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Basso I, Gonella S, Bassi E, Caristia S, Campagna S, Dal Molin A. Impact of Quality Improvement Interventions on Hospital Admissions from Nursing Homes: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2024; 25:105261. [PMID: 39343421 DOI: 10.1016/j.jamda.2024.105261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/06/2024] [Accepted: 08/08/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVE To synthesize evidence assessing the effectiveness of quality improvement (QI) interventions in reducing hospital service use from nursing homes (NHs). DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs), controlled before-after (CBA), uncontrolled before-after (UBA), and interrupted time series studies. Searches were conducted in MEDLINE, CINAHL, The Cochrane Library, Embase, and Web of Science from 2000 to August 2023 (PROSPERO: CRD42022364195). SETTING AND PARTICIPANTS Long-stay NH residents (>30 days). METHODS Included QI interventions using a continuous and data-driven approach to assess solutions aimed at reducing hospital service use. Risk of bias was assessed using JBI tools. Delivery arrangements and implementation strategies were categorized through EPOC taxonomy. RESULTS Screening of 14,076 records led to the inclusion of 22 studies describing 29 QI interventions from 6 countries across 964 NHs. Ten studies, comprising 4 of 5 RCTs, 3 of 4 CBAs, and 1 of 12 UBAs were deemed to have a low risk of bias. All but 3 QI interventions used multiple component delivery arrangements (median 6; IQR 3-8), focusing on the "coordination of care and management of care processes" alone or combined with "changes in how, when, where, and by whom health care is delivered." The most frequently used implementation strategies were educational meetings (n = 25) and materials (n = 20). The meta-analysis of 11 studies showed a significant reduction in "all-cause hospital admissions" for QI interventions compared with standard care (rate ratio, 0.60; 95% CI, 0.41-0.87; I2 = 99.3%), with heterogeneity due to study design, QI intervention duration, type of delivery arrangements, and number of implementation strategies. No significant effects were found for emergency department (ED) visits or potentially avoidable hospitalizations. CONCLUSIONS AND IMPLICATIONS The study provides preliminary evidence supporting the implementation of QI interventions seeking to reduce hospital admissions from NHs. However, these findings require confirmation through future experimental research.
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Affiliation(s)
- Ines Basso
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
| | - Silvia Gonella
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Erika Bassi
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Silvia Caristia
- Department of Sustainable Development and Ecological Transition, University of Piemonte Orientale, Vercelli, Italy
| | - Sara Campagna
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Alberto Dal Molin
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
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Wall C, Blomberg K, Bergdahl E, Sjölin H, Alm F. Patients near death receiving specialized palliative home care being transferred to inpatient care - a registry study. BMC Palliat Care 2024; 23:215. [PMID: 39182053 PMCID: PMC11344375 DOI: 10.1186/s12904-024-01549-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 08/16/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND The majority of palliative care patients express a preference for remaining at home for as long as possible. Despite progression of disease there is a strong desire to die at home. Nonetheless, there are transfers between care settings, demonstrating a discrepancy between desired and actual place of death. AIM To map the prevalence of patients near death undergoing specialized palliative home care and being transferred to inpatient care in Sweden. METHODS A national retrospective cross-sectional study based on data from the Swedish Register of Palliative Care. Patients ≥ 18 years of age enrolled in specialized palliative home care with dates of death between 1 November 2015 and 31 October 2022 were included (n = 39,698). Descriptive statistics were used. RESULTS Seven thousand three hundred eighty-three patients (18.6%), approximately 1,000 per year, were transferred to inpatient care and died within seven days of arrival. A considerable proportion of these patients died within two days after admission. The majority (73.6%) were admitted to specialized palliative inpatient care units, 22.9% to non-specialized palliative inpatient care units and 3.5% to additional care units. Transferred patients had more frequent dyspnoea (30.9% vs. 23.2%, p < 0.001), anxiety (60.2% vs. 56.5%, p < 0.001) and presence of several simultaneous symptoms was significantly more common (27.0% vs. 24.8%, p 0.001). CONCLUSION The results show that patients admitted to specialized palliative home care in Sweden are being transferred to inpatient care near death. A notable proportion of these patients dies within two days of admission. Common features, such as symptoms and symptom burden, can be observed in the patients transferred. The study highlights a phenomenon that may be experienced by patients, relatives and healthcare personnel as a significant event in a vulnerable situation. A deeper understanding of the underlying causes of these transfers is required to ascertain whether they are compatible with good palliative care and a dignified death.
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Affiliation(s)
- Camilla Wall
- Department of Oncology, Faculty of Medicine & Health, Örebro University, SE 70182, Örebro, Sweden.
- School of Health Sciences, Faculty of Medicine & Health, Örebro University, SE 70182, Örebro, Sweden.
| | - Karin Blomberg
- School of Health Sciences, Faculty of Medicine & Health, Örebro University, SE 70182, Örebro, Sweden
| | - Elisabeth Bergdahl
- School of Health Sciences, Faculty of Medicine & Health, Örebro University, SE 70182, Örebro, Sweden
| | - Helena Sjölin
- School of Health Sciences, Faculty of Medicine & Health, Örebro University, SE 70182, Örebro, Sweden
| | - Fredrik Alm
- School of Health Sciences, Faculty of Medicine & Health, Örebro University, SE 70182, Örebro, Sweden
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Vicente-Guijarro J, San Jose-Saras D, Aranaz-Andres JM. [Inappropriate Hospitalization: Measurement approaches]. Med Clin (Barc) 2024; 163:91-97. [PMID: 38637219 DOI: 10.1016/j.medcli.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Jorge Vicente-Guijarro
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, España; Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja (UNIR). La Rioja, Logroño, España
| | - Diego San Jose-Saras
- Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja (UNIR). La Rioja, Logroño, España; Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, España.
| | - Jesús María Aranaz-Andres
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, España; Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja (UNIR). La Rioja, Logroño, España
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Cummings GG, Tate K, Spiers J, El‐Bialy R, McLane P, Park CS, Penconek T, Cummings G, Robinson CA, Reid RC, Estabrooks CA, Rowe BH, Anderson C. The development and validation of a conceptual definition of avoidable transitions from long-term care to the emergency department: A mixed methods study. Health Sci Rep 2024; 7:e2204. [PMID: 38974331 PMCID: PMC11224026 DOI: 10.1002/hsr2.2204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 07/09/2024] Open
Abstract
Background/Objectives Transitions to and from Emergency Departments (EDs) can be detrimental to long-term care (LTC) residents and burden the healthcare system. While reducing avoidable transfers is imperative, various terms are used interchangeably including inappropriate, preventable, or unnecessary transitions. Our study objectives were to develop a conceptual definition of avoidable LTC-ED transitions and to verify the level of stakeholder agreement with this definition. Methods The EXamining Aged Care Transitions study adopted an exploratory sequential mixed-method design. The study was conducted in 2015-2016 in 16 LTC facilities, 1 ED, and 1 Emergency Medical Service (EMS) in a major urban center in western Canada. Phase 1 included 80 participants, (healthcare aides, licensed practical nurses, registered nurses, LTC managers, family members of residents, and EMS staff). We conducted semistructured interviews (n = 25) and focus groups (n = 19). In Phase 2, 327 ED staff, EMS staff, LTC staff, and medical directors responded to a survey based on the qualitative findings. Results Avoidable transitions were attributed to limited resources in LTC, insufficient preventive care, and resident or family wishes. The definition generated was: A transition of an LTC resident to the ED is considered avoidable if: (a) Diagnostic testing, medical assessment, and treatment can be accessed in a timely manner by other means; (b) the reasons for a transfer are unclear and the transition would increase the disorientation, pain, or discomfort of a resident, outweighing a clear benefit of a transfer; and (c) the transition is against the wishes expressed by the resident over time, including through informal and undocumented conversations. There was a high level of agreement with the definition across the four participant groups. Conclusions and Implications To effectively reduce LTC resident avoidable transitions, stakeholders must share a common definition. Our conceptual definition may significantly contribute to improved care for LTC residents.
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Affiliation(s)
- Greta G. Cummings
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Kaitlyn Tate
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Jude Spiers
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Rowan El‐Bialy
- Schulich School of BusinessYork UniversityTorontoOntarioCanada
| | - Patrick McLane
- Emergency Strategic Clinical NetworkAlberta Health Services (AHS)EdmontonAlbertaCanada
| | - Claire Su‐Yeon Park
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Tatiana Penconek
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Garnet Cummings
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Carole A. Robinson
- School of NursingUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Robert Colin Reid
- School of Health and Exercise SciencesUniversity of British Columbia—Okanagan CampusKelownaBritish ColumbiaCanada
| | - Carole A. Estabrooks
- Faculty of Nursing, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
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Morioka N, Kashiwagi M, Kashiwagi K, Abe K, Miyawaki A. Characteristics of first-time users of the nursing small-scale multifunctional home care service: a pooled cross-sectional study using Japanese long-term care insurance claims data from 2012 to 2019. BMJ Open 2024; 14:e080664. [PMID: 38772582 PMCID: PMC11110544 DOI: 10.1136/bmjopen-2023-080664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 05/08/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES In April 2012, the Japanese government launched a new nursing service called the nursing small-scale multifunctional home care (NSMHC) to meet the nursing care demands of individuals with moderate-to-severe activities of daily living (ADLs) dysfunction and who require medical care, thereby allowing them to continue living in the community. We aimed to preliminarily analyse the characteristics of first-time users of NSMHC service. DESIGN This pooled cross-sectional study used the Japanese long-term care insurance (LTCI) claims data from the users' first use of NSMHC (from April 2012 to December 2019). SETTING NSMHC includes nursing home visits, home care, daycare, overnight stays and medical treatment. PARTICIPANTS The study population included LTCI beneficiaries who received their first long-term care requirement certification in Japan from April 2012 onwards, died between April 2012 and December 2019, and used any LTCI service at least once. RESULTS Among the 836 563 individuals who used any LTCI service at least once, 3957 (0.47%) used NSMHC. We analysed 3634 individuals without any missing data regarding long-term care requirement certification. Most individuals were aged 80 years or older, with 64.3% requiring care level 3 or above, indicating complete assistance with ADLs. Regarding ADLs in individuals with dementia, 70.6% were at level 2 or below, indicating they can live almost independently even with dementia. A large proportion of NSMHC users availed the service approximately 6 months before death, with no prior use of any LTCI services; they continued using the service for around 4 months, although some people continued to use NSMHC until their month of death. CONCLUSIONS Using individual data on nationwide LTCI, we described the characteristics of first-time users of NSMHC among those who died within 7.5 years from the first certification of care needs. Further studies are needed to investigate the effect of NSMHC use on user outcomes.
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Affiliation(s)
- Noriko Morioka
- Department of Nursing Health Services Research, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Masayo Kashiwagi
- Department of Nursing Health Services Research, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | | | - Kazuhiro Abe
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of International Cooperation for Medical Education, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School ofPublic Health, Boston, MA, USA
| | - Atsushi Miyawaki
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Özkaytan Y, Kukla H, Schulz-Nieswandt F, Zank S. We need a radical change to take place now´-The potential of integrated healthcare for rural long-term care facilities. Geriatr Nurs 2024; 56:270-277. [PMID: 38402806 DOI: 10.1016/j.gerinurse.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES This study explores healthcare professionals' perceptions in rural German long-term care facilities, focusing on integrated health systems. The aim is to understand experiences, challenges, and preferences. METHODS Twenty nurses and paramedics participated in in-depth interviews. Thematic analysis was applied to transcripts, revealing key themes: acute healthcare provision, interdisciplinary collaboration, telemedicine use, and preferences for the future healthcare landscape. RESULTS Themes highlighted factors influencing acute care situations and the crucial role of interdisciplinary collaboration. Integrated care was infrequently encountered despite high demand in rural long-term care facilities. CONCLUSIONS Though uncommon, integrated healthcare remains crucial in addressing long-term care facility residents' complex needs. Healthcare professionals express a strong demand for integrated care in rural areas, citing potential benefits for resident wellbeing, healthcare effectiveness, and job satisfaction. The findings guide healthcare organizations in developing institutional-level strategies for integrated care integration, emphasizing its importance in rural settings.
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Affiliation(s)
- Yasemin Özkaytan
- Faculty of Human Sciences, Graduate School GROW - Gerontological Research on Well-being, University of Cologne, Cologne, Germany.
| | - Helena Kukla
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Frank Schulz-Nieswandt
- Department of Social Policy and Methods of Qualitative Social Research, Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Susanne Zank
- Faculty of Human Sciences, Rehabilitative Gerontology, University of Cologne, Germany
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Zafeiridi E, McMichael A, O’Hara L, Passmore P, McGuinness B. Hospital admissions and emergency department visits for people with dementia. QJM 2024; 117:119-124. [PMID: 37812203 PMCID: PMC10896632 DOI: 10.1093/qjmed/hcad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/26/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Previous studies have suggested that people with dementia (PwD) are more likely to be admitted to hospital, have prolonged hospital stay, or visit an emergency department (ED), compared to people without dementia. AIM This study assessed the rates of hospital admissions and ED visits in PwD and investigated the causes and factors predicting this healthcare use. Further, this study assessed survival following hospital admissions and ED visits. DESIGN This was a retrospective study with data from 26 875 PwD and 23 961 controls. METHODS Data from national datasets were extracted for demographic characteristics, transitions to care homes, hospital and ED use and were linked through the Honest Broker Service. PwD were identified through dementia medication and through causes for hospital admissions and death. RESULTS Dementia was associated with increased risk of hospital admissions and ED visits, and with lower odds of hospital readmission. Significant predictors for hospital admissions and readmissions in PwD were transitioning to a care home, living in urban areas and being widowed, while female gender and living in less deprived areas reduced the odds of admissions. Older age and living in less deprived areas were associated with lower odds of an ED visit for PwD. In contrast to predictions, mortality rates were lower for PwD following a hospital admission or ED visit. CONCLUSIONS These findings result in a better understanding of hospital and ED use for PwD. Surprisingly, survival for PwD was prolonged following hospital admissions and ED visits and thus, policies and services enabling these visits are necessary, especially for people who live alone or in rural areas; however, increased primary care and other methods, such as eHealth, could provide equally effective care in order to avoid distress and costs for hospital admissions and ED visits.
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Affiliation(s)
- E Zafeiridi
- Centre for Public Health, Queen’s University, Belfast, UK
| | - A McMichael
- Centre for Public Health, Queen’s University, Belfast, UK
| | - L O’Hara
- Centre for Public Health, Queen’s University, Belfast, UK
| | - P Passmore
- Centre for Public Health, Queen’s University, Belfast, UK
| | - B McGuinness
- Centre for Public Health, Queen’s University, Belfast, UK
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Segelman M, Hariharan D, Fletcher D, Gasdaska A, Ingber MJ, Khatutsky G, Bercaw L, Feng Z. Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative. J Am Med Dir Assoc 2024; 25:12-16.e3. [PMID: 37301224 DOI: 10.1016/j.jamda.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DESIGN Cross-sectional retrospective study. SETTINGS AND PARTICIPANTS The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. METHODS We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. RESULTS Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). CONCLUSIONS AND IMPLICATIONS Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.
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Affiliation(s)
| | - Dhwani Hariharan
- Brandeis University, Waltham, MA, USA; RTI International, Waltham, MA, USA
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Javier Afonso-Argilés F, Comas Serrano M, Castells Oliveres X, Cirera Lorenzo I, García Pérez D, Pujadas Lafarga T, Ichart Tomás X, Puig-Campmany M, Vena Martínez AB, Renom-Guiteras A. Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes. Rev Clin Esp 2023; 223:585-595. [PMID: 37838224 DOI: 10.1016/j.rceng.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 09/27/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES To assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs. METHOD This multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC. RESULTS A total of 2444 ED admissions were analysed. The patients' mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million. CONCLUSIONS Emergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.
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Affiliation(s)
- F Javier Afonso-Argilés
- Servicio de Geriatría, Fundació Sanitària Mollet, Barcelona, Spain; Estudiante de doctorado de la Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M Comas Serrano
- Servicio de Epidemiología y Evaluación, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Hospital del Mar, Barcelona, Spain; Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain
| | - X Castells Oliveres
- Servicio de Epidemiología y Evaluación, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Hospital del Mar, Barcelona, Spain; Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain
| | | | - D García Pérez
- Servicio de Urgencias, Fundació Althaia, Xarxa Assistencial Universitaria de Manresa, Barcelona, Spain
| | - T Pujadas Lafarga
- Servicio de Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Barcelona, Spain
| | - X Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - M Puig-Campmany
- Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A B Vena Martínez
- Servicio de Geriatría, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - A Renom-Guiteras
- Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain; Servicio de Geriatría, Hospital del Mar, Barcelona, Spain
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Kim MH, Dunkle R, Clarke P. Neighborhood resources and risk of cognitive decline among a community-dwelling long-term care population in the U.S. PUBLIC HEALTH IN PRACTICE 2023; 6:100433. [PMID: 37823022 PMCID: PMC10562742 DOI: 10.1016/j.puhip.2023.100433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/18/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023] Open
Abstract
Objective To examine the associations between neighborhood resources (i.e., number of restaurants, recreation centers, or social services for seniors and persons with disability per land area) and cognitive decline among a community-dwelling long-term care population and whether they differ by baseline cognition status. Study design Prospective longitudinal cohort study. Methods We used a longitudinal dataset that assessed over a two-year period older adults receiving state-funded home- and community-based services in Michigan Metropolitan areas (N = 9,802) and applied nonlinear mixed models with a random intercept with Poisson distribution. Results Cognitively intact older adults were less likely to experience cognitive decline when they resided in resource-rich neighborhoods, compared to those cognitively intact but living in neighborhoods that lacked resources. But their cognitively impaired or dementia-diagnosed counterparts did not similarly benefit from living in neighborhoods with rich resources. Conclusions Neighborhood resources may be an important aspect of intervention to mitigate cognitive decline before older adults become cognitively impaired.
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Affiliation(s)
- Min Hee Kim
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Ruth Dunkle
- School Social Work, University of Michigan, 1080 S. University Ave., Ann Arbor, MI, 48109, USA
| | - Philippa Clarke
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI, 48104-1248, USA
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Choi JW, Yoo AJ. Outcomes of the Pilot Project for Community Care Among Older Adults in South Korea. J Aging Soc Policy 2023:1-18. [PMID: 38007618 DOI: 10.1080/08959420.2023.2284571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/27/2023] [Indexed: 11/27/2023]
Abstract
The Korean government implemented the pilot project for community care for older adults in June 2019. This study investigated the outcomes of the pilot project among Korean older adults by linking survey data from the pilot project with data of Korean National Health Insurance Service. The final sample included 17,801 pilot project participants and 68,145 in a matched comparison group. Pilot program participants experienced an increase of 4.8 days for length of home stay and a reduction of $956 (US) per participant relative to the matched comparison group. Pilot program participants with long-term care insurance who used home care services experienced an increase of 8.9 days for length of home stay and a reduction in $1,177 (US) in total costs, along with a reduction in the admission to long-term care facilities, compared to the matched comparison group. Patients discharged from hospitals indicated an increase of 35.2 days for length of home stay and a reduction of $6,947 (US) in total costs, but a 3.53 times increase in hospital readmissions relative to the matched comparison group. The pilot project for community care resulted in increased length of home stay and reduced total costs among older adults in Korea.
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Affiliation(s)
- Jae Woo Choi
- Community Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, Korea
| | - Ae Jung Yoo
- Community Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, Korea
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12
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Hamasaki Y, Sakata N, Jin X, Sugiyama T, Morita K, Uda K, Matsuda S, Tamiya N. Facility staffing associated with potentially avoidable hospitalizations in nursing home residents in Japan: a retrospective cohort study. BMC Geriatr 2023; 23:566. [PMID: 37715180 PMCID: PMC10504825 DOI: 10.1186/s12877-023-04278-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
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.
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Affiliation(s)
- Yoko Hamasaki
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Nobuo Sakata
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan.
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan.
- Heisei Medical Welfare Research Institute, Shibuya-ku, Tokyo, Japan.
| | - Xueying Jin
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Social Science, Research Institute, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kojiro Morita
- Global Nursing Research Center, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kazuaki Uda
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan
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13
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Cetin-Sahin D, Karanofsky M, Cummings GG, Vedel I, Wilchesky M. Measuring Potentially Avoidable Acute Care Transfers From Long-Term Care Homes in Quebec: a Cross Sectional Study. Can Geriatr J 2023; 26:339-349. [PMID: 37662066 PMCID: PMC10444526 DOI: 10.5770/cgj.26.620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Background Potentially avoidable emergency department transfers (PAEDTs) and hospitalizations (PAHs) from long-term care (LTC) homes are two key quality improvement metrics. We aimed to: 1) Measure proportions of PAEDTs and PAHs in a Quebec sample; and 2) Compare them with those reported for the rest of Canada. Methods We conducted a repeated cross-sectional study of residents who were received at one tertiary hospital between April 2017 and March 2019 from seven LTC homes in Quebec, Canada. The MedUrge emergency department database was used to extract transfers and resident characteristics. Using published definitions, PAEDTs and PAHs were identified from principal emergency department and hospitalization diagnoses, respectively. PAEDT and PAH proportions were compared to those reported by the Canadian Institute for Health Information. Results A total of 1,233 transfers by 692 residents were recorded, among which 36.3% were classified as being potentially avoidable: 22.8% 'PAEDT only', 11.6% 'both PAEDT & PAH', and 1.9% 'PAH only'. Shortness of breath was the most common reason for transfer. Pneumonia was the most common diagnosis from the 'both PAEDT & PAH' category. PAEDTs and PAHs accounted for 95% and 37% of potentially avoidable transfers, respectively. Among 533 hospitalizations, 31.3% were PAHs. These proportions were comparable to the rest of Canada, with some differences in proportions of transfers due to congestive heart failure, urinary tract infection, and implanted device management. Conclusions PAEDTs far outweigh PAHs in terms of frequency, and their monitoring is important for quality assurance as they may inform LTC-level interventions aimed at their reduction.
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Affiliation(s)
- Deniz Cetin-Sahin
- Department of Family Medicine, McGill University, Montreal, QC
- Donald Berman Maimonides Geriatric Centre for Research in Aging, Montreal, QC
| | - Mark Karanofsky
- Department of Family Medicine, McGill University, Montreal, QC
- Herzl Family Practice Centre, Jewish General Hospital CIUSSS Centre-Ouest-de-l’Île-de-Montréal, Montreal, QC
| | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, QC
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC
| | - Machelle Wilchesky
- Department of Family Medicine, McGill University, Montreal, QC
- Donald Berman Maimonides Geriatric Centre for Research in Aging, Montreal, QC
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC
- Division of Geriatric Medicine, McGill University, Montreal, QC, Canada
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Guerbaai RA, Dollinger C, Kressig RW, Zeller A, Wellens NIH, Popejoy LL, Serdaly C, Zúñiga F. Factors associated with avoidable hospital transfers among residents in Swiss nursing homes. Geriatr Nurs 2023; 53:12-18. [PMID: 37399613 DOI: 10.1016/j.gerinurse.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
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.
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Affiliation(s)
- Raphaëlle-Ashley Guerbaai
- Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland; Rehabilitation, Ageing and Independent Living (RAIL) research centre, School of Primary and Allied Health Care, Monash University, Frankston, Australia
| | - Claudia Dollinger
- Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland; Lindenhofgruppe AG, Lindenhof Spital, Bern, Switzerland
| | - Reto W Kressig
- University Department of Geriatric Medicine FELIX PLATTER & Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Nathalie I H Wellens
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Lori L Popejoy
- University of Missouri, Sinclair School of Nursing, Columbia, United States
| | | | - Franziska Zúñiga
- Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland.
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15
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Feng Z, Vadnais A, Huber B, Deutsch A, Li Q, Bercaw L, Ingber MJ, Segelman M, Khatutsky G, Sroczynski N, Xu L. Hospital Transfer Rates among Long-Stay Nursing Home Residents: Variation by Day of the Week. J Am Med Dir Assoc 2023; 24:1361-1362. [PMID: 37507100 DOI: 10.1016/j.jamda.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/30/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Lanlan Xu
- Centers for Medicare & Medicaid Services, Baltimore, MD, USA
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Powell KR, Popescu M, Lee S, Mehr DR, Alexander GL. Examining the Use of Text Messages Among Multidisciplinary Care Teams to Reduce Avoidable Hospitalization of Nursing Home Residents with Dementia: Protocol for a Secondary Analysis. JMIR Res Protoc 2023; 12:e50231. [PMID: 37556199 PMCID: PMC10448283 DOI: 10.2196/50231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Reducing avoidable nursing home (NH)-to-hospital transfers of residents with Alzheimer disease or a related dementia (ADRD) has become a national priority due to the physical and emotional toll it places on residents and the high costs to Medicare and Medicaid. Technologies supporting the use of clinical text messages (TMs) could improve communication among health care team members and have considerable impact on reducing avoidable NH-to-hospital transfers. Although text messaging is a widely accepted mechanism of communication, clinical models of care using TMs are sparsely reported in the literature, especially in NHs. Protocols for assessing technologies that integrate TMs into care delivery models would be beneficial for end users of these systems. Without evidence to support clinical models of care using TMs, users are left to design their own methods and protocols for their use, which can create wide variability and potentially increase disparities in resident outcomes. OBJECTIVE Our aim is to describe the protocol of a study designed to understand how members of the multidisciplinary team communicate using TMs and how salient and timely communication can be used to avert poor outcomes for NH residents with ADRD, including hospitalization. METHODS This project is a secondary analysis of data collected from a Centers for Medicare & Medicaid Services (CMS)-funded demonstration project designed to reduce avoidable hospitalizations for long-stay NH residents. We will use two data sources: (1) TMs exchanged among the multidisciplinary team across the 7-year CMS study period (August 2013-September 2020) and (2) an adapted acute care transfer tool completed by advanced practice registered nurses to document retrospective details about NH-to-hospital transfers. The study is guided by an age-friendly model of care called the 4Ms (What Matters, Medications, Mentation, and Mobility) framework. We will use natural language processing, statistical methods, and social network analysis to generate a new ontology and to compare communication patterns found in TMs occurring around the time NH-to-hospital transfer decisions were made about residents with and without ADRD. RESULTS After accounting for inclusion and exclusion criteria, we will analyze over 30,000 TMs pertaining to over 3600 NH-to-hospital transfers. Development of the 4M ontology is in progress, and the 3-year project is expected to run until mid-2025. CONCLUSIONS To our knowledge, this project will be the first to explore the content of TMs exchanged among a multidisciplinary team of care providers as they make decisions about NH-to-hospital resident transfers. Understanding how the presence of evidence-based elements of high-quality care relate to avoidable hospitalizations among NH residents with ADRD will generate knowledge regarding the future scalability of behavioral interventions. Without this knowledge, NHs will continue to rely on ineffective and outdated communication methods that fail to account for evidence-based elements of age-friendly care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50231.
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Affiliation(s)
- Kimberly R Powell
- Sinclair School of Nursing, University of Missouri, Columbia, MO, United States
| | - Mihail Popescu
- School of Medicine, University of Missouri, Columbia, MO, United States
| | - Suhwon Lee
- College of Arts and Sciences, University of Missouri, Columbia, MO, United States
| | - David R Mehr
- School of Medicine, University of Missouri, Columbia, MO, United States
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Chae HW, Zhao J, Ah YM, Choi KH, Lee JY. Potentially inappropriate medication use as predictors of hospitalization for residents in nursing home. BMC Geriatr 2023; 23:467. [PMID: 37532993 PMCID: PMC10394923 DOI: 10.1186/s12877-023-04165-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/11/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Hospitalization of nursing home (NH) residents impose a significant healthcare burden. However, there is still a lack of information regarding the risk of hospitalization from inappropriate prescribing in NH residents. We aimed to estimate the nationwide prevalence of potentially inappropriate medication (PIM) use among NH residents using the Korean tool and 2019 Beers criteria and to assess their associations with hospitalization or emergency department (ED) visits. METHODS We included older adults aged 65 years or above who were admitted to NHs between July 2008 and December 2018 using national senior cohort database. The prevalence of PIM use based on the Korean medication review tool and Beers criteria on the date of admission to NH was estimated. And the adjusted hazard ratios (aHRs) of polypharmacy, numbers of PIM, each PIM category for hospitalization/ED visits within 30 days of admission to NH was calculated using Cox proportional hazard model to show the association. RESULTS Among 20,306 NH residents, the average number of medications per person was 7.5 ± 4.7. A total of 89.3% and 67.9% of the NH residents had at least one PIM based on the Korean tool and 2019 Beers criteria, respectively. The risk of ED visits or hospitalization significantly increased with the number of PIMs based on the Korean tool (1-3: aHR = 1.24, CI 1.03-1.49; ≥4: aHR = 1.46, CI 1.20-1.79). Having four or more PIMs based on the Beers criteria increased the risk significantly (aHR = 1.30, CI 1.06-1.53) while using 1-3 PIMs was not significantly associated (aHR = 1.07, CI 0.97-1.19). Residents with any potential medication omission according to the Korean criteria, were at 23% higher risk of hospitalization or ED visits (aHR = 1.23, CI 1.07-1.40). CONCLUSIONS This study demonstrated that PIMs, based on the Korean tool and Beers criteria, were prevalent among older adults living in NHs and the use of PIMs were associated with hospitalization or ED visits. The number of PIMs based on the Korean tool showed dose-response increase in the risk of hospitalization or ED visits.
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Affiliation(s)
- Hyun-Woo Chae
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Jing Zhao
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongsangbuk, 38541, Republic of Korea
| | - Kyung Hee Choi
- College of Pharmacy, Gachon University, 191 Hambakmoero, Yeonsu-gu, Incheon, 21936, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea.
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Mitsutake S, Ishizaki T, Yano S, Tsuchiya-Ito R, Uda K, Toba K, Ito H. All-Cause Readmission or Potentially Avoidable Readmission: Which Is More Predictable Using Frailty, Comorbidities, and ADL? Innov Aging 2023; 7:igad043. [PMID: 37342490 PMCID: PMC10278982 DOI: 10.1093/geroni/igad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Indexed: 06/23/2023] Open
Abstract
Background and Objectives Readmission-related health care reforms have shifted their focus from all-cause readmissions (ACR) to potentially avoidable readmissions (PAR). However, little is known about the utility of analytic tools from administrative data in predicting PAR. This study determined whether 30-day ACR or 30-day PAR is more predictable using tools that assess frailty, comorbidities, and activities of daily living (ADL) from administrative data. Research Design and Methods This retrospective cohort study was conducted at a large general acute care hospital in Tokyo, Japan. We analyzed patients aged ≥70 years who had been admitted to and discharged from the subject hospital between July 2016 and February 2021. Using administrative data, we assessed each patient's Hospital Frailty Risk Score, Charlson Comorbidity Index, and Barthel Index on admission. To determine the influence of each tool on readmission predictions, we constructed logistic regression models with different combinations of independent variables for predicting unplanned ACR and PAR within 30 days of discharge. Results Among 16 313 study patients, 4.1% experienced 30-day ACR and 1.8% experienced 30-day PAR. The full model (including sex, age, annual household income, frailty, comorbidities, and ADL as independent variables) for 30-day PAR showed better discrimination (C-statistic: 0.79, 95% confidence interval: 0.77-0.82) than the full model for 30-day ACR (0.73, 0.71-0.75). The other prediction models for 30-day PAR also had consistently better discrimination than their corresponding models for 30-day ACR. Discussion and Implications PAR is more predictable than ACR when using tools that assess frailty, comorbidities, and ADL from administrative data. Our PAR prediction model may contribute to the accurate identification of at-risk patients in clinical settings who would benefit from transitional care interventions.
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Affiliation(s)
- Seigo Mitsutake
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Shohei Yano
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
- The Salvation Army Booth Memorial Hospital, Tokyo, Japan
| | - Rumiko Tsuchiya-Ito
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
| | - Kazuaki Uda
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kenji Toba
- Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Hideki Ito
- Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
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Kristensen GS, Kjeldgaard AH, Søndergaard J, Andersen-Ranberg K, Pedersen AK, Mogensen CB. Associations between care home residents' characteristics and acute hospital admissions - a retrospective, register-based cross-sectional study. BMC Geriatr 2023; 23:234. [PMID: 37072701 PMCID: PMC10114422 DOI: 10.1186/s12877-023-03895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/15/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Care home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents' health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions. METHOD Data on all care home residents aged 65 + years living in Southern Jutland in 2018-2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression. RESULTS Most care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions. CONCLUSION This study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes. TRIAL REGISTRATION Not relevant.
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Affiliation(s)
- Gitte Schultz Kristensen
- Emergency Department, Aabenraa Hospital, Department of Regional Health Research, Faculty of Health Science, University Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark.
| | | | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karen Andersen-Ranberg
- Geriatric Research Unit, Department of Clinical Research, Department of Public Health, Department of Regional Health Research, Faculty of Health Science, Clinical research Department, Aabenraa Hospital, University of Southern Denmark University Hospital of Southern Denmark, Odense, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
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Kay S, Unroe KT, Lieb KM, Kaehr EW, Blackburn J, Stump TE, Evans R, Klepfer S, Carnahan JL. Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program. J Appl Gerontol 2023; 42:194-204. [PMID: 36205006 PMCID: PMC9981342 DOI: 10.1177/07334648221131469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Incomplete communication between staff and providers may cause adverse outcomes for nursing home residents. The Situation-Background-Assessment-Recommendation (SBAR) tool is designed to improve communication around changes in condition (CIC). An adapted SBAR was developed for the Centers for Medicare and Medicaid Services demonstration project, OPTIMISTIC, to increase its use during a resident CIC and to improve documentation. METHODS Four Plan-Do-Study-Act (PDSA) cycles to develop and refine successive protocol implementation of the OPTIMISTIC SBAR were deployed in four Indiana nursing homes. Use of SBAR, documentation quality, and participant surveys were assessed pre- and post-intervention implementation. RESULTS OPTIMISTIC SBAR use and documentation quality improved in three of the four buildings. Participants reported improved collaboration between nurses and providers after SBAR intervention. CONCLUSION Successive PDSA cycles implementing changes in an OPTIMISTIC SBAR protocol for resident CIC led to an increase in SBAR use, improved documentation, and better collaboration between nursing staff and providers.
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Affiliation(s)
- Samantha Kay
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T. Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA,Regenstrief Institute, Indiana University Center for Aging Research, Indianapolis, IN, USA
| | - Kristi M. Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA,Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Ellen W. Kaehr
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Justin Blackburn
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Timothy E. Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Jennifer L. Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA,Regenstrief Institute, Indiana University Center for Aging Research, Indianapolis, IN, USA,Roudebush VA Medical Center, Indianapolis, IN, USA
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21
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Wright B, Akiyama J, Potter AJ, Sabik LM, Stehlin GG, Trivedi AN, Wolinsky FD. Racial and Ethnic Disparities in Hospital-Based Care Among Dual Eligibles Who Use Health Centers. Health Equity 2023; 7:9-18. [PMID: 36744239 PMCID: PMC9892926 DOI: 10.1089/heq.2022.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction Health center use may reduce hospital-based care among Medicare-Medicaid dual eligibles, but racial and ethnic disparities in this population have not been widely studied. We examined the extent of racial and ethnic disparities in hospital-based care among duals using health centers and the degree to which disparities occur within or between health centers. Methods We used 2012-2018 Medicare claims and health center data to model emergency department (ED) visits, observation stays, hospitalizations, and 30-day unplanned returns as a function of race and ethnicity among dual eligibles using health centers. Results In rural and urban counties, age-eligible Black individuals had more ED visits (7.9 [4.0, 11.7] and 13.7 [10.0, 17.4] per 100 person-years) and were more likely to experience an unplanned return (1.4 [0.4, 2.4] and 1 [0.4, 1.6] percentage points [pp]) than White individuals, but were less likely to be hospitalized (-3.3 [-3.9, -2.8] and -1.2 [-1.6, -0.9] pp). In urban counties, age-eligible Black individuals were 1.2 [0.9, 1.5] pp more likely than White individuals to have observation stays. Other racial and ethnic groups used the same or less hospital-based care than White individuals. Including state and health center fixed effects eliminated Black versus White disparities in all outcomes, except hospitalization. Results were similar among disability-eligible duals. Conclusion Racial and ethnic disparities in hospital-based care among dual eligibles are less common within than between health centers. If health centers are to play a more central role in eliminating racial and ethnic health disparities, these differences across health centers must be understood and addressed.
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Affiliation(s)
- Brad Wright
- Department of Family Medicine, UNC-Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, North Carolina, USA.,*Address correspondence to: Brad Wright, PhD, Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Suite 355, Columbia, SC 29208, USA,
| | - Jill Akiyama
- Department of Health Policy and Management, Gillings School of Public Health, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrew J. Potter
- Department of Political Science and Criminal Justice, California State University, Chico, California, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Grace G. Stehlin
- Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Fredric D. Wolinsky
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
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22
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[Inappropriate admissions of Ehpad residents to emergency departments]. SOINS. GERONTOLOGIE 2023; 28:42-45. [PMID: 36717177 DOI: 10.1016/j.sger.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Mills CA, Tran Y, Yeager VA, Unroe KT, Holmes A, Blackburn J. Perceptions of Nurses Delivering Nursing Home Virtual Care Support: A Qualitative Pilot Study. Gerontol Geriatr Med 2023; 9:23337214231163438. [PMID: 36968120 PMCID: PMC10037723 DOI: 10.1177/23337214231163438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/29/2023] Open
Abstract
Avoidable hospitalizations among nursing home residents result in poorer health outcomes and excess costs. Consequently, efforts to reduce avoidable hospitalizations have been a priority over the recent decade. However, many potential interventions are time-intensive and require dedicated clinical staff, although nursing homes are chronically understaffed. The OPTIMISTIC project was one of seven programs selected by CMS as "enhanced care & coordination providers" and was implemented from 2012 to 2020. This qualitative study explores the perceptions of the nurses that piloted a virtual care support project developed to expand the program's reach through telehealth, and specifically considered how nurses perceived the effectiveness of this program. Relationships, communication, and access to information were identified as common themes facilitating or impeding the perceived effectiveness of the implementation of virtual care support programs within nursing homes.
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Affiliation(s)
- Carol A. Mills
- The Pennsylvania State University,
Department of Health Policy and Administration, University Park, USA
| | - Yvette Tran
- Indiana University, Richard M.
Fairbanks School of Public Health at IUPUI, Indianapolis, USA
| | - Valerie A. Yeager
- Indiana University, Richard M.
Fairbanks School of Public Health at IUPUI, Indianapolis, USA
| | - Kathleen T. Unroe
- Indiana University School of Medicine,
Department of Medicine, Division of General Internal Medicine and Geriatrics,
Indianapolis, USA
| | - Ann Holmes
- Indiana University, Richard M.
Fairbanks School of Public Health at IUPUI, Indianapolis, USA
| | - Justin Blackburn
- Indiana University, Richard M.
Fairbanks School of Public Health at IUPUI, Indianapolis, USA
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TYLER DENISEA, FENG ZHANLIAN, GRABOWSKI DAVIDC, BERCAW LAWREN, SEGELMAN MICAH, KHATUTSKY GALINA, WANG JOYCE, GASDASKA ANGELA, INGBER MELVINJ. CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned. Milbank Q 2022; 100:1243-1278. [PMID: 36573335 PMCID: PMC9836234 DOI: 10.1111/1468-0009.12594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022] Open
Abstract
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.
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25
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Wright B, Akiyama J, Potter AJ, Sabik LM, Stehlin GG, Trivedi AN, Wolinsky FD. Health center use and hospital-based care among individuals dually enrolled in Medicare and Medicaid, 2012-2018. Health Serv Res 2022; 57:1045-1057. [PMID: 35124817 PMCID: PMC9441286 DOI: 10.1111/1475-6773.13946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid. DATA SOURCES Data were obtained from 2012 to 2018 Medicare claims. STUDY DESIGN We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality. DATA EXTRACTION METHODS Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease. PRINCIPAL FINDINGS After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period). CONCLUSIONS FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.
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Affiliation(s)
- Brad Wright
- Department of Family MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jill Akiyama
- Department of Health Policy and ManagementUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Andrew J. Potter
- Department of Political Science and Criminal JusticeCalifornia State UniversityChicoCaliforniaUSA
| | - Lindsay M. Sabik
- Department of Health Policy and ManagementUniversity of Pittsburgh School of Public HealthPittsburghPennsylvaniaUSA
| | - Grace G. Stehlin
- Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Amal N. Trivedi
- Department of Health Services Policy and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Fredric D. Wolinsky
- Department of Health Management and PolicyUniversity of Iowa College of Public HealthIowa CityIowaUSA
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26
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Zúñiga F, Gaertner K, Weber-Schuh SK, Löw B, Simon M, Müller M. Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review. BMC Geriatr 2022; 22:659. [PMID: 35948872 PMCID: PMC9367060 DOI: 10.1186/s12877-022-03308-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital. Methods This is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits—measured as ambulatory-care sensitive conditions (ACSCs)—were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis. Results Six percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits. Conclusions We revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings’ public health implications. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03308-9.
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Affiliation(s)
- Franziska Zúñiga
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Katharina Gaertner
- Institute of Integrative Medicine, Witten/Herdecke University, Witten, Germany
| | - Sabine K Weber-Schuh
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland.,GP practice, Praxis Weissenbühl, Bern, Switzerland
| | - Barbara Löw
- Department of Practice Development in Nursing, Solothurner Spitaler AG, Solothurn, Switzerland
| | - Michael Simon
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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Tyler DA, Kordomenos C, Ingber MJ. Reducing Hospitalizations Among Nursing Facility Residents: Policy Environment and Suggestions for the Future in Seven States. J Gerontol Nurs 2022; 48:10-16. [PMID: 35914083 DOI: 10.3928/00989134-20220629-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study examined the policy and market context existing in the seven states where the Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents took place. Stakeholder organizations with knowledge of the skilled nursing facility environment but who were not directly involved with the CMS Initiative were interviewed to assess the impact of policies and programs affecting transfers to the hospital from long-term care facilities. Focused interviews were used to identify areas of quality improvement as well as market forces that contributed to hospitalization rates. Interviews were qualitatively coded and emerging patterns and themes were identified. Market pressures were similar across states. Few policies were found that may have affected the Initiative, but most states had regional coalitions focused on improving some aspect of care. When asked what else could be done to reduce hospitalizations among nursing facility residents, participants across the stakeholder organizations suggested greater presence of physicians and nurse practitioners in nursing facilities, better training around behavioral health issues for frontline staff, and more advance care planning and education for families regarding end of life. [Journal of Gerontological Nursing, 48(8), 10-16.].
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Ogando YM, Rodriguez de Bittner M, Park L, Osotimehin S, Sokan O, Tran D, Sebastian DG, Beaulieu M, Onukwugha E. The impact of an interprofessional care transitions clinic on readmission rates and costs. J Interprof Care 2022; 37:689-692. [PMID: 35895580 DOI: 10.1080/13561820.2022.2095363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The objective of this study was to assess the effectiveness of the Interprofessional Care Transitions Clinic (ICTC) in reducing preventable readmissions and their associated costs among Medicare/Medicaid patients. A prospective cohort study was conducted among adults who were discharged from the University of Maryland Prince George's Hospital Center to assess the comparative effectiveness of a clinic-based intervention in terms of readmission events, potentially avoidable utilization, length of stay, and hospital charges. Outcomes were evaluated at 1 month, 3 months, and 6 months post-discharge. There were statistically significant differences in the following outcomes (follow-up period): proportion of readmissions (3 months), potentially avoidable utilization (1 month), and mean medical charges for ICTC patients compared to non-ICTC patients (1 month). This program was aimed at testing the impact of having an interprofessional team focused on providing holistic patient-centered care.
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Affiliation(s)
- Yoscar M Ogando
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | | | - Leah Park
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | - Sadé Osotimehin
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | - Olufunke Sokan
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | - Deanna Tran
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | | | - Michele Beaulieu
- University of Maryland Baltimore School of Social Work, Baltimore, MD, USA
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
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Dollard J, Edwards J, Yadav L, Gaget V, Tivey D, Inacio M, Maddern G, Visvanathan R. Residents' perspectives of mobile X-ray services in support of healthcare-in-place in residential aged care facilities: a qualitative study. BMC Geriatr 2022; 22:525. [PMID: 35752763 PMCID: PMC9233760 DOI: 10.1186/s12877-022-03212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background Mobile X-ray services (MXS) could be used to investigate clinical issues in aged care residents within familiar surroundings, reducing transfers to and from emergency departments and enabling healthcare to be delivered in residential aged care facilities. There is however little research exploring consumer perspectives about such services. The objective of this research was to explore the perspectives and preferences of residents about the provision of MXS in residential aged care facilities, including their knowledge about the service, perceived benefits, and factors that require consideration for effective implementation. Methods A qualitative study design was used. The setting for the study included four residential aged care facilities of different sizes from different parts of a South Australian city. Purposive sampling was used to recruit participants. 16 residents participated in semi-structured interviews that were audio-recorded and transcribed verbatim. Data were inductively derived using thematic analysis. Results Participants had a mean age of 85 years, 56% were female, 25% had dementia and 25% had had a mobile X-ray in the last 12 months. Four themes were developed. Participants preferred mobile X-rays, provided as healthcare-in-place, to improve accessibility to them and minimize physical and psychological discomfort. Participants had expectations about the processes for receiving mobile X-rays. Costs of X-rays to people, family and society were a consideration. Decision making required residents be informed about mobile X-rays. Conclusions Residents have positive views of MXS as they can receive healthcare-in-place, with familiar people and surroundings. They emphasised that MXS delivered in residential aged care facilities need to be of equivalent quality to those found in other settings. Increased awareness of mobile X-ray services is required. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03212-2.
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Affiliation(s)
- Joanne Dollard
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia. .,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia.
| | - Jane Edwards
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia.,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia
| | - Lalit Yadav
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia.,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia
| | - Virginie Gaget
- Surgical Specialties, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - David Tivey
- Surgical Specialties, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Maria Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,UniSA Allied Health and Human Movement, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Guy Maddern
- Surgical Specialties, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Renuka Visvanathan
- Adelaide Geriatrics Training and Research With Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 37a Woodville Rd, Woodville South, South Australia, 5011, Australia.,Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, 37 Woodville Rd, Woodville South, South Australia, 5011, Australia.,Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia
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Carnahan JL, Unroe KT, Evans R, Klepfer S, Stump TE, Monahan PO, Torke AM. The Avoidable Transfer Scale: A New Tool for Identifying Potentially Avoidable Hospital Transfers of Nursing Home Residents. Innov Aging 2022; 6:igac031. [PMID: 35832205 PMCID: PMC9273404 DOI: 10.1093/geroni/igac031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Indexed: 12/05/2022] Open
Abstract
Background and Objectives Prior approaches to identifying potentially avoidable hospital transfers (PAHs) of nursing home residents have involved detailed root cause analyses that are difficult to implement and sustain due to time and resource constraints. They relied on the presence of certain conditions but did not identify the specific issues that contributed to avoidability. We developed and tested an instrument that can be implemented using review of the electronic medical record. Research Design and Methods The OPTIMISTIC project was a Centers for Medicare and Medicaid Services demonstration to reduce avoidable hospital transfers of nursing home residents. The OPTIMISTIC team conducted a series of root cause analyses of transfer events, leading to development of a 27-item instrument to identify common characteristics of PAHs (Stage 1). To refine the instrument, project nurses used the electronic medical record (EMR) to score the avoidability of transfers to the hospital for 154 nursing home residents from 7 nursing homes from May 2019 through January 2020, including their overall impression of whether the transfer was avoidable (Stage 2). Each transfer was rated independently by 2 nurses and assessed for interrater reliability with a kappa statistic. Results Kappa scores ranged from −0.045 to 0.556. After removing items based on our criteria, 12 final items constituted the Avoidable Transfer Scale. To assess validity, we compared the 12-item scale to nurses’ overall judgment of avoidability of the transfer. The 12-item scale scores were significantly higher for submissions rated as avoidable than those rated unavoidable by the nurses (mean 5.3 vs 2.6, p < .001). Discussion and Implications The 12-item Avoidable Transfer Scale provides an efficient approach to identify and characterize PAHs using available data from the EMR. Increased ability to quantitatively assess the avoidability of resident transfers can aid nursing homes in quality improvement initiatives to treat more acute changes in a resident’s condition in place.
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Affiliation(s)
- Jennifer L Carnahan
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., IU Center for Aging Research, Indianapolis, Indiana, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., IU Center for Aging Research, Indianapolis, Indiana, USA
| | | | | | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Patrick O Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexia M Torke
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., IU Center for Aging Research, Indianapolis, Indiana, USA
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Oosterveld-Vlug MG, Heins MJ, Boddaert MSA, Engels Y, Heide AVD, Onwuteaka-Philipsen BD, Reyners AKL, Francke AL. Evaluating quality of care at the end of life and setting best practice performance standards: a population-based observational study using linked routinely collected administrative databases. BMC Palliat Care 2022; 21:51. [PMID: 35413862 PMCID: PMC9003976 DOI: 10.1186/s12904-022-00927-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background A high percentage of people dying at home, and a low percentage of people being admitted to hospital and dying there are regarded as indicators of appropriate care at the end of life. However, performance standards for these quality indicators are often lacking, which makes it difficult to state whether an indicator score falls between the ranges of good or poor quality care. The aim of this study was to assess quality indicators concerning place of death and hospital care utilization in people with diseases relevant for palliative care, and to establish best practice performance standards based on indicator scores in 31 regions in the Netherlands. Methods A retrospective nationwide population-based observational study was conducted, using routinely collected administrative data concerning persons who died in 2017 in the Netherlands with underlying causes relevant for palliative care (N = 109,707). Data from four registries were linked for analysis. Scores on eight quality indicators concerning place of death and hospital care utilization were calculated, and compared across 31 healthcare insurance regions to establish relative benchmarks. Results On average, 36.4% of the study population died at home (range between regions 30.5%-42.6%) and 20.4% in hospital (range 16.6%-25.5%). Roughly half of the population who received hospital care at any time in the last year of life were found to (also) receive hospital care in the last month of life. In the last month, 32.0% of the study population were admitted to hospital (range 29.4-36.4%), 5.3% to an Intensive Care Unit (range 3.2-6.9%) and 23.9% visited an Emergency Department (range 21.0-27.4%). In the same time period, less than 1% of the study population was resuscitated in hospital or received tube or intravenous feeding in hospital. Conclusions The variation between regions points towards opportunities for practice improvement. The best practice performance standards as set in this study serve as ambitious but attainable targets for those regions that currently do not meet the standards. Policymakers, healthcare providers and researchers can use the suggested performance standards to further analyze causes of variance between regions and develop and test interventions that can improve practice.
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Bohnet-Joschko S, Valk-Draad MP, Schulte T, Groene O. Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations. F1000Res 2022; 10:1223. [PMID: 35464174 PMCID: PMC9021670 DOI: 10.12688/f1000research.73875.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Sabine Bohnet-Joschko
- Chair of Management and Innovation in Health Care, Witten/Herdecke University, Witten, 58448, Germany
| | - Maria Paula Valk-Draad
- Chair of Management and Innovation in Health Care, Witten/Herdecke University, Witten, 58448, Germany
| | - Timo Schulte
- Chair of Management and Innovation in Health Care, Witten/Herdecke University, Witten, 58448, Germany
- OptiMedis AG, Hamburg, 20095, Germany
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Webb HT, Lieb KM, Stump TE, Unroe KT, Carnahan JL. Describing Transfers Originating Out-of-Facility for Nursing Home Residents. J Am Med Dir Assoc 2022; 23:105-110. [PMID: 34181908 PMCID: PMC8709881 DOI: 10.1016/j.jamda.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/06/2021] [Accepted: 05/29/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers). DESIGN Secondary data analysis with multivariable model for community transfer risk factors. SETTING AND PARTICIPANTS Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016. METHODS Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis. RESULTS Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement. CONCLUSIONS AND IMPLICATIONS Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.
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Affiliation(s)
- Hanna T Webb
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristi M Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA
| | - Jennifer L Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA.
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Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study. Palliat Support Care 2021; 20:637-645. [DOI: 10.1017/s1478951521001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objective
Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.
Method
Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.
Results
Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.
Significance of results
Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.
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Bohnet-Joschko S, Valk-Draad MP, Schulte T, Groene O. Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations. F1000Res 2021; 10:1223. [PMID: 35464174 PMCID: PMC9021670 DOI: 10.12688/f1000research.73875.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 09/30/2023] Open
Abstract
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.
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Affiliation(s)
- Sabine Bohnet-Joschko
- Chair of Management and Innovation in Health Care, Witten/Herdecke University, Witten, 58448, Germany
| | - Maria Paula Valk-Draad
- Chair of Management and Innovation in Health Care, Witten/Herdecke University, Witten, 58448, Germany
| | - Timo Schulte
- Chair of Management and Innovation in Health Care, Witten/Herdecke University, Witten, 58448, Germany
- OptiMedis AG, Hamburg, 20095, Germany
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Mooi NM, Ncama BP. Preparedness to implement national enteral nutritional therapy practice guidelines: An observational study of primary health care institutions in South Africa. Afr J Prim Health Care Fam Med 2021. [DOI: 10.4102/phcfm.v13i1.3056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Wong BM, Rotteau L, Feldman S, Lamb M, Liang K, Moser A, Mukerji G, Pariser P, Pus L, Razak F, Shojania KG, Verma A. A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic. J Am Med Dir Assoc 2021; 23:304-307.e3. [PMID: 34922907 PMCID: PMC8610963 DOI: 10.1016/j.jamda.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 10/29/2022]
Abstract
The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.
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Affiliation(s)
- Brian M Wong
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leahora Rotteau
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada.
| | - Sid Feldman
- Baycrest Health Sciences Centre, Toronto, Ontario, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Lamb
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, North York General Hospital, North York, Ontario, Canada
| | - Kyle Liang
- Womens College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Andrea Moser
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Sienna Senior Living Canada, Markham, Ontario, Canada
| | - Geetha Mukerji
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Womens College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada; Women's College Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Pauline Pariser
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura Pus
- Womens College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Kaveh G Shojania
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amol Verma
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
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Mashhadi SF, Hisam A, Sikander S, Rathore MA, Rifaq F, Khan SA, Hafeez A. Post Discharge mHealth and Teach-Back Communication Effectiveness on Hospital Readmissions: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910442. [PMID: 34639741 PMCID: PMC8508113 DOI: 10.3390/ijerph181910442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022]
Abstract
Hospital readmissions pose a threat to the constrained health resources, especially in resource-poor low-and middle-income countries. In such scenarios, appropriate technologies to reduce avoidable readmissions in hospitals require innovative interventions. mHealth and teach-back communication are robust interventions, utilized for the reduction in preventable hospital readmissions. This review was conducted to highlight the effectiveness of mHealth and teach-back communication in hospital readmission reduction with a view to provide the best available evidence on such interventions. Two authors independently searched for appropriate MeSH terms in three databases (PubMed, Wiley, and Google Scholar). After screening the titles and abstracts, shortlisted manuscripts were subjected to quality assessment and analysis. Two authors checked the manuscripts for quality assessment and assigned scores utilizing the QualSyst tool. The average of the scores assigned by the reviewers was calculated to assign a summary quality score (SQS) to each study. Higher scores showed methodological vigor and robustness. Search strategies retrieved a total of 1932 articles after the removal of duplicates. After screening titles and abstracts, 54 articles were shortlisted. The complete reading resulted in the selection of 17 papers published between 2002 and 2019. Most of the studies were interventional and all the studies focused on hospital readmission reduction as the primary or secondary outcome. mHealth and teach-back communication were the two most common interventions that catered for the hospital readmissions. Among mHealth studies (11 out of 17), seven studies showed a significant reduction in hospital readmissions while four did not exhibit any significant reduction. Among the teach-back communication group (6 out of 17), the majority of the studies (5 out of 6) showed a significant reduction in hospital readmissions while one publication did not elicit a significant hospital readmission reduction. mHealth and teach-back communication methods showed positive effects on hospital readmission reduction. These interventions can be utilized in resource-constrained settings, especially low- and middle-income countries, to reduce preventable readmissions.
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Affiliation(s)
- Syed Fawad Mashhadi
- Department of Community Medicine, Army Medical College, National University of Medical Sciences, Rawalpindi 46000, Pakistan; (A.H.); (M.A.R.)
- Department of Public Health, Health Services Academy, Opposite National Institute of Health, Islamabad 44000, Pakistan
- Correspondence:
| | - Aliya Hisam
- Department of Community Medicine, Army Medical College, National University of Medical Sciences, Rawalpindi 46000, Pakistan; (A.H.); (M.A.R.)
| | - Siham Sikander
- Global Health Department, Health Services Academy, Opposite National Institute of Health, Islamabad 44000, Pakistan;
- Institute of Population Health, University of Liverpool, Liverpool L69 3BX, UK
| | - Mommana Ali Rathore
- Department of Community Medicine, Army Medical College, National University of Medical Sciences, Rawalpindi 46000, Pakistan; (A.H.); (M.A.R.)
| | - Faisal Rifaq
- Sehat Sahulat Program, Ministry of National Health Services, Regulations and Coordination, Government of Pakistan, Hall 3A, 3rd Floor, Kohsar Block, Pak Secretariat, Islamabad 44000, Pakistan;
| | - Shahzad Ali Khan
- Health Services Academy, Opposite National Institute of Health, Islamabad 44000, Pakistan; (S.A.K.); (A.H.)
| | - Assad Hafeez
- Health Services Academy, Opposite National Institute of Health, Islamabad 44000, Pakistan; (S.A.K.); (A.H.)
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Mitsutake S, Ishizaki T, Yano S, Tsuchiya-Ito R, Jin X, Watanabe T, Uda K, Livingstone I, Tamiya N. Characteristics associated with hospitalization within 30 days of geriatric intermediate care facility admission. Geriatr Gerontol Int 2021; 21:1010-1017. [PMID: 34549493 PMCID: PMC9290842 DOI: 10.1111/ggi.14278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Seigo Mitsutake
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Shohei Yano
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,The Salvation Army Booth Memorial Hospital, Tokyo, Japan
| | - Rumiko Tsuchiya-Ito
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
| | - Xueying Jin
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Taeko Watanabe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Kazuaki Uda
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | | | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Kim MH, Xiang X. Hospitalization Trajectories in Home- and Community-Based Services Recipients: The Influence of Physician and Social Care Density. J Gerontol B Psychol Sci Soc Sci 2021; 76:1679-1690. [PMID: 33170274 DOI: 10.1093/geronb/gbaa199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Min Hee Kim
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Xiaoling Xiang
- School of Social Work, University of Michigan, Ann Arbor
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Hatfield LA, Caudry D, Grabowski DC. Change in condition alerts for home care recipients: A stepped wedge cluster randomized trial. J Am Geriatr Soc 2021; 69:2548-2555. [PMID: 34138464 DOI: 10.1111/jgs.17324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Paid home care providers (caregivers) are in close, regular contact with people for whom they care (clients). This study evaluated whether caregivers, by noting changes in physical and mental health, could prevent hospitalizations. DESIGN Stepped wedge cluster randomized trial with 4 sequences, 244 clusters, an open cohort, and continuous outcome assessment. SETTING Franchises of a national home care company. PARTICIPANTS Eligible clusters were all franchises operating at the study start, excluding those in a previous pilot. The sample included all clients who received private-pay home care services from an eligible franchise, could be linked to Medicare enrollment records, and were enrolled in fee-for-service Medicare. INTERVENTION A telephone- and app-based questionnaire at the end of each caregiving shift asked caregivers whether they noted changes in mental or physical health of their client. This generated a change-in-condition report that staff at the franchise office addressed at their discretion (e.g., by contacting clients or primary care providers). The control condition was no questionnaire. The study was unblinded. Clusters were randomized to four treatment sequences in eight strata of franchise characteristics. MEASUREMENTS The primary outcome was hospitalization during months of home care enrollment. Secondary outcomes were emergency department (ED) visits and mortality. RESULTS Two hundred and forty-four franchises were randomized to the four sequences (n = 40, 66, 68, 70 franchises, respectively) and 40,137 people were observed during 276,938 person-months of home care enrollment. We found no evidence of impact on hospitalization (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.97, 1.10), ED visits (OR 1.03, 95% CI: 0.98, 1.08), or mortality (OR 1.07, 95% CI: 0.96, 1.19). CONCLUSION A technology-enabled intervention to identify health changes among home care recipients did not show evidence of impact on hospitalizations, ED visits, or mortality. Providing change-in-condition reports to home care staff, without a structured response to manage these changes, was not effective at improving care.
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Affiliation(s)
- Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Daryl Caudry
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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Keohane LM, Zhou Z, Stevenson DG. Aligning Medicaid and Medicare Advantage Managed Care Plans for Dual-Eligible Beneficiaries. Med Care Res Rev 2021; 79:207-217. [PMID: 34075825 DOI: 10.1177/10775587211018938] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To coordinate Medicare and Medicaid benefits, multiple states are creating opportunities for dual-eligible beneficiaries to join Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) and Medicaid plans operated by the same insurer. Tennessee implemented this approach by requiring insurers who offered Medicaid plans to also offer a D-SNP by 2015. Tennessee's aligned D-SNP participation increased from 7% to 24% of dual-eligible beneficiaries aged 65 years and above between 2011 and 2017. Within a county, a 10-percentage-point increase in aligned D-SNP participation was associated with 0.3 fewer inpatient admissions (p = .048), 13.9 fewer prescription drugs per month (p = .048), and 0.3 fewer nursing home users (p = .06) per 100 dual-eligible beneficiaries aged 65 years and older. Increased aligned plan participation was associated with 0.2 more inpatient admissions (p = .004) per 100 dual-eligible beneficiaries younger than 65 years. For some dual-eligible beneficiaries, increasing Medicare and Medicaid managed plan alignment has the potential to promote more efficient service use.
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Affiliation(s)
- Laura M Keohane
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Zilu Zhou
- Vanderbilt University Medical Center, Nashville, TN, USA
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Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project. BMC Health Serv Res 2021; 21:492. [PMID: 34030672 PMCID: PMC8142645 DOI: 10.1186/s12913-021-06419-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/19/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Ouslander JG, Reyes B, Yang Z, Engstrom G, Tappen R, Newman D, Huckfeldt PJ. Nursing home performance in a trial to reduce hospitalizations: Implications for future trials. J Am Geriatr Soc 2021; 69:2316-2326. [PMID: 34018181 DOI: 10.1111/jgs.17231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/29/2021] [Accepted: 04/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care. DESIGN Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers. PARTICIPANTS Seventy-one NHs that completed the 12-month trial INTERVENTION: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support. MEASUREMENTS Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes. RESULTS The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings. CONCLUSION Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.
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Affiliation(s)
- Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA.,Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA
| | - Bernardo Reyes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Zhiyou Yang
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gabriella Engstrom
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Ruth Tappen
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA
| | - David Newman
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA
| | - Peter J Huckfeldt
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
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45
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Gracner T, Agarwal M, Murali KP, Stone PW, Larson EL, Furuya EY, Harrison JM, Dick AW. Association of Infection-Related Hospitalization With Cognitive Impairment Among Nursing Home Residents. JAMA Netw Open 2021; 4:e217528. [PMID: 33890988 PMCID: PMC8065379 DOI: 10.1001/jamanetworkopen.2021.7528] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/03/2021] [Indexed: 12/28/2022] Open
Abstract
Importance Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown. Objective To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents. Design, Setting, and Participants This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020. Exposure Infection-related hospitalization lasting 1 to 14 days. Main Outcomes and Measures Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment). Results Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P < .001), or 3%. The increase in scores was greatest among residents aged 85 years or older vs younger residents by approximately 0.022 CFS points (95% CI, 0.004-0.040 points; P < .05). The prevalence of severe cognitive impairment increased by 1.6 percentage points (95% CI, 1.2-2.0 percentage points; P < .001), or 18%; the increases were observed among individuals with ADRD but not among those without it. After an infection-related hospitalization, cognition among residents who had experienced sepsis declined more than for residents who had not by about 0.02 CFS points (95% CI, 0.00-0.04 points; P < .05). All observed differences persisted without an accelerated rate of decline for at least 6 quarters after infection-related hospitalization. No differences were observed by sex. Conclusions and Relevance In this cohort study, infection-related hospitalization was associated with immediate and persistent cognitive decline among nursing home residents, with the largest increase in CFS scores among older residents, those with ADRD, and those who had experienced sepsis. Identification of NH residents at risk of worsened cognition after an infection-related hospitalization may help to ensure that their care needs are addressed to prevent further cognitive decline.
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Affiliation(s)
- Tadeja Gracner
- RAND Corporation, Arlington, Virginia
- Now with RAND Corporation, Santa Monica, California
| | - Mansi Agarwal
- Center for Health Policy, Columbia University School of Nursing, New York, New York
- Now with Washington University School of Medicine, St Louis, Missouri
| | - Komal P. Murali
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Patricia W. Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Elaine L. Larson
- Columbia University School of Nursing, New York, New York
- Columbia University Mailman School of Public Health, New York, New York
| | - E. Yoko Furuya
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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46
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Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW. Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents? J Palliat Med 2021; 24:1334-1341. [PMID: 33605787 DOI: 10.1089/jpm.2020.0577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA
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47
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Kasdorf A, Dust G, Vennedey V, Rietz C, Polidori MC, Voltz R, Strupp J. What are the risk factors for avoidable transitions in the last year of life? A qualitative exploration of professionals' perspectives for improving care in Germany. BMC Health Serv Res 2021; 21:147. [PMID: 33588851 PMCID: PMC7885553 DOI: 10.1186/s12913-021-06138-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/31/2021] [Indexed: 11/18/2022] Open
Abstract
Background Little is known about the nature of patients’ transitions between healthcare settings in the last year of life (LYOL) in Germany. Patients often experience transitions between different healthcare settings, such as hospitals and long-term facilities including nursing homes and hospices. The perspective of healthcare professionals can therefore provide information on transitions in the LYOL that are avoidable from a medical perspective. This study aims to explore factors influencing avoidable transitions across healthcare settings in the LYOL and to disclose how these could be prevented. Methods Two focus groups (n = 11) and five individual interviews were conducted with healthcare professionals working in hospitals, hospices and nursing services from Cologne, Germany. They were asked to share their observations about avoidable transitions in the LYOL. The data collection continued until the point of information power was reached and were audio recorded and analysed using qualitative content analysis. Results Four factors for potentially avoidable transitions between care settings in the LYOL were identified: healthcare system, organization, healthcare professional, patient and relatives. According to the participants, the most relevant aspects that can aid in reducing unnecessary transitions include timely identification and communication of the LYOL; consideration of palliative care options; availability and accessibility of care services; and having a healthcare professional taking main responsibility for care planning. Conclusions Preventing avoidable transitions by considering the multicomponent factors related to them not only immediately before death but also in the LYOL could help to provide more value-based care for patients and improving their quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06138-4.
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Affiliation(s)
- Alina Kasdorf
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.
| | - Gloria Dust
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Vera Vennedey
- Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Christian Rietz
- Department of Educational Science and Mixed-Methods-Research, University of Education Heidelberg, Faculty of Educational and Social Sciences, Heidelberg, Germany
| | - Maria C Polidori
- Department II of Internal Medicine and Cologne Center for Molecular Medicine, Ageing Clinical Research, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Cluster of Excellence CECAD, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Clinical Trials Center (ZKS), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Center for Health Services Research, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Julia Strupp
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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48
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Carnahan JL, Shearn AJ, Lieb KM, Unroe KT. Pneumonia Management in Nursing Homes: Findings from a CMS Demonstration Project. J Gen Intern Med 2021; 36:570-572. [PMID: 32495100 PMCID: PMC7878612 DOI: 10.1007/s11606-020-05885-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Jennifer L Carnahan
- Indiana University Center for Aging Research, Indianapolis, IN, USA.
- Regenstrief Institute Inc, Indianapolis, IN, USA.
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Andrew J Shearn
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristi M Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Indianapolis, IN, USA
- Regenstrief Institute Inc, Indianapolis, IN, USA
- Indiana University School of Medicine, Indianapolis, IN, USA
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49
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Hathaway EE, Carnahan JL, Unroe KT, Stump TE, Phillips EO, Hickman SE, Fowler NR, Sachs GA, Bateman DR. Nursing Home Transfers for Behavioral Concerns: Findings from the OPTIMISTIC Demonstration Project. J Am Geriatr Soc 2021; 69:415-423. [PMID: 33216954 PMCID: PMC10602584 DOI: 10.1111/jgs.16920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth E. Hathaway
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jennifer L. Carnahan
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T. Unroe
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Timothy E. Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin O’Kelly Phillips
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
| | - Susan E. Hickman
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - Nicole R. Fowler
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Greg A. Sachs
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel R. Bateman
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
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50
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Downs M, Blighe A, Carpenter R, Feast A, Froggatt K, Gordon S, Hunter R, Jones L, Lago N, McCormack B, Marston L, Nurock S, Panca M, Permain H, Powell C, Rait G, Robinson L, Woodward-Carlton B, Wood J, Young J, Sampson E. A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support.
Objectives
Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted.
Design
A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect.
Setting
Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7).
Participants
We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting.
Intervention
This ran from February to July 2018.
Data sources
Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed.
Results
The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, background, assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individual-level data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated.
Limitations
The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent.
Conclusion
A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies.
Future work
Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses.
Trial registration
Current Controlled Trials ISRCTN74109734 and ISRCTN86811077.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Murna Downs
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Alan Blighe
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Robin Carpenter
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Alexandra Feast
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Katherine Froggatt
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Sally Gordon
- National Institute for Health Research Clinical Research Network Yorkshire and Humber, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Rachael Hunter
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Liz Jones
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Natalia Lago
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Brendan McCormack
- Division of Nursing and Division of Occupational Therapy and Arts Therapies, School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Louise Marston
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | | | - Monica Panca
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Helen Permain
- Research Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Catherine Powell
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Greta Rait
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Louise Robinson
- Institute for Ageing and Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - John Wood
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Bradford, UK
| | - Elizabeth Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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