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Riffin C, Mei L, Brody L, Herr K, Pillemer KA, Reid MC. Program of All-Inclusive Care for the Elderly: an untapped setting for research to advance pain care in older persons. FRONTIERS IN PAIN RESEARCH 2024; 5:1347473. [PMID: 38712020 PMCID: PMC11070459 DOI: 10.3389/fpain.2024.1347473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/10/2024] [Indexed: 05/08/2024] Open
Abstract
The Program of All-Inclusive Care for the Elderly (PACE) is a community-based care model in the United States that provides comprehensive health and social services to frail, nursing home-eligible adults aged 55 years and older. PACE organizations aim to support adequate pain control in their participants, yet few evidence-based pain interventions have been adopted or integrated into this setting. This article provides a roadmap for researchers who are interested in collaborating with PACE organizations to embed and evaluate evidence-based pain tools and interventions. We situate our discussion within the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework that considers multi-level influences to implementation and evaluation of evidence-based programs. Within each CFIR domain, we identify key factors informed by our own work that merit consideration by research teams and PACE collaborators. Inner setting components pertain to the organizational culture of each PACE organization, the type and quality of electronic health record data, and availability of staff to assist with data abstraction. Outer setting components include external policies and regulations by the National PACE Association and audits conducted by the Centers for Medicare and Medicaid Services, which have implications for research participant recruitment and enrollment. Individual-level characteristics of PACE organization leaders include their receptivity toward new innovations and perceived ability to implement them. Forming and sustaining research-PACE partnerships to deliver evidence-based pain interventions pain will require attention to multi-level factors that may influence future uptake and provides a way to improve the health and well-being of patients served by these programs.
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Affiliation(s)
- Catherine Riffin
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Lauren Mei
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Lilla Brody
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, IA, United States
| | - Karl A. Pillemer
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- College of Human Ecology, Cornell University, Ithaca, NY, United States
| | - M. Carrington Reid
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
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Jin H, Yang S, Bankes D, Finnel S, Turgeon J, Stein A. Evaluating the Impact of Medication Risk Mitigation Services in Medically Complex Older Adults. Healthcare (Basel) 2022; 10:healthcare10030551. [PMID: 35327028 PMCID: PMC8950840 DOI: 10.3390/healthcare10030551] [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: 12/13/2021] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/29/2022] Open
Abstract
Adverse drug events (ADEs) represent an expensive societal burden that disproportionally affects older adults. Therefore, value-based organizations that provide care to older adults—such as the Program of All-Inclusive Care for the Elderly (PACE)—should be highly motivated to identify actual or potential ADEs to mitigate risks and avoid downstream costs. We sought to determine whether PACE participants receiving medication risk mitigation (MRM) services exhibit improvements in total healthcare costs and other outcomes compared to participants not receiving structured MRM. Data from 2545 PACE participants from 19 centers were obtained for the years 2018 and 2019. We compared the year-over-year changes in outcomes between patients not receiving (control) or receiving structured MRM services. Data were adjusted based on participant multimorbidity and geographic location. Our analyses demonstrate that costs in the MRM cohort exhibited a significantly smaller year-to-year increase compared to the control (MRM: USD 4386/participant/year [95% CI, USD 3040−5732] vs. no MRM: USD 9410/participant/year [95% CI, USD 7737−11,084]). Therefore, receipt of structured MRM services reduced total healthcare costs (p < 0.001) by USD 5024 per participant from 2018 to 2019. The large majority (75.8%) of the reduction involved facility-related expenditures (e.g., hospital admission, emergency department visits, skilled nursing). In sum, our findings suggest that structured MRM services can curb growing year-over-year healthcare costs for PACE participants.
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Affiliation(s)
- Hubert Jin
- Office of Healthcare Analytics, Tabula Rasa HealthCare, Moorestown, NJ 08057, USA; (H.J.); (S.Y.); (S.F.)
| | - Sue Yang
- Office of Healthcare Analytics, Tabula Rasa HealthCare, Moorestown, NJ 08057, USA; (H.J.); (S.Y.); (S.F.)
| | - David Bankes
- Office of Translational Research and Residency Programs, Tabula Rasa HealthCare, Moorestown, NJ 08057, USA;
| | - Stephanie Finnel
- Office of Healthcare Analytics, Tabula Rasa HealthCare, Moorestown, NJ 08057, USA; (H.J.); (S.Y.); (S.F.)
| | - Jacques Turgeon
- Precision Pharmacotherapy Research and Development Institute, 13485 Veteran’s Way, Suite 410, Lake Nona, Orlando, FL 32827, USA;
| | - Alan Stein
- Office of Healthcare Analytics, Tabula Rasa HealthCare, Moorestown, NJ 08057, USA; (H.J.); (S.Y.); (S.F.)
- Correspondence: ; Tel.: +1-856-242-2595
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Gaugler JE, Marx K, Dabelko-Schoeny H, Parker L, Anderson KA, Albers E, Gitlin LN. COVID-19 and the Need for Adult Day Services. J Am Med Dir Assoc 2021; 22:1333-1337. [PMID: 34044009 PMCID: PMC8103140 DOI: 10.1016/j.jamda.2021.04.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/31/2022]
Abstract
COVID-19 has shone a harsh light on the inequities of health care in the United States, particularly in how we care for older people. We summarize some of the effects of lockdown orders on clients, family caregivers, and staff of adult day service programs throughout the United States, which may serve as a counterpoint to scientific evidence suggesting a lack of efficacy of these programs. Given the ramifications of state lockdown orders for users and staff of the long-term services and support system, we provide recommendations to better support community-based programs and those they serve. Specifically, (1) adult day programs should be classified as essential, (2) a focus on the value of adult day and similar programs is needed, and (3) an exploration of new ways to finance home and community-based services is warranted. Such advances in policy and science would help to integrate adult day services more effectively into the broader health care landscape.
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Affiliation(s)
- Joseph E Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
| | - Katherine Marx
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | | | - Lauren Parker
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Keith A Anderson
- School of Social Work, University of Texas at Arlington, Arlington, TX, USA
| | - Elizabeth Albers
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
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Association of a Novel Medication Risk Score with Adverse Drug Events and Other Pertinent Outcomes Among Participants of the Programs of All-Inclusive Care for the Elderly. PHARMACY 2020; 8:pharmacy8020087. [PMID: 32443719 PMCID: PMC7356194 DOI: 10.3390/pharmacy8020087] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/08/2020] [Accepted: 05/15/2020] [Indexed: 12/20/2022] Open
Abstract
Preventable adverse drug events (ADEs) represent a significant public health challenge for the older adult population, since they are associated with higher medical expenditures and more hospitalizations and emergency department (ED) visits. This study examines whether a novel medication risk prediction tool, the MedWise Risk Score™ (MRS), is associated with ADEs and other pertinent outcomes in participants of the Programs of All-Inclusive Care for the Elderly (PACE). Unlike other risk predictors, this tool produces actionable information that pharmacists can easily use to reduce ADE risk. This was a retrospective cross-sectional study that analyzed administrative medical claims data of 1965 PACE participants in 2018. To detect ADEs, we identified all claims that had ADE-related International Classification of Diseases and Health Related Problems, 10th revision (ICD-10) codes. Using logistic and linear regression models, we examined the association between the MRS and a variety of outcomes, including the number of PACE participants with an ADE, total medical expenditures, ED visits, hospitalizations, and hospital length of stay. We found significant associations for every outcome. Specifically, every point increase in the MRS corresponded to an 8.6% increase in the odds of having one or more ADEs per year (OR = 1.086, 95% CI: 1.060, 1.113), $1037 USD in additional annual medical spending (adjusted R2 of 0.739; p < 0.001), 3.2 additional ED visits per 100 participants per year (adjusted R2 of 0.568; p < 0.001), and 2.1 additional hospitalizations per 100 participants per year (adjusted R2 of 0.804; p < 0.001). Therefore, the MRS can risk stratify PACE participants and predict a host of important and relevant outcomes pertaining to medication-related morbidity.
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Viktorovna SE, Alekseevich NY, Yakovlevich PV, Michailovich MI. Association of Arterial Hypertension with Hepatobiliary Pathology: The Occurrence of Comorbidity and Features of Metabolic Processes. Curr Hypertens Rev 2020; 16:138-147. [PMID: 31368876 PMCID: PMC7499357 DOI: 10.2174/1573402115666190801104227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 11/22/2022]
Abstract
Comorbidity of hypertension and hepatobiliary pathology has negative medical and social consequences, including an increase in the indicators of hospital admissions, disability and mortality. OBJECTIVE The aim was to study the occurrence of hypertension combined with hepatobiliary diseases depending on social status, gender and age in 2003-2017 and their influence on indicators of metabolic processes in patients with a therapeutic profile. METHODS A cross-sectional study using the inpatients' medical record database of the clinic of Federal Research Centre for Basic and Translational Medicine (Novosibirsk, Russia), which collects demographics, diagnoses (using ICD-10 codes), procedures and examinations of all inpatients from 2003-2017 was conducted. The incidence of comorbidity of hypertension and hepatobiliary pathology depending on age, gender and social status, based on the analysis of 13496 medical records was examined. A comparative analysis of biochemical parameters characterizing the main types of metabolism (lipid, protein, carbohydrate and purine) was carried out in 3 groups of patients: with hypertension; with hepatobiliary pathology, and with a combined pathology. RESULTS During the years 2003-2005, there was the greatest frequency of this comorbidity in workers, in women, in the age group 60 years and older. In 2009-2017, the highest incidence was observed in the male administrative staff. In patients with this comorbidity, more pronounced changes in carbohydrate, protein, lipid and purine metabolism were found in comparison with groups of patients with isolated diseases. CONCLUSION The results highlight the need to improve the system of prevention and treatment of comorbidity taking into account sex, age, occupation and features of metabolism.
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Affiliation(s)
- Sevostyanova E. Viktorovna
- Department of Medical and Environmental Studies, Federal Research Center for Basic and Translational Medicine, Timakova str.2, Novosibirsk, 630117, Russian Federation
| | - Nikolaev Y. Alekseevich
- Department of Medical and Environmental Studies, Federal Research Center for Basic and Translational Medicine, Timakova str.2, Novosibirsk, 630117, Russian Federation
| | - Polyakov V. Yakovlevich
- Department of Medical and Environmental Studies, Federal Research Center for Basic and Translational Medicine, Timakova str.2, Novosibirsk, 630117, Russian Federation
| | - Mitrofanov I. Michailovich
- Department of Medical and Environmental Studies, Federal Research Center for Basic and Translational Medicine, Timakova str.2, Novosibirsk, 630117, Russian Federation
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Falvey JR, Burke RE, Levy CR, Gustavson AM, Price L, Forster JE, Stevens-Lapsley JE. Impaired Physical Performance Predicts Hospitalization Risk for Participants in the Program of All-Inclusive Care for the Elderly. Phys Ther 2019; 99:28-36. [PMID: 30602041 PMCID: PMC6314329 DOI: 10.1093/ptj/pzy127] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/14/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medicaid spending on the Program of All-Inclusive Care for the Elderly (PACE) has grown rapidly over the last 5 years. Reducing hospitalization rates is a major goal for PACE. However, there is a paucity of research evaluating the relationship between impaired physical performance and hospitalizations in PACE. OBJECTIVE This study tested whether physical therapist-assessed physical performance, measured by the Short Physical Performance Battery (SPPB), can be used to identify participants in PACE at risk for all-cause hospitalizations or potentially avoidable hospitalizations (PAH). DESIGN This was a retrospective cohort study of 1093 participants in PACE facilities in the Denver, Colorado, area. METHODS Data were acquired from linked electronic medical record data and hospitalization claims. Unadjusted and adjusted Cox proportional hazards regression models were used to evaluate the relationship between SPPB scores and the probabilities of both all-cause hospitalizations and PAH. RESULTS The unadjusted likelihood of hospitalization increased with greater physical performance impairment (for SPPB scores ≥8/12: 12.2%; for SPPB scores of 4/12 to 7/12: 15.7%; for SPPB scores <4/12: 21.1%). Compared with participants with SPPB scores ≥8/12, participants with SPPB scores <4/12 had nearly double the unadjusted hazard for hospitalization (hazard ratio = 1.99; 95% CI = 1.34-2.96). In adjusted Cox regression models, participants with SPPB scores <4/12 remained significantly more likely to be hospitalized (hazard ratio = 1.87; 95% CI = 1.24-2.84). Similar relationships were observed for PAH. LIMITATIONS The use of data from a single network of PACE facilities might limit generalizability to states with different Medicaid guidelines. CONCLUSIONS The findings suggest that impaired physical performance is an independent risk factor for hospitalization among participants in PACE. These findings could help guide the development of PACE program modifications for measuring and intervening on impairments in physical function.
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Affiliation(s)
- Jason R Falvey
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora; and Yale University, School of Medicine, Division of Geriatrics, New Haven, Connecticut
| | - Robert E Burke
- Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Cari R Levy
- Rocky Mountain Regional Veterans Affairs Medical Center
| | - Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, and Rocky Mountain Regional Veterans Affairs Medical Center
| | | | - Jeri E Forster
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, and Rocky Mountain Regional Veterans Affairs Medical Center, Mental Illness, Research, Education, and Clinical Center
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO 80045 (USA); and Veterans Affairs Geriatric Research, Education and Clinical Center, Denver, Colorado,Address all correspondence to Dr Stevens-Lapsley at:
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McPhail SM. Multimorbidity in chronic disease: impact on health care resources and costs. Risk Manag Healthc Policy 2016; 9:143-56. [PMID: 27462182 PMCID: PMC4939994 DOI: 10.2147/rmhp.s97248] [Citation(s) in RCA: 283] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.
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Affiliation(s)
- Steven M McPhail
- Centre for Functioning and Health Research, Metro South Health; Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
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Scholz J. Finding the research questions for care coordination of older adults. Creat Nurs 2015; 21:21-5. [PMID: 25842521 DOI: 10.1891/1078-4535.21.1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With the growing number of older adults needing complex medical care, new models of care are needed to reduce unnecessary Medicare costs while helping older adults achieve their highest level of well-being. Advances in models for care coordination have occurred over the past 10 years, yet the research is not complete. Now is the time for nurses to examine the literature and identify research questions for future studies. This article identifies 2 research questions that will fill the gaps in the state of the science on how best to meet the needs of older adults with multiple chronic conditions.
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Fretwell MD, Old JS, Zwan K, Simhadri K. The Elderhaus Program of All-inclusive Care for the Elderly in North Carolina: improving functional outcomes and reducing cost of care: preliminary data. J Am Geriatr Soc 2015; 63:578-83. [PMID: 25752225 DOI: 10.1111/jgs.13249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Program of All-inclusive Care for the Elderly (PACE) is at a crossroads in its evolution as a community-based alternative to institutionally based nursing home care. Because of their perceived value and cost savings to Medicaid and Medicare, PACE programs are under increasing pressure to expand the numbers of individuals they serve while simultaneously reducing the overall cost of care. During the first 5 years of operations, the Elderhaus PACE Program in Wilmington, North Carolina, has reduced use of acute hospital care and skilled nursing home care while demonstrating that 46% of their participants improved and 20% of participants maintained their level of functional independence. It is felt that use of a plan of care organized according to standard domains of function and the quantifiable method of documenting improvement in functional health outcomes represent a critical factor in improved outcomes despite lower use of costly hospital and institutional care. The next step will be to disseminate the plan of care process to other PACE programs and measure its effect on participant functional outcomes and cost of care. The fact that the majority of PACE programs in North Carolina are using an electronic medical record that has the standard domains and quantitative functional measures embedded in the software will facilitate this step. Benchmarks for service use data are already being collected and will be compared with service use after the implementation of the plan of care process.
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Affiliation(s)
- Marsha D Fretwell
- Elderhaus Program of All-inclusive Care for the Elderly, Wilmington, North Carolina
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