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Seaman K, Huang G, Wabe N, Nguyen A, Pinto S, Westbrook J. Hospitalisations before and after entry into a residential aged care facility: An interrupted time series analysis. Australas J Ageing 2024; 43:61-70. [PMID: 37861132 DOI: 10.1111/ajag.13249] [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: 02/15/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Hospitalisations are an important indicator of safety and quality of care in residential aged care facilities (RACFs). This study aimed to investigate changes in hospital use 12 months before and 12 months after RACF entry using routinely collected data from 25 Australian RACFs. METHODS This was a retrospective longitudinal cohort study using linked aged care provider and hospital record data. The sample comprised 1029 residents living in an aged care facility between July 2014 and December 2019 who had stayed a minimum of 12 months in an RACF. The outcome measures were all-cause hospitalisations and fall-related hospitalisations. We applied an interrupted time series analysis using segmented regression to examine changes in both outcome measures over time. Stratified analyses were conducted by gender and dementia status. RESULTS The rate of all-cause hospitalisations increased dramatically over the 12 months before RACF entry, from 97 per 1000 residents per month 12 months prior to RACF admission to 303 per 1000 residents at the second month prior to RACF entry. All-cause hospitalisations then decreased considerably to 55 per 1000 residents upon RACF admission and stabilised across the next 12 months. Such trajectories were also observed in fall-related hospitalisations and were consistent for gender and dementia status. CONCLUSIONS In this study, hospitalisation rates decreased significantly after RACF entry, and such reductions were maintained for residents who stayed for 12 months in RACFs. Multiple hospital admissions are likely to precipitate entry into RACF. Additional investigation of how community-based services can be successful in reducing the escalating hospitalisations is needed.
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Affiliation(s)
- Karla Seaman
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Guogui Huang
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Nasir Wabe
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Amy Nguyen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Sonali Pinto
- Sydney Anglican Diocese, Sydney, New South Wales, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Huang G, Wabe N, Raban MZ, Seaman KL, Silva SM, Westbrook JI. The relationship between fall incidents and place of birth in residential aged care facilities: a retrospective longitudinal cohort study. BMC Geriatr 2023; 23:257. [PMID: 37118675 PMCID: PMC10148446 DOI: 10.1186/s12877-023-03954-7] [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: 09/20/2022] [Accepted: 04/05/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Older populations in residential aged care facilities (RACFs) in many immigrant-receiving countries are now being increasingly culturally and linguistically diverse (CALD). CALD populations require tailored social and health services to support their needs and improve health outcomes. Falls among the elderly are common and can have significant health and psychosocial consequences. There is some evidence to suggest that country of birth may influence risk of falls among older people, but such evidence has been scarce. This study aimed to determine the association between place of birth and the incidence of falls in RACFs. METHODS Routinely collected incident data relating to 5,628 residents aged ≥ 65 years in 25 RACFs in Sydney, New South Wales, Australia were used. RACF residents were classified into two groups, Australia-born (N = 4,086) and overseas-born (N = 1,542). Overseas-born RACF residents were further categorised into two subgroups: overseas-English-speaking-country (N = 743) and overseas-non-English-speaking-country (N = 799). Outcomes measures were rate of all falls, injurious falls and falls requiring hospitalisation. Multilevel binary negative regression was used to examine the relationship between fall risk and place of birth. RESULTS Incidence rates of all falls, injurious falls and falls requiring hospitalisation were 8.62, 3.72 and 1.07 incidents per 1,000 resident days, respectively, among the Australia-born RACF residents, but were higher at 11.02, 4.13 and 1.65, respectively, among the overseas-born RACF residents. Within those born overseas, fall rates were higher among the overseas-non-English-speaking-country-born residents (11.32, 4.29 and 2.22, respectively) than those overseas-English-speaking-country-born (10.70, 3.96 and 1.05, respectively). After controlling for confounders, the overseas-born RACF residents overall experienced a higher risk of all three types of falls (incidence rate ratios: [IRR] = 1.278, 95% confidence interval [CI] = 1.131, 1.443; injurious falls: IRR = 1.164 [95% CI = 1.013, 1.338]; falls requiring hospitalisation: IRR = 1.460 [95% CI = 1.199, 1.777]) than the Australia-born RACF residents. Among the overseas-born RACF residents, males, respite residents and those overseas-non-English-speaking-country-born experienced higher rates of falls. CONCLUSIONS Fall incidence in RACFs varies significantly by place of birth. With increasingly diverse RACF populations, fall intervention and prevention programs should consider cultural and linguistical backgrounds of RACF residents. Greater attention to understand the mechanisms for the differences by place of birth in risk profiles is warranted.
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Affiliation(s)
- Guogui Huang
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, NSW, 2109, Macquarie, Australia.
| | - Nasir Wabe
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, NSW, 2109, Macquarie, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, NSW, 2109, Macquarie, Australia
| | - Karla L Seaman
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, NSW, 2109, Macquarie, Australia
| | - Sandun Malpriya Silva
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, NSW, 2109, Macquarie, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, NSW, 2109, Macquarie, Australia
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Lau YS, Malisauskaite G, Brookes N, Hussein S, Sutton M. Complements or substitutes? Associations between volumes of care provided in the community and hospitals. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:1167-1181. [PMID: 34138375 PMCID: PMC8526459 DOI: 10.1007/s10198-021-01329-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 05/27/2021] [Indexed: 06/12/2023]
Abstract
Policymakers often suggest that expansion of care in community settings may ease increasing pressures on hospital services. Substitution may lower overall health system costs, but complementarity due to previously unidentified needs might raise them. We used new national data on community and primary medical care services in England to undertake system-level analyses of whether activity in the community acts as a complement or a substitute for activity provided in hospitals. We used two-way fixed effects regression to relate monthly counts of community care and primary medical care contacts to emergency department attendances, outpatient visits and admissions for 242 hospitals between November 2017 and September 2019. We then used national unit costs to estimate the effects of increasing community activity on overall system expenditure. The findings show community care contacts to be weak substitutes with all types of hospital activity and primary care contacts are weak substitutes for emergency hospital attendances and admissions. Our estimates ranged from 28 [95% CI 21, 45] to 517 [95% CI 291, 7265] community care contacts and from 34 [95% CI 17, 1283] to 1655 [95% CI - 1995, 70,145] GP appointments to reduce one hospital service visit. Primary care and planned hospital services are complements. Increases in community services and primary care activity are both associated with increased overall system expenditure of £34 [95% CI £156, £54] per visit for community care and £41 [95% CI £78, £74] per appointment in general practice. Expansion of community-based services may not generate reductions in hospital activity and expenditure.
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Affiliation(s)
- Yiu-Shing Lau
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK.
| | | | - Nadia Brookes
- Centre for Health Services Studies, University of Kent, Kent, UK
| | - Shereen Hussein
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK
- Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Melbourne, Australia
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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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Takahashi PY, Chandra A, McCoy RG, Borkenhagen LS, Larson ME, Thorsteinsdottir B, Hickman JA, Swanson KM, Hanson GJ, Naessens JM. Outcomes of a Nursing Home-to-Community Care Transition Program. J Am Med Dir Assoc 2021; 22:2440-2446.e2. [PMID: 33984293 DOI: 10.1016/j.jamda.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes. DESIGN Propensity-matched control-intervention trial. INTERVENTION Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls). SETTING AND PARTICIPANTS Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF. METHODS Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use. RESULTS Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001). CONCLUSIONS AND IMPLICATIONS We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.
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Affiliation(s)
- Paul Y Takahashi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA.
| | - Anupam Chandra
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Lynn S Borkenhagen
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mary E Larson
- Employee and Community Health, Mayo Clinic, Rochester, MN, USA
| | | | - Joel A Hickman
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kristi M Swanson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Gregory J Hanson
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA; Division of Community Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Coe NB, Konetzka RT, Berkowitz M, Blecker E, Van Houtven CH. The Effects of Home Care Provider Mix on the Care Recipient: An International, Systematic Review of Articles from 2000 to 2020. Annu Rev Public Health 2021; 42:483-503. [PMID: 33395544 DOI: 10.1146/annurev-publhealth-090419-102354] [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] [Indexed: 11/09/2022]
Abstract
In this systematic review, we examine the literature from 2000 to 2020 to ascertain whether we can make strong conclusions about the relative benefit of adding informal care or formal care providers to the care mix among individuals receiving care in the home, specifically focusing on care recipient outcomes. We evaluate how informal care and formal care affect (or are associated with) health care use of care recipients, health care costs of care recipients, and health outcomes of care recipients. The literature to date suggests that informal care, either alone or in concert with formal care, delivers improvements in the health and well-being of older adults receiving care. The conclusions one can draw about the effects of formal care are less clear.
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Affiliation(s)
- Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4884, USA; , ,
| | - R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois 60637-1447, USA;
| | - Melissa Berkowitz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4884, USA; , ,
| | - Emily Blecker
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4884, USA; , ,
| | - Courtney H Van Houtven
- Department of Population Health Sciences, Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina 27708, USA; .,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina 27705, USA
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Konetzka RT, Jung DH, Gorges RJ, Sanghavi P. Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles. Health Serv Res 2020; 55:973-982. [PMID: 33258129 PMCID: PMC7704475 DOI: 10.1111/1475-6773.13573] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To provide the first plausibly causal national estimates of health outcomes for older dual-eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect. DATA SOURCES We use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable. STUDY DESIGN We model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long-term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated. POPULATION STUDIED 1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long-term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia. PRINCIPAL FINDINGS HCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending. CONCLUSIONS Shifting Medicaid long-term care funding for older adults from nursing homes to HCBS, while well-motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes-not just expansion-need more attention.
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Affiliation(s)
- R. Tamara Konetzka
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
| | - Daniel H. Jung
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
| | - Rebecca J. Gorges
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
| | - Prachi Sanghavi
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
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Gorges RJ, Sanghavi P, Konetzka RT. A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles. Health Aff (Millwood) 2020; 38:1110-1118. [PMID: 31260370 DOI: 10.1377/hlthaff.2018.05409] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The benefits of expanding funding for Medicaid long-term care home and community-based services (HCBS) relative to institutional care are often taken as self-evident. However, little is known about the outcomes of these services, especially for racial and ethnic minority groups, whose members tend to use the services more than whites do, and for people with dementia who may need high-intensity care. Using national Medicaid claims data on older adults enrolled in both Medicare and Medicaid, we found that overall hospitalization rates were similar for HCBS and nursing facility users, although nursing facility users were generally sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites were, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than for nonwhites, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. Our findings suggest that home and community-based services need to be carefully targeted to avoid adverse outcomes and that the racial/ethnic disparities in access to high-quality institutional long-term care are also present in HCBS. Policy makers should consider the full costs and benefits of shifting care from nursing facilities to home and community settings and the potential implications for equity.
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Affiliation(s)
- Rebecca J Gorges
- Rebecca J. Gorges is a PhD candidate in the Harris School of Public Policy, University of Chicago, in Illinois
| | - Prachi Sanghavi
- Prachi Sanghavi is an assistant professor in the Department of Public Health Sciences, University of Chicago
| | - R Tamara Konetzka
- R. Tamara Konetzka ( ) is a professor in the Department of Public Health Sciences and the Department of Medicine, University of Chicago
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Bakx P, Wouterse B, van Doorslaer E, Wong A. Better off at home? Effects of nursing home eligibility on costs, hospitalizations and survival. JOURNAL OF HEALTH ECONOMICS 2020; 73:102354. [PMID: 32663638 DOI: 10.1016/j.jhealeco.2020.102354] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 05/15/2023]
Abstract
Encouraging and helping elderly to postpone a nursing home admission appears to be a win-win that keeps long-term care spending in check and is in line with the target population's preferences, but there is little evidence about its effects. We study the causal impact of nursing home admission eligibility using Dutch administrative data and exploiting variation between randomly assigned assessors in their tendency to grant eligibility for a nursing home admission. We find a drop in medical care use when eligibility is granted, especially in hospital admissions, while total healthcare spending is unaffected. This suggests that postponing an admission may not always be a win-win after all.
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Affiliation(s)
- Pieter Bakx
- Erasmus School of Health Policy and Management, the Netherlands; Network for Studies on Pensions, Ageing and Retirement, the Netherlands.
| | - Bram Wouterse
- Erasmus School of Health Policy and Management, the Netherlands; Network for Studies on Pensions, Ageing and Retirement, the Netherlands
| | - Eddy van Doorslaer
- Erasmus School of Health Policy and Management, the Netherlands; Network for Studies on Pensions, Ageing and Retirement, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, the Netherlands; Tinbergen Institute, the Netherlands
| | - Albert Wong
- Network for Studies on Pensions, Ageing and Retirement, the Netherlands; RIVM National Institute for Public Health and the Environment, the Netherlands
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Hass Z, Woodhouse M, Arling G. Using a Semi-Markov Model to Estimate Medicaid Cost Savings due to Minnesota's Return to Community Initiative. J Am Med Dir Assoc 2020; 22:642-647.e1. [PMID: 32868250 DOI: 10.1016/j.jamda.2020.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To provide an estimate and level of uncertainty for Medicaid cost savings due to Minnesota's Return to Community Initiative (RTCI). DESIGN Medicaid cost savings are estimated using a semi-Markov model and simulation approach. SETTING AND PARTICIPANTS RTCI is a statewide program that assists private paying nursing home residents with discharge to the community. When originally proposed, it was expected that the program would reduce state Medicaid expenditures, primarily through the shifting of residents from nursing homes to a less costly community setting. In prior analysis, we estimated that approximately 1 in 9 residents targeted for transition by the program would not have returned to the community without the RTCI. Accurate cost savings estimates require consideration of complex resident care trajectories, that is, nursing home readmissions, use of assisted living and community-based services, and mortality. MEASURES Data were from 30,234 private pay nursing home residents admitted during 2011, primarily for post-acute stays, to 378 facilities in Minnesota, and followed for 4 years postadmission for outcomes and time to event. Resident characteristics were taken from the Minimum Data Set (MDS) admission assessment. We modeled variability in care trajectories with a semi-Markov formulation. Transition probabilities were estimated using Multinomial regression. Time to event was modeled using the best-fitting, positive, right-skewed distribution for each path. The simulation was run (1000 times) with and without the RTCI impact to estimate change in Medicaid days in various settings. RESULTS Program savings was estimated at $4.1 million per year of effort over a 4-year accumulation period. CONCLUSIONS AND IMPLICATIONS The RTCI produced a modest Medicaid cost savings in excess of the annual program budget of $3.5 million. Findings from the semi-Markov model and simulation increase our understanding of care transitions between nursing home, community, Medicaid status, and mortality.
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Affiliation(s)
- Zachary Hass
- Purdue University School of Nursing, West Lafayette, IN; Regenstrief Center for Healthcare Engineering, Purdue University School of Industrial Engineering, West Lafayette, IN.
| | - Mark Woodhouse
- University of Minnesota School of Public Health, Minneapolis, MN
| | - Greg Arling
- Purdue University School of Nursing, West Lafayette, IN
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11
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Shippee TP, Duan Y, Olsen Baker M, Angert J. Racial/Ethnic Disparities in Self-Rated Health and Sense of Control for Older Adults Receiving Publicly Funded Home- and Community-Based Services. J Aging Health 2020; 32:1376-1386. [DOI: 10.1177/0898264320929560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: This study examines racial/ethnic differences in self-rated health (SRH) and sense of control among older adults receiving publicly funded home- and community-based services (HCBS) and tests the mediating role of functional, emotional, and financial stressors. Methods: Data are from 2015 National Core Indicators—Aging and Disability Survey collected from face-to-face interviews with 1936 older adults aged 65 years or older receiving HCBS in Minnesota. Path analysis based on logistic regression was used. Results: Racial/ethnic minority HCBS users had lower SRH and sense of control than white participants, with Asian participants reporting the lowest scores. Whereas functional impairment was a common explanatory factor for the racial/ethnic differences, negative mood and financial strain were mediators for Asian and Hispanic/Latino participants, respectively. Discussion: Racial/ethnic disparities in well-being exist among older HCBS users, with different mediators at play. Customized services are needed to meet diverse needs of older adults of different racial/ethnic groups.
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Affiliation(s)
- Tetyana P. Shippee
- University of Minnesota School of Public Health – Division of Health Policy and Management, MN, USA
| | - Yinfei Duan
- University of Minnesota School of Nursing, MN, USA
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Do Residents Participating in Minnesota’s Return to Community Initiative Experience Similar Postdischarge Outcomes to Their Peers? Med Care 2019; 58:399-406. [DOI: 10.1097/mlr.0000000000001281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Segelman M, Intrator O, Li Y, Mukamel D, Temkin‐Greener H. Variations in HCBS Spending, Use, and Hospitalizations among Medicaid 1915(c) Waiver Enrollees. WORLD MEDICAL & HEALTH POLICY 2019. [DOI: 10.1002/wmh3.315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Spiers G, Matthews FE, Moffatt S, Barker R, Jarvis H, Stow D, Kingston A, Hanratty B. Does older adults' use of social care influence their healthcare utilisation? A systematic review of international evidence. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:e651-e662. [PMID: 31314142 DOI: 10.1111/hsc.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 06/10/2023]
Abstract
Improving our understanding of the complex relationship between health and social care utilisation is vital as populations age. This systematic review aimed to synthesise evidence on the relationship between older adults' use of social care and their healthcare utilisation. Ten databases were searched for international literature on social care (exposure), healthcare use (outcome) and older adults (population). Searches were carried out in October 2016, and updated May 2018. Studies were eligible if they were published after 2000 in a high income country, examined the relationship between use of social care and healthcare utilisation by older adults (aged ≥60 years), and controlled for an indicator of need. Study quality and bias were rated using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Study data were extracted and a narrative synthesis was conducted. Data were not suitable for quantitative synthesis. Thirteen studies were identified from 12,065 citations. Overall, the quality and volume of evidence was low. There was limited evidence to suggest that longer lengths of stay in care homes were associated with a lower risk of inpatient admissions. Residents of care homes with onsite nursing had fewer than expected admissions to hospital, compared to people in care homes without nursing, and adjusting for need. Evidence for other healthcare use outcomes was even more limited and heterogeneous, with notable gaps in primary care. We conclude that older adults' use of care homes may moderate inpatient admissions. In particular, the presence of registered nurses in care homes may reduce the need to transfer residents to hospital. However, further evidence is needed to add weight to this conclusion. Future research should build on this evidence and address gaps regarding the influence of community based social care on older adults' healthcare use. A greater focus on primary care outcomes is imperative.
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Affiliation(s)
- Gemma Spiers
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona E Matthews
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Suzanne Moffatt
- Institute for Health & Society, Newcastle University, Royal Victoria Infirmary, Newcastle University, Newcastle upon Tyne, UK
| | - Robert Barker
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Jarvis
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Stow
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Kingston
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Racial Disparities in Medicaid Home and Community-Based Service Utilization among White, Black, and Hispanic Adults with Multiple Sclerosis: Implications of State Policy. J Racial Ethn Health Disparities 2019; 6:1200-1207. [PMID: 31359384 DOI: 10.1007/s40615-019-00621-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/14/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
Home- and community-based services (HCBS) provide support to individuals needing assistance with daily activities, like people with multiple sclerosis (MS) who often experience functional impairment. Research notes racial differences in HCBS utilization among people with MS, which may be attributed to state's relative amount of long-term service and support (LTSS) expenditures dedicated to HCBS (HCBS priority). As a first step in untangling this mechanism, we explored how HCBS priority may contribute to racial differences in service utilization. Using Medicaid claims data for a national cohort of dual eligibles with MS, we find state HCBS priority is associated with disparities in utilization-blacks and Hispanics receiving HCBS more often do so in low-priority states compared with whites. Findings indicate a need for additional research focusing on health equity to further examine effects on quality of life and health outcomes of individuals who would benefit from more generous HCBS policies, specifically determining whether minorities in low-HCBS states fare worse than those in high-priority states. Findings from the present study can help policymakers more effectively design HCBS programs for diverse individuals.
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AbuDagga A, Weech-Maldonado R, Tian F. Organizational characteristics associated with the provision of cultural competency training in home and hospice care agencies. Health Care Manage Rev 2019; 43:328-337. [PMID: 27984407 PMCID: PMC5472501 DOI: 10.1097/hmr.0000000000000144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the increasing interest in community-based health care, little information exists on cultural competency training (CCT) and its predictors in this setting. PURPOSE We examined the associations between six organizational characteristics and the provision of CCT in home health care and hospice agencies. METHODOLOGY We used cross-sectional data from the agency component of the 2007 National Home and Hospice Care Survey. The CCT provision composite was composed of three items: whether the agency provides mandatory cultural training to understand cultural differences/beliefs that may affect delivery of services to (a) all administrators, clerical, and management staff; (b) all direct service providers; and (c) all volunteers. Organizational characteristics were volume, ownership status, chain membership, teaching status, Joint Commission accreditation status, and formal contracts. PRINCIPAL FINDINGS The weighted sample (n = 14,469) had a mean CCT provision score of 1.75 (range = 0-3). Our ordinal logistic regression model showed that Joint Commission accreditation increased CCT provision odds in the home health (odds ratio [OR] = 2.07, 95% confidence interval [CI] [1.01, 4.24]) and hospice (OR = 4.40, 95% CI [2.07, 9.38]) settings. Teaching status increased CCT provision odds (OR = 2.71, 95% CI [1.19, 6.17]) in the home health setting. Formal contracts increased CCT provision odds (OR = 4.03, 95% CI [1.80, 9.00]), whereas not-for-profit ownership decreased CCT provision odds (OR = 0.19; 95% CI [0.07, 0.50]) in the hospice setting. PRACTICE IMPLICATIONS Home health care and hospice agencies need to increase their CCT practices to overcome health disparities in an increasingly diverse and aging population.
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Affiliation(s)
- Azza AbuDagga
- Azza AbuDagga, PhD, MHA, is Health Services Researcher, Health Research Group, Public Citizen, Washington, DC. E-mail: . Robert Weech-Maldonado, PhD, MBA, is Professor and L.R. Jordan Endowed Chair, Department of Health Services Administration, University of Alabama at Birmingham. Fang Tian, PhD, MS, is Research Manager, Government and Academic Research, HealthCore, Inc., Alexandria, Virginia
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Hass Z, Woodhouse M, Grabowski DC, Arling G. Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents. Health Serv Res 2019; 54:555-563. [PMID: 30729509 DOI: 10.1111/1475-6773.13118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To evaluate Minnesota's Return to Community Initiative's (RTCI) impact on community discharges from nursing homes. DATA SOURCES Secondary data were from the Minimum Data Set and RTCI staff (April 2014 - December 2016). The sample consisted of 18 444 non-Medicaid nursing home admissions in Minnesota remaining for at least 45 days, with high predicted probability of community discharge. STUDY DESIGN The RTCI facilitates community discharge for non-Medicaid nursing home residents by assisting with discharge planning, transitioning to the community, and postdischarge follow-up. A key evaluation question is how many of those transitions were directly attributable to the program. Return to Community Initiative was implemented statewide without a control group. Program impact was measured using regression discontinuity, a quasi-experimental design approach that leverages the programs targeting model. PRINCIPAL FINDINGS Return to Community Initiative increased community discharge rates by an estimated 11 percent (P < 0.05) for the targeted population. The program effect was robust to time and increased with level of facility participation in RTCI. CONCLUSIONS The RTCI had a modest yet significant impact on the community discharge rates for its targeted population. Findings have been applied in strengthening the RTCI's targeting approach and transitioning process.
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Affiliation(s)
- Zachary Hass
- Schools of Nursing and Industrial Engineering & Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana
| | - Mark Woodhouse
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David C Grabowski
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana
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Noureldin M, Hass Z, Abrahamson K, Arling G. Fall Risk, Supports and Services, and Falls Following a Nursing Home Discharge. THE GERONTOLOGIST 2018; 58:1075-1084. [PMID: 28958032 DOI: 10.1093/geront/gnx133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Falls are a major source of morbidity and mortality among older adults; however, little is known regarding fall occurrence during a nursing home (NH) to community transition. This study sought to examine whether the presence of supports and services impacts the relationship between fall-related risk factors and fall occurrence post NH discharge. Research Design and Methods Participants in the Minnesota Return to Community Initiative who were assisted in achieving a community discharge (N = 1459) comprised the study sample. The main outcome was fall occurrence within 30 days of discharge. Factor analyses were used to estimate latent models from variables of interest. A structural equation model (SEM) was estimated to determine the relationship between the emerging latent variables and falls. Results Fifteen percent of participants fell within 30 days of NH discharge. Factor analysis of fall-related risk factors produced three latent variables: fall concerns/history; activities of daily living impairments; and use of high-risk medications. A supports/services latent variable also emerged that included caregiver support frequency, medication management assistance, durable medical equipment use, discharge location, and receipt of home health or skilled nursing services. In the SEM model, high-risk medications use and fall concerns/history had direct positive effects on falling. Receiving supports/services did not affect falling directly; however, it reduced the effect of high-risk medication use on falling (p < .05). Discussion and Implications Within the context of a state-implemented transition program, findings highlight the importance of supports/services in mitigating against medication-related risk of falling post NH discharge.
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Affiliation(s)
- Marwa Noureldin
- Department of Pharmaceutical Sciences, College of Pharmacy, Natural and Health Sciences, Manchester University, Fort Wayne, Indiana
| | - Zachary Hass
- School of Nursing, Purdue University, West Lafayette, Indiana
| | - Kathleen Abrahamson
- School of Nursing, Purdue University, West Lafayette, Indiana.,Center on Aging and the Life Course, Purdue University, West Lafayette, Indiana
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana.,Center on Aging and the Life Course, Purdue University, West Lafayette, Indiana
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19
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Fabius CD. Disparities in Clinical Outcomes in Medicare Home Health Care. J Am Geriatr Soc 2018; 66:222-223. [DOI: 10.1111/jgs.15163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Chanee D. Fabius
- School of Public Health; Brown University; Providence Rhode Island
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20
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Freeman S, Bishop K, Spirgiene L, Koopmans E, Botelho FC, Fyfe T, Xiong B, Patchett S, MacLeod M. Factors affecting residents transition from long term care facilities to the community: a scoping review. BMC Health Serv Res 2017. [PMID: 28978324 DOI: 10.1186/s12913‐017‐2571‐y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community. METHODS This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person's own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review. RESULTS The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community. CONCLUSIONS Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.
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Affiliation(s)
- Shannon Freeman
- School of Nursing, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada.
| | - Kristen Bishop
- Faculty of Health Sciences, Health and Rehabilitation Sciences, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Lina Spirgiene
- Department of Nursing and Care, Lithuanian University of Health Sciences, Mickevičiaus 9, -44307, Kaunas, LT, Lithuania
| | - Erica Koopmans
- School of Health Sciences, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada
| | - Fernanda C Botelho
- School of Public Health, University of Sao Paulo, Dr. Arnaldo Street 715, Sao Paulo, SP, 01246-904, Brazil
| | - Trina Fyfe
- Northern Medical Program, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada
| | - Beibei Xiong
- School of Health Sciences, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada.,School of Nursing, Jilin University, 965 XinJiang Street, ChangChun, JiLin, 130012, China
| | - Stacey Patchett
- Department of Quality, Planning and Information, Northern Health, 543 Front Street, Quesnel, BC, V2J 5K7, Canada
| | - Martha MacLeod
- School of Nursing, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada
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21
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Freeman S, Bishop K, Spirgiene L, Koopmans E, Botelho FC, Fyfe T, Xiong B, Patchett S, MacLeod M. Factors affecting residents transition from long term care facilities to the community: a scoping review. BMC Health Serv Res 2017; 17:689. [PMID: 28978324 PMCID: PMC5628420 DOI: 10.1186/s12913-017-2571-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 08/25/2017] [Indexed: 11/23/2022] Open
Abstract
Background Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community. Methods This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person’s own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review. Results The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community. Conclusions Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.
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Affiliation(s)
- Shannon Freeman
- School of Nursing, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada.
| | - Kristen Bishop
- Faculty of Health Sciences, Health and Rehabilitation Sciences, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Lina Spirgiene
- Department of Nursing and Care, Lithuanian University of Health Sciences, Mickevičiaus 9, -44307, Kaunas, LT, Lithuania
| | - Erica Koopmans
- School of Health Sciences, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada
| | - Fernanda C Botelho
- School of Public Health, University of Sao Paulo, Dr. Arnaldo Street 715, Sao Paulo, SP, 01246-904, Brazil
| | - Trina Fyfe
- Northern Medical Program, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada
| | - Beibei Xiong
- School of Health Sciences, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada.,School of Nursing, Jilin University, 965 XinJiang Street, ChangChun, JiLin, 130012, China
| | - Stacey Patchett
- Department of Quality, Planning and Information, Northern Health, 543 Front Street, Quesnel, BC, V2J 5K7, Canada
| | - Martha MacLeod
- School of Nursing, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada
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Young C, Hall AM, Gonçalves‐Bradley DC, Quinn TJ, Hooft L, van Munster BC, Stott DJ. Home or foster home care versus institutional long-term care for functionally dependent older people. Cochrane Database Syst Rev 2017; 4:CD009844. [PMID: 28368550 PMCID: PMC6478250 DOI: 10.1002/14651858.cd009844.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Changing population demographics have led to an increasing number of functionally dependent older people who require care and medical treatment. In many countries, government policy aims to shift resources into the community from institutional care settings with the expectation that this will reduce costs and improve the quality of care compared. OBJECTIVES To assess the effects of long-term home or foster home care versus institutional care for functionally dependent older people. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, MEDLINE, Embase, CINAHL, and two trials registers to November 2015. SELECTION CRITERIA We included randomised and non-randomised trials, controlled before-after studies and interrupted time series studies complying with the EPOC study design criteria and comparing the effects of long-term home care versus institutional care for functionally dependent older people. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed the risk of bias of each included study. We reported the results narratively, as the substantial heterogeneity across studies meant that meta-analysis was not appropriate. MAIN RESULTS We included 10 studies involving 16,377 participants, all of which were conducted in high income countries. Included studies compared community-based care with institutional care (care homes). The sample size ranged from 98 to 11,803 (median N = 204). There was substantial heterogeneity in the healthcare context, interventions studied, and outcomes assessed. One study was a randomised trial (N = 112); other included studies used designs that had potential for bias, particularly due lack of randomisation, baseline imbalances, and non-blinded outcome assessment. Most studies did not select (or exclude) participants for any specific disease state, with the exception of one study that only included patients if they had a stroke. All studies had methodological limitations, so readers should interpret results with caution.It is uncertain whether long-term home care compared to nursing home care decreases mortality risk (2 studies, N = 314, very-low certainty evidence). Estimates ranged from a nearly three-fold increased risk of mortality in the homecare group (risk ratio (RR) 2.89, 95% confidence interval (CI) 1.57 to 5.32) to a 62% relative reduction (RR 0.38, 95% CI 0.17 to 0.61). We did not pool data due to the high degree of heterogeneity (I2 = 94%).It is uncertain whether the intervention has a beneficial effect on physical function, as the certainty of evidence is very low (5 studies, N = 1295). Two studies reported that participants who received long-term home care had improved activities of daily living compared to those in a nursing home, whereas a third study reported that all participants performed equally on physical function.It is uncertain whether long-term home care improves happiness compared to nursing home care (RR 1.97, 95% CI 1.27 to 3.04) or general satisfaction because the certainty of evidence was very low (2 studies, N = 114).The extent to which long-term home care was associated to more or fewer adverse health outcomes than nursing home care was not reported.It is uncertain whether long-term home care compared to nursing home care decreases the risk of hospital admission (very low-certainty evidence, N = 14,853). RR estimates ranged from 2.75 (95% CI 2.59 to 2.92), showing an increased risk for those receiving care at home, to 0.82 (95% CI 0.72 to 0.93), showing a slightly reduced risk for the same group. We did not pool data due to the high degree of heterogeneity (I2 = 99%). AUTHORS' CONCLUSIONS There are insufficient high-quality published data to support any particular model of care for functionally dependent older people. Community-based care was not consistently beneficial across all the included studies; there were some data suggesting that community-based care may be associated with improved quality of life and physical function compared to institutional care. However, community alternatives to institutional care may be associated with increased risk of hospitalisation. Future studies should assess healthcare utilisation, perform economic analysis, and consider caregiver burden.
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Affiliation(s)
- Camilla Young
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 0SF
| | - Amanda M Hall
- Memorial University of NewfoundlandFaculty of MedicineSt. John'sCanada
| | | | - Terry J Quinn
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 0SF
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtDutch Cochrane CentreRoom Str. 6.127P.O. Box 85500UtrechtNetherlands3508 GA
| | - Barbara C van Munster
- Section of Geriatrics, Academic Medical Center, University of AmsterdamDepartment of Internal MedicineAmsterdamNetherlands
- Gelre HospitalsDepartment of Geriatric MedicineApeldoornNetherlands
| | - David J Stott
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 0SF
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Ferrah N, Ibrahim JE, Kipsaina C, Bugeja L. Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process. J Aging Health 2017; 30:584-604. [PMID: 28553803 DOI: 10.1177/0898264316686575] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.
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Affiliation(s)
| | | | | | - Lyndal Bugeja
- Monash University, Victoria, Australia
- Coroners Court of Victoria, Australia
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24
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Cloutier DS, Penning MJ. Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context. THE GERONTOLOGIST 2016; 57:68-81. [PMID: 27852640 DOI: 10.1093/geront/gnw158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 08/15/2016] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF THE STUDY Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers' experiences? (b) What lessons do our mothers' experiences offer for the care of older women with dementia? DESIGN AND METHODS Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives-the stories of our mothers who made the transition from home care into residential (nursing home) care. RESULTS Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families. IMPLICATIONS A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeys-health and service trajectories of older women with dementia.
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Affiliation(s)
| | - Margaret J Penning
- Department of Sociology, Institute on Aging and Lifelong Health, University of Victoria, British Columbia, Canada
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Boyd M, Broad JB, Zhang TX, Kerse N, Gott M, Connolly MJ. Hospitalisation of older people before and after long-term care entry in Auckland, New Zealand. Age Ageing 2016; 45:558-63. [PMID: 27055876 DOI: 10.1093/ageing/afw051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 02/09/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION global population projections forecast large growth in demand for long-term care (LTC) and acute hospital services for older people. Few studies report changes in hospitalisation rates before and after entry into LTC. This study compares hospitalisation rates 1 year before and after LTC entry. METHODS the Older Persons' Ability Level (OPAL) study was a 2008 census-type survey of LTC facilities in Auckland, New Zealand. OPAL resident hospital admissions and deaths were obtained from routinely collected national databases. RESULTS all 2,244 residents (66% = female) who entered LTC within 12 months prior to OPAL were included. There were 3,363 hospitalisations, 2,424 in 12 months before and 939 in 12 months after entry, and 364 deaths. In the 6 to 12 months before LTC entry, the hospitalisation rate/100 person-years was 67.3 (95% confidence interval [CI] 62.5-72.1). Weekly rates then rose steeply to over 450/100 person-years in the 6 months immediately before LTC entry. In the 6 months after LTC entry, the rate fell to 49.1 (CI 44.9-53.3; RR 0.73 (CI 0.65-0.82, P < 0.0001)) and decreased further 6 to 12 months after entry to 41.1 (CI 37.1-45.1; rate ratio [RR] 0.61 (CI 0.54-0.69, P < 0.0001)). CONCLUSIONS increased hospitalisations a few months before LTC entry suggest functional and medical instability precipitates LTC entry. New residents utilise hospital beds less frequently than when at home before that unstable period. Further research is needed to determine effective interventions to avoid some hospitalisations and possibly also LTC entry.
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Allen SM, Piette ER, Mor V. The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries. J Gerontol B Psychol Sci Soc Sci 2014; 69 Suppl 1:S51-8. [PMID: 25342823 PMCID: PMC4303067 DOI: 10.1093/geronb/gbu124] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/13/2014] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Our objective is to estimate and compare the prevalence of selected adverse consequences associated with unmet need for assistance among a socioeconomically and medically vulnerable subgroup of the older adult population, those who are dually eligible for Medicare and Medicaid, with those eligible for Medicare only. METHOD Using data from the National Health and Aging Trends Study (NHATS), a representative survey of the older Medicare population, we calculated the prevalence of disability-related need for assistance with self-care, household tasks, and mobility activities and the prevalence of adverse consequences of unmet need by dually eligible and Medicare only status. RESULTS Over 2 million community-dwelling older persons experienced an adverse consequence due to unmet need for assistance with self-care (e.g., soiled their clothes), over 2 million experienced adverse consequences due to unmet need for assistance with household tasks (e.g., went without groceries), and over 3 million persons experienced at least one adverse consequence of unmet need for assistance with mobility-related activities (e.g., had to stay in bed) in the month prior to the NHATS interview. Dually eligible persons experienced higher rates of 6 of the 11 adverse consequences studied and were more likely to have at least one adverse consequence in all 3 domains than others. DISCUSSION Several care models are emerging with the goal of integrating medical care, behavioral health, and long-term services for the dual eligible population. Indicators of adverse consequences of unmet need could be used to monitor the quality and adequacy of such care systems.
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Affiliation(s)
- Susan M. Allen
- Providence VA HSR&D Center for Innovation (COIN) in Long Term Services and Supports for Vulnerable Veterans and
- Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island
| | - Elizabeth R. Piette
- Institute for Quantitative Biomedical Sciences, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Vincent Mor
- Providence VA HSR&D Center for Innovation (COIN) in Long Term Services and Supports for Vulnerable Veterans and
- Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island
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