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization.

OBJECTIVE

Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017.

DESIGN

Prospective cohort, pre/post study.

SETTING

Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center.

PARTICIPANTS

Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs.

INTERVENTION

RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers.

MEASURES

ED and hospital utilization.

RESULTS

RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents.

CONCLUSIONS/IMPLICATIONS

The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.

Postacute care outcomes and medicare payments for patients treated by physicians and advanced practitioners who specialize in nursing home practice

OBJECTIVE

To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs).

DATA SOURCES

Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians.

STUDY DESIGN

Generalist physicians and advanced practitioners with ≥ 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects.

PRINCIPAL FINDINGS

Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429).

CONCLUSIONS

Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs.

Building Capacity in Long-Term Care: Supporting Homes to Provide Intravenous Therapy

Background

Typically, long-term care home (LTCH) residents are transferred to hospital to access intravenous (IV) therapy. The aim of this study was to pilot-test an in-home IV therapy service, and to describe outcomes and key informants’ perceptions of this service.

Method

This service was pilot-tested in four LTCH in the Hamilton-Niagara region, Ontario. Interviews were conducted with six caregivers of residents who received IV therapy and ten key informants representing LTC home staff and service partners to assess their perceptions of the service. A chart review was conducted to describe the resident population served and service implementation.

Results

Twelve residents received IV therapy. This service potentially avoided nine emergency department visits and reduced hospital lengths of stay for three residents whose IV therapy was initiated in hospital. There were no adverse events. The service was well received by caregivers and key informants, as it provided care in a familiar environment and was perceived to be less stressful and better quality care than when provided in hospital.

Conclusion

IV therapy is feasible to implement in LTCHs, particularly when there are supportive resources available and clinical pathways to support decision-making. This service has the potential to increase capacity in LTCHs to provide medical care.

Patterns of emergency ambulance use, 2009-13: a comparison of older people living in Residential Aged Care Facilities and the Community

OBJECTIVE

to examine demand for emergency ambulances by older people.

DESIGN

retrospective cohort study using secondary analysis of routinely collected clinical and administrative data from Ambulance Victoria, and population data from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare.

SETTING

Victoria, Australia.

PARTICIPANTS

people aged 65 years and over, living in Residential Aged Care Facilities (RACF) and the community, attended by emergency ambulance paramedics, 2009-13.

MAIN OUTCOME MEASURES

rates of emergency ambulance attendance.

RESULTS

older people living in RACF experienced high rates of emergency ambulance attendance, up to four times those for age- and sex-matched people living in the community. Rates remained constant during the study period equating to a consistent, 1.45% average annual increase in absolute demand. Rates peak among the 80-84-year group where the number of attendances equates to greater than one for every RACF-dwelling person each year. Increased demand was associated with winter months, increasing age and being male.

CONCLUSION

these data provide strong evidence of high rates of emergency ambulance use by people aged 65 years and over living in RACF. These results demonstrate a clear relationship between increased rate of ambulance use among this vulnerable group of older Australians and residence, sex, age and season. Overall, absolute demand continues to increase each year adding to strain on health resources. Additional research is needed to elucidate individual characteristics, illness and health system contributors to ambulance use to inform strategies to appropriately reduce demand.

Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review

BACKGROUND

Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries.

PURPOSES

We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find out which topics have been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assess the conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership.

METHODOLOGY/APPROACH

Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics.

FINDINGS

For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being.

PRACTICAL IMPLICATIONS

For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.

Involvement of Advanced Practice Nurse in the Management of Geriatric Conditions: Examples from Different Countries

The increasing demand for healthcare services is placing great strain on healthcare systems throughout the world. Although the older population is increasing worldwide, there is a marked deficit in the number of persons trained in geriatrics. It is now recognized that early detection and treatment of geriatric conditions (e.g., frailty, sarcopenia, falls, anorexia of aging, and cognitive decline) will delay or avert the development of disability. At the same time, recent years have seen an increased interest and use of advanced practice nurses (APN). Models of best practices of supervision and collaboration have been promulgated by many organizations. APN's roles and scope of practice have been expanded in many countries and the quality and cost-effectiveness of healthcare systems have improved. Nevertheless, in older people, evidence of advanced practice roles remains scattered, and there is little synthesis of evidence, and therefore it is not easy to visualize the different practice models and their components. The aim of this paper is to explain the need for advanced practice nurses to manage geriatric conditions.

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.

Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees

Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities.