1
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Smith JM, Burgdorf JG, Riser TJ, Ryvicker M. Skilled home healthcare utilization and outcomes for older adults with dementia: A scoping review. J Am Geriatr Soc 2024. [PMID: 39355968 DOI: 10.1111/jgs.19203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/21/2024] [Accepted: 09/10/2024] [Indexed: 10/03/2024]
Abstract
OBJECTIVES This study aims to summarize the existing research literature examining Medicare-skilled home health (HH) utilization and clinical outcomes for persons with dementia (PwD). We sought to answer the following questions: (1) How is dementia defined and classified in the HH literature? (2) What associations have been observed between dementia status and patterns of HH utilization? (3) What associations have been observed between dementia status and HH outcomes? METHODS Using Arksey and O'Malley's framework for scoping reviews, we searched PubMed, Google Scholar, and select relevant journals for quantitative studies conducted in the United States between 2000 and 2023 examining Medicare HH use and outcomes for PwD. We describe and compare approaches to classify dementia, identify findings related to HH utilization and outcomes supported by the preponderance of evidence, and comment on existing gaps and areas of ambiguity in the literature. RESULTS Thirty-two articles met the inclusion criteria. Most used claims-based data to classify dementia, leveraged national data, and were limited to traditional Medicare beneficiaries. Studies found meaningful differences in HH utilization by dementia status; most notably, PwD were more likely to access HH without a preceding hospitalization, had longer lengths of stay, and incurred higher HH costs. Literature relating to clinical outcomes was more difficult to interpret, due to significant variation in study objectives, samples, and outcome measures which prompted more nuanced and even contradictory conclusions. There is a dearth of research identifying how specific HH care pathways (e.g., service types, visit frequency) impact outcomes for this patient population. CONCLUSIONS This review supports the understanding that PwD are a unique subpopulation of HH patients who require special attention in policy development and evaluation. Critical research is needed to examine clinical outcomes in PwD further to inform practice and improve care quality.
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Affiliation(s)
- Jamie M Smith
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Julia G Burgdorf
- Center for Home Care Policy & Research at VNS Health, New York, New York, USA
| | | | - Miriam Ryvicker
- Center for Home Care Policy & Research at VNS Health, New York, New York, USA
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Jung D, Jarrín OF, Choi JHS, Knox S, Emerson KG, Chen Z. The Role of Neighborhood Socioeconomic Status in Institutionalization of Home Health Care Patients With and Without Alzheimer's Disease and Related Dementias. J Am Med Dir Assoc 2024; 25:105170. [PMID: 39067862 DOI: 10.1016/j.jamda.2024.105170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES To assess whether neighborhood socioeconomic status (SES) moderates the association between Alzheimer's disease and related dementias (ADRD) and successful discharge to the community. In addition, to explore whether the role of neighborhood SES on successful discharge for patients with ADRD varies by the severity of ADRD. DESIGN This is a retrospective cohort study. SETTING AND PARTICIPANTS Medicare Fee-for-service beneficiaries, aged 65 or older, who received home health care in 2019. METHODS We used linear probability regression models with successful discharge to the community as the main outcome, and neighborhood SES and ADRD as independent variables. Also, we modified the Functional Assessment Staging Tool (FAST) to measure ADRD severity. RESULTS Our study results show ADRD and residing in neighborhoods with lower socioeconomic conditions were independently associated with lower probabilities of successful discharge to the community. We also found that the differences in probabilities of remaining at home between patients with and without ADRD were larger among those in neighborhoods with lower SES (ADRD∗less disadvantaged neighborhood, coeff: -0.01, P < .001; ADRD∗more disadvantaged neighborhood, coeff: -0.02, P < .001; ADRD∗most disadvantaged neighborhood, coeff: 0.032, P < .001). Among patients with ADRD, patients with the most advanced ADRD were less likely to remain in their homes and community when living in neighborhoods with lower SES. CONCLUSIONS AND IMPLICATIONS Our study results show that when patients with ADRD receiving home health care live in neighborhoods with lower SES, they face further challenges to remaining in their homes and community. Public health officials and community planners should consider using area-level interventions to improve care and health outcomes for patients with ADRD. Also, further research aimed at identifying the specific factors and resources influencing lower care quality and poorer health outcomes in socioeconomically disadvantaged neighborhoods, particularly for patients with ADRD, can provide valuable insights for the development and implementation of targeted interventions.
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Affiliation(s)
- Daniel Jung
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA.
| | - Olga F Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA; Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Jeong Ha Steph Choi
- Department of Psychology, College of Arts & Sciences, Georgia State University, Atlanta, GA, USA
| | - Sara Knox
- Department of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Kerstin Gerst Emerson
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA; Institute of Gerontology, University of Georgia, Athens, GA, USA
| | - Zhuo Chen
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
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3
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Semelka C, Freeman V, Williamson J, Frechman E. Post-Acute Care Rehabilitation for Persons Living With Dementia: A Systematic Review. J Am Med Dir Assoc 2024; 25:105189. [PMID: 39122235 DOI: 10.1016/j.jamda.2024.105189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 06/21/2024] [Accepted: 06/26/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVES To identify the results of post-acute care (PAC) rehabilitation for persons living with dementia (PLWD). DESIGN Systematic review of published literature without date restrictions through April 2023. SETTING AND PARTICIPANTS PLWD undergoing rehabilitation in PAC facilities after an acute care hospitalization. METHODS A systematic search was carried out in PubMed, Scopus, Google Scholar, Embase, Medline, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Included studies were peer-reviewed, available in English, and focused on PLWD admitted to rehabilitation facilities following hospitalization in the US and international settings. Studies on long-term care and acute inpatient rehabilitation units were excluded. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. A narrative synthesis approach was used for analysis of results with rehabilitation themes encompassing "outcomes" and "experiences." RESULTS Forty-one articles met inclusion criteria, with a heterogeneity of study designs including observational (n = 33), randomized clinical trials (n = 3), and qualitative studies (n = 5). Narrative synthesis demonstrated that PAC rehabilitation for PLWD contained themes of "outcomes," including health service utilization and physical and cognitive function, providing evidence for a lower likelihood to return home and achieving less functional improvement compared to individuals without cognitive impairment. The second theme, "experiences," included health care transitions, knowledge and education, goal alignment, and care models. Findings detailed poor communication around care transitions, lack of dementia knowledge among health care workers, goal alignment strategies, and innovative rehabilitation models specific for PLWD. CONCLUSIONS AND IMPLICATIONS Overall, this systematic review covers a breadth of literature across time and international settings on PAC rehabilitation for PLWD. The findings highlight the importance of rehabilitation models specific for dementia care, with a need for personalized approaches around care transitions, goal setting, and increased dementia education. Addressing these aspects of rehabilitative care for PLWD may enhance the delivery of PAC and improve health care outcomes and experiences.
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Affiliation(s)
- Charles Semelka
- Department of Medicine Section on Geriatric Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA.
| | - Valerie Freeman
- Atrium Health Charlotte, Area Health Education Center Library, Charlotte, NC, USA
| | - Jeff Williamson
- Department of Medicine Section on Geriatric Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Erica Frechman
- Department of Medicine Section on Geriatric Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
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Dufour I, Margo-Dermer E, Hudon C, Sirois C, Godard-Sebillotte C, Sourial N, Rochette L, Quesnel-Vallée A, Vedel I. Profiles of healthcare use of persons living with dementia: A population-based cohort study. Geriatr Gerontol Int 2024; 24:789-796. [PMID: 38967091 DOI: 10.1111/ggi.14930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/06/2024] [Accepted: 06/18/2024] [Indexed: 07/06/2024]
Abstract
AIM Persons living with dementia are a heterogeneous population with complex needs whose healthcare use varies widely. This study aimed to identify the healthcare use profiles in a cohort of persons with incident dementia, and to describe their characteristics. METHODS This is a retrospective cohort study of health administrative data in Quebec (Canada). The study population included persons who: (i) had an incident dementia diagnosis between 1 April 2015 and 31 March 2016; (ii) were aged ≥65 years and living in the community at the time of diagnosis. We carried out a latent class analysis to identify subgroups of healthcare users. The final number of groups was chosen based on clinical interpretation and statistical indicators. RESULTS The study cohort consisted of 15 584 individuals with incident dementia. Four profiles of healthcare users were identified: (i) Low Users (36.4%), composed of individuals with minimal healthcare use and fewer comorbidities; (ii) Ambulatory Care-Centric Users (27.5%), mainly composed of men with the highest probability of visiting cognition specialists; (iii) High Acute Hospital Users (23.6%), comprised of individuals mainly diagnosed during hospitalization, with higher comorbidities and mortality rate; and (iv) Long-Term Care Destined Users (12.5%), who showed the highest proportion of antipsychotics prescriptions and delayed hospitalization discharge. CONCLUSIONS We identified four distinct subgroups of healthcare users within a population of persons living with dementia, providing a valuable context for the development of interventions tailored to specific needs within this diverse population. Geriatr Gerontol Int 2024; 24: 789-796.
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Affiliation(s)
- Isabelle Dufour
- School of Nursing, Faculty of medicine and health sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Research Center of Aging, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Eva Margo-Dermer
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency medicine, Faculty of medicine and health sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Quebec City, Quebec, Canada
| | - Claire Godard-Sebillotte
- Department of Medicine Division of Geriatrics, McGill University, Montreal, Quebec, Canada
- McGill University Health Centre (MUHC) Research Institute, Montreal, Quebec, Canada
| | - Nadia Sourial
- Department of Health Management, Evaluation and Policy; School of Public Health, University of Montreal, Montréal, Quebec, Canada
| | - Louis Rochette
- National Public Health Institute of Québec, Quebec City, Quebec, Canada
| | - Amélie Quesnel-Vallée
- Department of Epidemiology, Biostatistics, and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Sociology, Faculty of Arts, McGill University, Montreal, Quebec, Canada
| | - Isabelle Vedel
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Quebec, Canada
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5
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Yang MT, Temkin-Greener H, Veazie P, Cai S. Home Health Quality among Hospitalized Older Adults with Alzheimer's Disease and Related Dementia: Association with Race/Ethnicity and Dual Eligibility before and during the COVID Pandemic. J Am Med Dir Assoc 2024; 25:105057. [PMID: 38843869 PMCID: PMC11283957 DOI: 10.1016/j.jamda.2024.105057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVES During the COVID-19 pandemic, home health agencies (HHAs) discharges following acute hospitalizations increased. This study examined whether racial and ethnic minoritized and socioeconomically disadvantaged patients (ie, Medicare-Medicaid dual-eligible) were differentially discharged to below-average quality HHAs before and during the COVID-19 pandemic. We focused on post-acute patients with Alzheimer's disease and related dementias (ADRD), who are generally frail and have high care needs. DESIGN Cohort study. SETTING AND PARTICIPANTS We linked 2019 to 2021 Medicare data with Area Deprivation Index (ADI), Home Health Compare, and COVID-19 infection data. We included Medicare beneficiaries with ADRD who were hospitalized for non-COVID-19 conditions and discharged to HHAs between January 2019 and November 2021. The final analytical sample included 426,766 qualified hospitalization events. METHODS The outcome variable was whether a patient received care from a below-average quality HHA, defined by an average Quality of Patient Care Star Rating lower than 3.0. Key independent variables included individual race, ethnicity, and Medicare-Medicaid dual status. Linear probability models with county fixed effects were estimated, sequentially adjusting for the individual- and community-level covariates. Sensitivity analysis using various definitions of below-average quality HHAs was conducted. RESULTS Before the pandemic, Black and Hispanic individuals had significantly higher probabilities of discharge to below-average quality HHAs compared with white individuals (3.4 and 3.9 percentage points, respectively). Dual-eligible individuals were also 2.5 percentage points more likely to be discharged to below-average quality HHAs. During the pandemic, disparities in being discharged to below-average quality HHAs persisted among racial and ethnic minoritized patients and increased among duals. Findings were consistent with and without adjusting for individual covariates and across different definitions of below-average quality HHA. CONCLUSIONS AND IMPLICATIONS Persistent disparities were observed in being discharged to below-average quality HHAs by race, ethnicity, and dual status. Further research is needed to identify factors contributing to these ongoing inequalities.
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Affiliation(s)
- Ming-Ting Yang
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
| | - Helena Temkin-Greener
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Peter Veazie
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
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6
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Yang MT, Temkin-Greener H, Veazie P, Cai S. Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia. J Am Geriatr Soc 2024; 72:2006-2016. [PMID: 38539279 PMCID: PMC11226367 DOI: 10.1111/jgs.18884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 01/18/2024] [Accepted: 03/04/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD). METHODS We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates. RESULTS SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA. CONCLUSIONS The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.
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Affiliation(s)
- Ming-Ting Yang
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Peter Veazie
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
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7
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Turbow SD, Perkins MM, Vaughan CP, Klemensen T, Culler SD, Rask KJ, Clevenger CK, Ali MK. Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries. J Appl Gerontol 2024:7334648241254282. [PMID: 38798097 DOI: 10.1177/07334648241254282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.
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Affiliation(s)
- Sara D Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Molly M Perkins
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, GA, USA
| | - Terry Klemensen
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Mohammed K Ali
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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8
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Lin H, Grafova IB, Zafar A, Setoguchi S, Roy J, Kobylarz FA, Halm EA, Jarrín OF. Place of care in the last three years of life for Medicare beneficiaries. BMC Geriatr 2024; 24:91. [PMID: 38267886 PMCID: PMC10809551 DOI: 10.1186/s12877-023-04610-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 12/16/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life. METHODS Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated. RESULTS The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states. CONCLUSIONS This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning.
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Affiliation(s)
- Haiqun Lin
- School of Nursing, Rutgers The State University of New Jersey, Newark, NJ, USA
- School of Public Health, Rutgers The State University of New Jersey, Piscataway, NJ, USA
| | - Irina B Grafova
- Edward J. Bloustein School of Planning & Public Policy, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
| | - Anum Zafar
- Institute for Health, Health Care Policy & Aging Research, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
| | - Soko Setoguchi
- School of Public Health, Rutgers The State University of New Jersey, Piscataway, NJ, USA
- Institute for Health, Health Care Policy & Aging Research, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
- Robert Wood Johnson School of Medicine, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
| | - Jason Roy
- School of Public Health, Rutgers The State University of New Jersey, Piscataway, NJ, USA
| | - Fred A Kobylarz
- Robert Wood Johnson School of Medicine, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
| | - Ethan A Halm
- Institute for Health, Health Care Policy & Aging Research, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
- Robert Wood Johnson School of Medicine, Rutgers The State University of New Jersey, New Brunswick, NJ, USA
| | - Olga F Jarrín
- School of Nursing, Rutgers The State University of New Jersey, Newark, NJ, USA.
- Institute for Health, Health Care Policy & Aging Research, Rutgers The State University of New Jersey, New Brunswick, NJ, USA.
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9
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Radcliffe KG, Halim M, Ritchie CS, Maus M, Harrison KL. Care Setting Transitions for People With Dementia: Qualitative Perspectives of Current and Former Care Partners. Am J Hosp Palliat Care 2023; 40:1310-1316. [PMID: 36730920 PMCID: PMC10394111 DOI: 10.1177/10499091231155601] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Care partners (CP) of people with dementia (PWD) report that decisions about care setting are aided by the support of healthcare providers. However, providers are often underprepared to offer adequate counseling. This qualitative study aimed to identify what support from providers will assist CPs in making decisions related to care setting throughout the dementia journey. We conducted semi-structured interviews with current CPs of PWD and former CPs of decedents. We utilized the constant comparative method to identify themes regarding preferences around care setting as the PWD progressed from diagnosis to end-of-life. Participants were 31 CPs, including 16 current and 15 former CPs. CPs had a mean age of 67 and were primarily white (n = 23/31), female (n = 21/31), and spouses (n = 24/31). Theme 1: Current CPs discussed overwhelming uncertainty pertaining to care setting, expressing "I don't know when I need to plan on more care," and a desire to understand "what stage we are at." Theme 2: Later in the disease, former CPs wanted guidance from healthcare providers on institutional placement ("I sure would've loved some help finding better places") or support to stay in the home ("a doctor had to come to the house"). CPs want early, specific guidance from healthcare providers related to transitions between home and long-term care. Early in the disease course, counseling geared toward prognosis and expected disease course helps CPs make plans. Later, caregivers want help identifying locations or institutionalization or finding home care resources.
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Affiliation(s)
- Kate G Radcliffe
- UC Berkeley-UCSF Joint Medical Program, University of California at Berkeley, Berkeley, CA, USA
- School of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Madina Halim
- Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marlon Maus
- School of Public Health, University of California at Berkeley, Berkeley, CA, USA
| | - Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Global Brain Health Institute, University of California, San Francisco, CA, USA
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10
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Holmes SD, Kuzucan A, Brandt N, Briesacher B, Desai A, Feng Z, Fleming S, Johnson A, Olopoenia A, Qato D, Wallem A, Zarowitz B, Wastila L. Examining transitions of care among nursing home residents with and without antipsychotic medication use. Aging Ment Health 2023; 27:1790-1795. [PMID: 35881040 PMCID: PMC9877244 DOI: 10.1080/13607863.2022.2103098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/05/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVES This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. METHODS This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. RESULTS Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. CONCLUSIONS Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.
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Affiliation(s)
- Sarah D. Holmes
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, USA
| | - Aida Kuzucan
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Nicole Brandt
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore, USA
| | - Becky Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, USA
| | | | - Zhaoyong Feng
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Sean Fleming
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Abree Johnson
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Abisola Olopoenia
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Danya Qato
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Alexandra Wallem
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
| | - Barbara Zarowitz
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore, USA
| | - Linda Wastila
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, USA
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore, USA
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11
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Hirschman KB, McHugh M, Morgan B. An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2023; 9:e12391. [PMID: 37555017 PMCID: PMC10404587 DOI: 10.1002/trc2.12391] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 08/10/2023]
Abstract
Introduction High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers. Methods This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered. Results Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses. Discussion Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.
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Affiliation(s)
| | - Molly McHugh
- University of PennsylvaniaSchool of NursingPhiladelphiaPennsylvaniaUSA
| | - Brianna Morgan
- University of PennsylvaniaSchool of NursingPhiladelphiaPennsylvaniaUSA
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12
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Gilmore-Bykovskyi A, Zuelsdorff M, Block L, Golden B, Kaiksow F, Sheehy AM, Bartels CM, Kind AJ, Powell WR. Disparities in 30-day readmission rates among Medicare enrollees with dementia. J Am Geriatr Soc 2023; 71:2194-2207. [PMID: 36896859 PMCID: PMC10363234 DOI: 10.1111/jgs.18311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses. METHODS This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds. RESULTS Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts. CONCLUSIONS There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Megan Zuelsdorff
- School of Nursing, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Laura Block
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
- School of Nursing, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Blair Golden
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Farah Kaiksow
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Ann M. Sheehy
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Christie M. Bartels
- Division of Rheumatology, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Amy J.H. Kind
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - W. Ryan Powell
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
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13
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Kovaleva MA, Kleinpell R, Dietrich MS, Jones AC, Boon JT, Duggan MC, Dennis BM, Lauderdale J, Maxwell CA. Caregivers’ experience with Tele-Savvy Caregiver Program post-hospitalization. Geriatr Nurs 2023; 51:156-166. [PMID: 36990041 DOI: 10.1016/j.gerinurse.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/30/2023]
Abstract
Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.
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Affiliation(s)
- Mariya A Kovaleva
- College of Nursing - Omaha Division, University of Nebraska Medical Center, 985330 Nebraska Medical Center, Omaha, NE 68198-5330, USA.
| | - Ruth Kleinpell
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| | - Mary S Dietrich
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Department of Biostatistics, Vanderbilt University School of Medicine, 1161 21st Ave S, #D3300, Nashville, TN 37232, USA
| | - Abigail C Jones
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Yale University School of Nursing, 400 West Campus Drive, Orange, CT 06477, USA
| | - Jeffrey T Boon
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Maria C Duggan
- Division of Geriatric Medicine, Vanderbilt University School of Medicine, 1161 21st Ave S, #D3300, Nashville, TN 37232, USA; Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, 1310 24th Ave South, Nashville, TN 37212-2637, USA
| | - Bradley M Dennis
- Division of Acute Care Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Jana Lauderdale
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
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14
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Kamdar N, Syrjamaki J, Aikens JE, Mahmoudi E. Readmission Rates and Episode Costs for Alzheimer Disease and Related Dementias Across Hospitals in a Statewide Collaborative. JAMA Netw Open 2023; 6:e232109. [PMID: 36929401 PMCID: PMC10020873 DOI: 10.1001/jamanetworkopen.2023.2109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 01/22/2023] [Indexed: 03/18/2023] Open
Abstract
Importance There has been a paucity of research examining the risk and cost of readmission among patients with Alzheimer disease and related dementias (ADRD) after a planned hospitalization for a broad set of medical and surgical procedures. Objective To examine 30-day readmission rates and episode costs, including readmission costs, for patients with ADRD compared with their counterparts without ADRD across Michigan hospitals. Design, Setting, and Participants This retrospective cohort study used 2012 to 2017 Michigan Value Collaborative data across different medical and surgical services stratified by ADRD diagnosis. A total of 66 676 admission episodes of care that occurred between January 1, 2012, and June 31, 2017, were identified for patients with ADRD using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes for ADRD, along with 656 235 admission episodes in patients without ADRD. Using a generalized linear model framework, this study risk adjusted, price standardized, and performed episode payment winsorization. Payments were risk adjusted for age, sex, Hierarchical Condition Categories, insurance type, and prior 6-month payments. Selection bias was accounted for using multivariable logistic regression with propensity score matching without replacement using calipers. Data analysis was performed from January to December 2019. Exposure Presence of ADRD. Main Outcomes and Measures Main outcomes were 30-day readmission rate at the patient and county levels, 30-day readmission cost, and 30-day total episode cost across 28 medical and surgical services. Results The study included 722 911 hospitalization episodes, of which 66 676 were related to patients with ADRD (mean [SD] age, 83.4 [8.6] years; 42 439 [63.6%] female) and 656 235 were related to patients without ADRD (mean [SD] age, 66.0 [15.4] years; 351 246 [53.5%] female). After propensity score matching, 58 629 hospitalization episodes were included for each group. Readmission rates were 21.5% (95% CI, 21.2%-21.8%) for patients with ADRD and 14.7% (95% CI, 14.4%-15.0%) for patients without ADRD (difference, 6.75 percentage points; 95% CI, 6.31-7.19 percentage points). Cost of 30-day readmission was $467 higher (95% CI of difference, $289-$645) among patients with ADRD ($8378; 95% CI, $8263-$8494) than those without ($7912; 95% CI, $7776-$8047). Across all 28 service lines examined, total 30-day episode costs were $2794 higher for patients with ADRD vs patients without ADRD ($22 371 vs $19 578; 95% CI of difference, $2668-$2919). Conclusions and Relevance In this cohort study, patients with ADRD had higher readmission rates and overall readmission and episode costs than their counterparts without ADRD. Hospitals may need to be better equipped to care for patients with ADRD, especially in the postdischarge period. Considering that any type of hospitalization may put patients with ADRD at a high risk of 30-day readmission, judicious preoperative assessment, postoperative discharge, and care planning are strongly advised for this vulnerable patient population.
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Affiliation(s)
- Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor
- Center for Population Health Sciences, Stanford University, Stanford, California
| | - John Syrjamaki
- Michigan Value Collaborative, University of Michigan Medical School, Ann Arbor
| | - James E. Aikens
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor
| | - Elham Mahmoudi
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor
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15
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Temkin‐Greener H, Yan D, Cai S. Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status. Health Serv Res 2023; 58:164-173. [PMID: 36054521 PMCID: PMC9836959 DOI: 10.1111/1475-6773.14059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To evaluate how post-acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare-Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market-level factors associated with PAC; (3) the association between PAC and outcomes. DATA SOURCES/STUDY SETTING We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI). STUDY DESIGN This observational study consisted of 619,262 community-residing Medicare fee-for-service (FFS) beneficiaries with ADRD who had a hospital stay in 2017. DATA COLLECTION/EXTRACTION METHODS PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30-day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit. PRINCIPAL FINDINGS Dual-related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%-points for non-duals and duals, respectively. The difference between non-dual/dual White patients was 21.6% points, and among Black patients 18.0%-points. The adjusted risk of 30-day readmission was 5.6 percentage point higher among non-duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30-day mortality were larger for duals and non-duals who transitioned to SNF, compared to those discharged home. CONCLUSIONS PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi-level variables that need to be incorporated in discharge decision making.
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Affiliation(s)
- Helena Temkin‐Greener
- Department of Public Health SciencesUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Di Yan
- Department of Public Health SciencesUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Shubing Cai
- Department of Public Health SciencesUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
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16
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Albers EA, Birkeland RW, Louwagie KW, Yam H, Baker ZG, Mittelman MS, Gaugler JE. A Qualitative Analysis of Mechanisms of Benefit in the Residential Care Transition Module: A Telehealth Intervention for Caregivers of Relatives With Dementia Living in Residential Long-Term Care. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231217981. [PMID: 38142369 PMCID: PMC10749513 DOI: 10.1177/00469580231217981] [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: 06/27/2023] [Revised: 10/30/2023] [Accepted: 11/06/2023] [Indexed: 12/25/2023]
Abstract
This study sought to determine the perceived benefits of the Residential Care Transition Module (RCTM), a novel multi-component, psychoeducational/psychosocial, telehealth intervention for caregivers of cognitively impaired relatives living in residential long-term care (RLTC). Few support programs exist for these caregivers. Determining the intervention's mechanisms of benefit will provide actionable clinical and research information regarding which key features aspects RLTC and public health agencies should offer their families. We conducted semi-structured interviews with 30 purposively selected participants randomly assigned to receive the RCTM. Additionally, an open-ended survey question solicited feedback at 4 (n = 90), 8 (n = 79), and 12 months (n = 77). Available qualitative data were analyzed for thematic content. Participants endorsed 9 mechanisms of benefit. Six mechanisms were related to RCTM content: education dementia progression and dementia behavior management, personalized resource provision, strategies for communication and engagement with the care recipient (CR) and others, management of multiple roles, and relaxation exercises. Three mechanisms were related to coaching: emotional support, knowledgeability, and being a neutral third party. Common benefits attributed to RCTM included improvement in mood, caregiving confidence, and communication and interactions with CR and others. Using qualitative data and analyses, we discovered the most valued aspects of the RCTM intervention. These mechanisms of benefit have not been described in the literature. Notably, we were unable to detect mechanisms of benefit in a separate analysis utilizing quantitative data. Findings emphasize the importance of including qualitative measures in intervention research and selecting quantitative measures that reflect the intervention's real effects, if any.
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Affiliation(s)
| | | | | | - Hawking Yam
- University of Minnesota-Twin Cities, Minneapolis, MN, USA
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17
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Miron AM, Groves CL, Thompson AE, McFadden SH, Bowers HR, DeBraal JM. Fear of Incompetence in Family Caregivers and Dementia Care Transitions. Int J Aging Hum Dev 2022; 96:447-470. [PMID: 35686309 DOI: 10.1177/00914150221106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Research on interpersonal interaction dynamics in relationships between persons with dementia and their family caregivers has been limited. We examine the role of these dynamics in decisions to transition a family member from home care to congregate care, with a particular focus on the role of fear of incompetence. Fear of incompetence is the fear of being unable to interact, communicate in a meaningful way, or take care of a close family member with dementia. In this study (N = 350 family caregivers), perceived negative changes in the family member with dementia predicted increased perceived dependency, which predicted both increased caregiver burden and greater fear of incompetence in caregivers, which, in turn, predicted stronger care transition desire. Strategies should be aimed not only at reducing dependency of the care recipient but also teaching family caregivers interaction skills that decrease their fear of interactional incompetence and thus promote home care continuation.
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Affiliation(s)
- Anca M Miron
- Department of Psychology, 200882University of Wisconsin Oshkosh, Oshkosh, WI, USA
| | - Christopher L Groves
- Department of Psychology, 200882University of Wisconsin Oshkosh, Oshkosh, WI, USA
| | - Ashley E Thompson
- 218995Department of Psychology, University of Minnesota Duluth, Duluth, MN, USA
| | - Susan H McFadden
- Department of Psychology, 200882University of Wisconsin Oshkosh, Oshkosh, WI, USA
| | - Haley R Bowers
- Department of Psychology, 200882University of Wisconsin Oshkosh, Oshkosh, WI, USA
| | - Jordyn M DeBraal
- Department of Psychology, 200882University of Wisconsin Oshkosh, Oshkosh, WI, USA
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18
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Smith L, Phillipson L. Using Journey Mapping to support staff, family members and allies of people with dementia to think and act differently during a care transition: The benefits and limits of care imagination. DEMENTIA 2022; 21:1873-1889. [DOI: 10.1177/14713012221097237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Research methods are not just for data collection, but can also be engaged in to promote more immediate benefits for participants and to create social change. This paper reports on how journey mapping was used with staff and family members of people with dementia in a residential aged care facility in regional NSW, Australia. The study was conducted in the context of a care transition, where residents, including people with dementia moved from an existing site to another new facility. Care transitions are frequent yet difficult for people with dementia to negotiate, so it was important to predict their nature and understand what might make the move easier. We used an innovative visual method known as ‘journey mapping’ to engage 45 staff and 18 family members to inform supports for 30 people with dementia, who had been identified as needing additional support during the planned transition. The journey mapping process was useful for fostering the caring imagination and encouraging active and creative planning around change for the people with dementia. It also highlighted the entrenched inequalities in the aged care sector, where poorly paid staff wanted to enact broad ranging supports but felt unsupported to do so. In other words, to improving and re-imagining transitional care for people with dementia requires structural and systemic change rather than just localised re-imaginings. [245]
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Affiliation(s)
- Louisa Smith
- School of Health and Social Development, Institute of Health Transformation, Deakin University, VIC, Australia
| | - Lyn Phillipson
- Health and Society, Arts, Social Sciences and Humanities Faculty, University of Wollongong, NSW, Australia
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Harrison KL, Ritchie CS, Hunt LJ, Patel K, Boscardin WJ, Yaffe K, Smith AK. Life expectancy for community-dwelling persons with dementia and severe disability. J Am Geriatr Soc 2022; 70:1807-1815. [PMID: 35357694 PMCID: PMC9177709 DOI: 10.1111/jgs.17767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 02/08/2022] [Accepted: 02/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Understanding life expectancy can help persons with dementia, their care partners, and policymakers plan for what lies ahead. We sought to determine life expectancy and predictors of mortality for community-dwelling persons with dementia and severe disability. METHODS Using the National Health and Aging Trends Study (NHATS) linked to Medicare claims, we identified community-dwelling respondents age 65+ who entered NHATS in 2011 with dementia and severe disability (defined as three impairments in activities of daily living), or who subsequently met criteria for dementia and then severe disability. We estimated time to death based on the timing of meeting severe disability criteria. We conducted parametric survival analyses using a Gompertz distribution to calculate risk of death and predicted median time to death. Predictors included demographic, functional, clinical characteristics, and behavioral symptoms (assessed among NHATS respondents with proxy interviews). RESULTS Among 842 community-dwelling persons with dementia and severe disability, 80.5% died during the study period. After adjusting for age and gender, overall predicted median time to death was 1.7 years (25th percentile 0.6, 75th percentile 3.8 years). Six notable characteristics were associated with shorter life expectancy: 1) older age (90+), with a predicted median time to death of 1.0 year (0.4, 2.1); 2) being bedbound, 1.1 years (0.4, 2.3); 3) being homebound, 1.2 years (0.5, 2.6); 4) having comorbid cancer, 1.2 years (0.5, 2.6); 5) unintended weight loss, 1.4 years (0.5, 3.1); and 6) comorbid depression, 1.5 years (0.6, 3.3). CONCLUSIONS Community-dwelling persons with dementia and severe disability lived a median of 1.7 years. Clinicians can use the study findings to provide anticipatory guidance to patients and care partners, and policymakers to inform design of longitudinal supportive services.
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Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren J Hunt
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, USA
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Kristine Yaffe
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Harrison KL, Cenzer I, Ankuda CK, Hunt LJ, Aldridge MD. Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:821-830. [PMID: 35666964 PMCID: PMC9662595 DOI: 10.1377/hlthaff.2021.01985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Medicare hospice benefit was originally designed around a cancer disease paradigm but increasingly serves people living with dementia. At this time, almost half of all older adults receiving hospice care have dementia. Yet there is minimal evidence as to whether hospice benefits people living with dementia outside of nursing facilities. We asked whether and how the perceived quality of last-month-of-life care differed between people with and without dementia and whether hospice use among people living with dementia was associated with perceived quality of care compared with the quality of care for those who did not use hospice. We used nationally representative data from the National Health and Aging Trends Study and Medicare claims from the period 2011-17 to examine the impact of hospice enrollment on proxy perceptions of last-month-of-life care quality. Proxies of people living with dementia enrolled in hospice compared with proxies of those not enrolled more often reported care to be excellent (predicted probability: 52 percent versus 41 percent), more often reported having anxiety or sadness managed (67 percent versus 46 percent), and less often reported changes in care settings in the last three days of life (10 percent versus 25 percent). There were no differences in the impact of hospice on proxy ratings of care for people with and without dementia. Policy makers should consider these benefits when weighing changes to hospice policy and regulations that may affect people living with dementia.
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Affiliation(s)
- Krista L Harrison
- Krista L. Harrison , University of California San Francisco, San Francisco, California
| | - Irena Cenzer
- Irena Cenzer, University of California San Francisco
| | - Claire K Ankuda
- Claire K. Ankuda, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco
| | - Melissa D Aldridge
- Melissa D. Aldridge, Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
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Davis MA, Chang CH, Simonton S, Bynum JPW. Trends in US Medicare Decedents’ Diagnosis of Dementia From 2004 to 2017. JAMA HEALTH FORUM 2022; 3:e220346. [PMID: 35977316 PMCID: PMC8976239 DOI: 10.1001/jamahealthforum.2022.0346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/09/2022] [Indexed: 12/22/2022] Open
Abstract
Question To what degree did the diagnosis of Alzheimer disease and related dementias (ADRD) change at the end of life between 2004 and 2017? Findings Among 3 515 329 Medicare fee-for-service decedents, the percentage who received an ADRD diagnosis within 2 years of death increased from 34.7% in 2004 to 47.2% in 2017. The likelihood of receiving an ADRD diagnosis particularly increased in the inpatient, hospice, and home health settings; individual characteristics and service use were stable over time, while the intensity of end-of-life care declined on most measures. Meaning Dying with an ADRD diagnosis has become more common among older US decedents, potentially owing to increased awareness and temporal changes in billing. Importance Alzheimer disease and related dementias (ADRD) have received considerable attention among clinicians, researchers, and policy makers in recent years. Despite increased awareness, few studies have documented temporal changes in the documentation of ADRD diagnoses despite its new importance for risk adjustment for health plans in Medicare. Objective To assess trends in frequency of ADRD diagnosis in the last 2 years of life from 2004 to 2017, as well as any associated changes in billing practices, characteristics of the population with diagnosed ADRD, and intensity of end-of-life care. Design, Setting, and Participants This is a serial cross-sectional study of older adult decedents (67 years or older) from 2004 to 2017 using a 20% sample of fee-for-service Medicare decedents. An ADRD diagnosis within the last 2 years of life was identified using diagnosis codes from inpatient, professional service, home health, or hospice claims, requiring the standard claims algorithm that required at least 1 claim and a more stringent algorithm that required at least 2 claims. Trends in ADRD diagnosis among decedents were used to lessen influence of new diagnostic technologies for early stage disease. Demographic characteristics, selected comorbidities, place of death, and health service use at the end-of-life were also examined. Data were analyzed from July 9, 2020, to May 3, 2021. Exposures Calendar year 2004 to 2017. Main Outcome and Measure An ADRD diagnosis within 2 years of death. Results Among the included 3 515 329 Medicare fee-for-service decedents, when adjusted for age and sex, the percentage of older decedents with an ADRD diagnosis increased from 34.7% in 2004 to 47.2% in 2017. The trend was attenuated (25.2% to 39.2%) using a stringent ADRD definition. There was an inflection in the curve from 2011 to 2013, the time at which additional diagnoses were added to Medicare claims and the National Alzheimer Care Act was enacted. The ADRD diagnosis frequency increased considerably in inpatient (49.0% to 67.3%), hospice (12.2% to 42.0%), and home health (10.1% to 28.7%) claims. However, individual characteristics, number of visits, and hospitalizations were similar across the study period, and the intensity of end-of-life care declined on most measures. Conclusions and Relevance In this cross-sectional study, nearly half of older Medicare decedents had a diagnosis of ADRD at the time of death. From 2004 to 2017, the percentage of older adult decedents who received an ADRD diagnosis increased substantially prior to announcement of the addition of ADRD to Medicare risk adjustment strategies.
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Affiliation(s)
- Matthew A. Davis
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Chiang-Hua Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Sharon Simonton
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Julie P. W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Simning A, Orth J, Temkin-Greener H, Li Y, Simons KV, Conwell Y. Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia. Am J Geriatr Psychiatry 2022; 30:223-234. [PMID: 34284892 PMCID: PMC8710182 DOI: 10.1016/j.jagp.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 03/24/2021] [Accepted: 06/21/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time. DESIGN Retrospective cohort study based on secondary data analyses. SETTING New York State Medicare beneficiaries who were admitted to an SNF in 2014. PARTICIPANTS Total of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home. MEASUREMENTS We used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics. RESULTS Among SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD. CONCLUSION Newly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.
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Affiliation(s)
- Adam Simning
- University of Rochester, Department of Psychiatry, Rochester, NY; University of Rochester, Department of Public Health Sciences, Rochester, NY.
| | | | | | - Yue Li
- UR, Department of Public Health Sciences
| | | | - Yeates Conwell
- University of Rochester (UR), Department of Psychiatry,UR, Office for Aging Research and Health Services
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Written discharge communication of diagnostic and decision-making information for persons living with dementia during hospital to skilled nursing facility transitions. Geriatr Nurs 2022; 45:215-222. [PMID: 35569425 PMCID: PMC9327092 DOI: 10.1016/j.gerinurse.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 01/26/2023]
Abstract
Hospital-to-skilled nursing facility (SNF) transitions constitute a vulnerable point in care for people with dementia and often precede important care decisions. These decisions necessitate accurate diagnostic/decision-making information, including dementia diagnosis, power of attorney for health care (POAHC), and code status; however, inter-setting communication during hospital-to-SNF transitions is suboptimal. This retrospective cohort study examined omissions of diagnostic/decision-making information in written discharge communication during hospital-to-SNF transitions. Omission rates were 22% for dementia diagnosis, 82% and 88% for POAHC and POAHC activation respectively, and 70% for code status. Findings highlight the need to clarify and intervene upon causes of hospital-to-SNF communication gaps.
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Knox S, Haas A, Downer B, Ottenbacher KJ. Association of Dementia Severity and Caregiver Support With Early Discharge From Home Health. Am J Alzheimers Dis Other Demen 2022; 37:15333175221129384. [PMID: 36242532 PMCID: PMC10581099 DOI: 10.1177/15333175221129384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION The objective of this study was to examine the relationship between dementia severity and early discharge from home health. METHODS This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health. RESULTS The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs. DISCUSSION The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.
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Affiliation(s)
- Sara Knox
- Medical University of South Carolina, Charleston, SC, USA
| | - Allen Haas
- University of Texas Medical Branch, Galveston, TX, USA
| | - Brian Downer
- University of Texas Medical Branch, Galveston, TX, USA
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25
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Saragosa M. Using meta-ethnography to understand the care transition experience of people with dementia and their caregivers. DEMENTIA 2022; 21:153-180. [PMID: 34333996 PMCID: PMC8721620 DOI: 10.1177/14713012211031779] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Older adults living with dementia are at risk for more complex health care transitions than individuals without this condition, non-impaired individuals. Poor quality care transitions have resulted in a growing body of qualitative empirical literature that to date has not been synthesized. We conducted a systematic literature review by applying a meta-ethnography approach to answer the following question: How do older adults with dementia and/or their caregivers experience and perceive healthcare transition: Screening resulted in a total of 18 studies that met inclusion criteria. Our analysis revealed the following three categories associated with the health care transition: (1) Feelings associated with the healthcare transition; (2) processes associated with the healthcare transition; and (3) evaluating the quality of care associated with the health care transition. Each category is represented by several themes that together illustrate an interconnected and layered experience. The health care transition, often triggered by caregivers reaching a "tipping point," is manifested by a variety of feelings, while simultaneously caregivers report managing abrupt transition plans and maintaining vigilance over care being provided to their family member. Future practice and research opportunities should be more inclusive of persons with dementia and should establish ways of better supporting caregivers through needs assessments, addressing feelings of grief, ongoing communication with the care team, and integrating more personalized knowledge at points of transition.
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Affiliation(s)
- Marianne Saragosa
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto; Sinai Health, Canada
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26
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Schumacher-Schönert F, Wucherer D, Nikelski A, Kreisel S, Vollmar HC, Hoffmann W, Thyrian JR. [Discharge management in German hospitals for cognitively impaired, older people-a scoping review]. Z Gerontol Geriatr 2021; 54:695-703. [PMID: 32383064 PMCID: PMC8551109 DOI: 10.1007/s00391-020-01732-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In German hospitals approximately 40% of all patients over the age of 65 years are cognitively impaired (MmkB). After discharge from hospital it is particularly important for MmkB that the transition to domestic life is organized as seamlessly and as well-coordinated as possible. OBJECTIVE The aim of the study was to determine the existing evidence on discharge management (EM) in MmkB and people with dementia (MmD). Furthermore, the study examined the necessity of an intersectoral concept for MmkB. MATERIAL AND METHODS Based on a scoping review a total of 102 publications were identified, of which 6 articles were finally used for the evaluation. RESULTS The article provides an overview of the current care of MmkB in acute care hospitals in Germany. General information on EM in hospitals was given in three of the six publications included. Information on special discharge and care management for MmkB and MmD was contained in five out of six papers. DISCUSSION The article illustrates significant gaps in the hospital care for older MmkB, in particular at the interface of discharge management and demonstrates the need for new care models. To what extent these new care models can be structurally, procedurally and systemically embedded in the standard care and financed, is an open and unexplored question.
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Affiliation(s)
- F Schumacher-Schönert
- AG Interventionelle Versorgungsforschung, Deutsches Zentrum für Neurodegenerative Erkrankungen e. V. (DZNE) Standort Rostock/Greifswald, Ellernholzstr. 1-2, 17487, Greifswald, Deutschland.
| | - D Wucherer
- AG Interventionelle Versorgungsforschung, Deutsches Zentrum für Neurodegenerative Erkrankungen e. V. (DZNE) Standort Rostock/Greifswald, Ellernholzstr. 1-2, 17487, Greifswald, Deutschland
| | - A Nikelski
- Evangelisches Klinikum Bethel gGmbH, Akademisches Lehrkrankenhaus, Universität Münster, Münster, Deutschland
| | - S Kreisel
- Evangelisches Klinikum Bethel gGmbH, Akademisches Lehrkrankenhaus, Universität Münster, Münster, Deutschland
| | - H C Vollmar
- Abteilung für Allgemeinmedizin, Ruhr-Universität Bochum, Bochum, Deutschland
| | - W Hoffmann
- AG Interventionelle Versorgungsforschung, Deutsches Zentrum für Neurodegenerative Erkrankungen e. V. (DZNE) Standort Rostock/Greifswald, Ellernholzstr. 1-2, 17487, Greifswald, Deutschland
- Institut für Community Medicine, Abteilung Versorgungsepidemiologie und Community Health, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - J R Thyrian
- AG Interventionelle Versorgungsforschung, Deutsches Zentrum für Neurodegenerative Erkrankungen e. V. (DZNE) Standort Rostock/Greifswald, Ellernholzstr. 1-2, 17487, Greifswald, Deutschland
- Institut für Community Medicine, Abteilung Versorgungsepidemiologie und Community Health, Universitätsmedizin Greifswald, Greifswald, Deutschland
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Lei L, Cai S, Conwell Y, Fortinsky RH, Intrator O. Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia. J Appl Gerontol 2021; 41:1035-1046. [PMID: 34686087 DOI: 10.1177/07334648211051867] [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: 11/16/2022] Open
Abstract
BACKGROUND Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization. METHODS National Veterans Health Administration data linked to Medicare claims in fiscal years 2014-2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0-1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities. RESULTS Veterans with a 0.1 higher BBC were 4.6% (p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities. CONCLUSION Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.
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Affiliation(s)
- Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.,VHA Office Geriatrics & Extended Care Data & Analyses Center (GECDAC), Washington, DC, USA
| | - Shubing Cai
- VHA Office Geriatrics & Extended Care Data & Analyses Center (GECDAC), Washington, DC, USA.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Orna Intrator
- VHA Office Geriatrics & Extended Care Data & Analyses Center (GECDAC), Washington, DC, USA.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Burke RE, Xu Y, Ritter AZ. Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia. J Am Med Dir Assoc 2021; 23:877-879.e3. [PMID: 34644532 DOI: 10.1016/j.jamda.2021.09.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Hospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia. DESIGN Retrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to 2016. SETTING AND PARTICIPANTS We identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment. METHODS We calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage). RESULTS Of the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population. CONCLUSIONS AND IMPLICATIONS One-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA; Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Yao Xu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Z Ritter
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
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Lehrer H, Lin JY, Kwon CS, Agarwal P, Mazumdar M, Jetté N. The co-occurrence of dementia in those with epilepsy is associated with 30-day readmission - A population-based study. Epilepsy Behav 2021; 122:108126. [PMID: 34153638 DOI: 10.1016/j.yebeh.2021.108126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Dementia and epilepsy often co-occur and are associated with poor health outcomes and increased healthcare utilization. The literature on the association between readmission and co-occurrence of dementia and epilepsy is scant. Our objective was to determine if dementia in patients with epilepsy >40 years old is associated with 30-day hospital readmission, in-hospital mortality, discharge disposition, and length-of-stay. METHODS This retrospective cohort study used the 2014 Nationwide Readmissions Database, containing data from hospital discharges across the US and readmissions. Epilepsy and dementia were identified using previously validated ICD-9-CM codes. Primary outcome was 30-day readmission, analyzed with univariable and multivariable logistic regressions. Secondary outcomes were discharge disposition, in-hospital mortality, and length-of-stay, analyzed with univariable multinomial logistic, univariable logistic, and univariable ordinary least squared regressions, respectively. The top ten causes of readmission in each group were compared as well. All analyses accounted for survey weights, cluster, and stratum. RESULTS Patients with epilepsy with dementia (n = 15,588) had longer hospital stays [15% (95%CI 10-20%)], and higher odds of readmission [OR 1.11 (95%CI 1.05-1.17)], transfer to another facility [OR 2.18 (95%CI 1.93-2.46)], and in-hospital mortality [OR 1.50 (95%CI 1.25-1.79)] compared to those without dementia (n = 186,289).The top two causes of readmission were septicemia (dementia: 14.81%; no dementia: 9.45%) and epilepsy/convulsions (dementia: 5.91%; no dementia: 6.25%). Other top 10 causes of readmissions in those with epilepsy and dementia which were not present in those without dementia included delirium (5.21%), urinary tract infections (4.98%), and aspiration pneumonitis (4.29%). SIGNIFICANCE Dementia in epilepsy is associated with worse outcomes, including higher in-hospital mortality and higher readmissions. Potentially preventable causes of readmission in those with epilepsy and dementia were identified, including septicemia, delirium, urinary tract infection, and aspiration pneumonitis. Future studies are needed to inform interventions aimed at decreasing premature mortality and reducing potentially preventable readmissions in this vulnerable population.
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Affiliation(s)
- Helaina Lehrer
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, USA.
| | - Jung-Yi Lin
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
| | - Churl-Su Kwon
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, USA
| | - Parul Agarwal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
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Gilmore-Bykovskyi AL, Hovanes M, Mirr J, Block L. Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions. J Geriatr Psychiatry Neurol 2021; 34:378-388. [PMID: 32812457 PMCID: PMC7892639 DOI: 10.1177/0891988720944245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.
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Affiliation(s)
- Andrea L Gilmore-Bykovskyi
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
- Division of Geriatrics, Department of Medicine, 5228University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- William S. Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center, Madison, WI, USA
| | - Melissa Hovanes
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
| | - Jacquelyn Mirr
- Division of Geriatrics, Department of Medicine, 5228University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- Mercy Hospital St. Louis, MO, USA
| | - Laura Block
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
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An investigation of new medications initiation during ambulatory care visits in patients with dementia. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100058. [PMID: 35480611 PMCID: PMC9030674 DOI: 10.1016/j.rcsop.2021.100058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 11/21/2022] Open
Abstract
Background Objectives Methods Results Conclusion What was already known?Dementia remains responsible for a large economic burden; research has shown that patients with dementia have increased utilization of ambulatory care visits before and after diagnosis. Prior research in patients with dementia has focused on inappropriate prescribing, adverse drug interactions, and polypharmacy, but little work has been published investigating new medications prescribed at outpatient visits. Opportunities exist for pharmacists to manage medications in the outpatient setting for patients with complex medication regimens.
What the study adds?Though fewer visits for patients with dementia provided new medications compared to visits for patients without dementia, there was no statistically significant difference in odds of a new medication being provided after adjustment for important confounders. Some of the new medications more commonly provided to dementia patients include anticoagulants and antipsychotics that often require close monitoring and dosage adjustments. Pharmacist led services would likely improve the care of the dementia population in an outpatient setting, but further investigation of new medication usage and the utility of pharmacists is needed.
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Gilmore-Bykovskyi A, Markart M, Imig K, Hunt K, Murray D, Block L, Dhein J. Implementation and Evaluation of an Acute Care Multicomponent Intervention for Dementia-Related Behavioral Expressions. J Gerontol Nurs 2021; 47:21-30. [PMID: 34432573 DOI: 10.3928/00989134-20210803-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite the high prevalence and negative outcomes associated with poorly managed dementia-related behavioral expressions (BE) during hospitalization, evidence-based interventions for BE management in acute care environments are lacking. To address this gap, we designed, implemented, and evaluated feasibility, utility, and exploratory nurse and patient outcomes associated with a low-cost, nurse-led multicomponent decision support intervention-the Personalized Approach and Targeted Interventions (PROACTIVE) Treatment Approach-which was implemented as a quality improvement program and evaluated with a historical matched comparison group. The intervention was feasibly implemented and improved nurse-sensitive outcomes (stress, confidence), practices (use of nonpharmacological approaches) for BE management, and perceived utility of intervention resources. Patients receiving the PROACTIVE Treatment Approach (N = 40) had higher rates of acetaminophen use, and shorter lengths of stay (N = 40). More rigorous evaluation is needed to better determine optimal implementation strategies and intervention impact. [Journal of Gerontological Nursing, 47(9), 21-30.].
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Burke RE, Xu Y, Ritter AZ, Werner RM. Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia. Health Serv Res 2021; 57:497-504. [PMID: 34389982 DOI: 10.1111/1475-6773.13855] [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: 03/12/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia. DATA SOURCES 100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016. STUDY DESIGN Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients. DATA COLLECTION/EXTRACTION METHODS We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back. PRINCIPAL FINDINGS Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings. CONCLUSIONS Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Yao Xu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Z Ritter
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Multiple transitions across care settings can be disruptive for older adults with dementia and their care partners, and can lead to fragmented care with adverse outcomes. This scoping review was conducted to identify and classify care trajectories across multiple settings for people with dementia, and to understand the prevalence of multiple transitions and associated factors at the individual and organizational levels. Searches of three databases, limited to peer-reviewed studies published between 2007 and 2017, provided 33 articles for inclusion. We identified 26 distinct care trajectories. Common trajectories involved hospital readmission or discharge from hospital to long-term care. Factors associated with transitions were identified mainly at the level of demographic and medical characteristics. Findings suggest a need for investing in stronger community-based systems of care that may reduce transitions. Further research is recommended to address knowledge gaps about complex and longitudinal care trajectories and trajectories experienced by sub-populations of people living with dementia.
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Kracht F, Boekholt M, Schumacher-Schönert F, Nikelski A, Chikhradze N, Lücker P, Vollmar HC, Hoffmann W, Kreisel SH, Thyrian JR. Describing people with cognitive impairment and their complex treatment needs during routine care in the hospital - cross-sectional results of the intersec-CM study. BMC Geriatr 2021; 21:425. [PMID: 34253180 PMCID: PMC8276375 DOI: 10.1186/s12877-021-02298-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/27/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cognitive impairment is an important determinant in health care. In the acute hospital setting cognition has a strong impact on treatment and care. Cognitive impairment can negatively affect diagnostics and treatment success. However, little is known about the individual situation and specific risks of people with cognitive impairments during hospital stays. The aim of the present research is to describe and analyze the treatment needs of people with cognitive impairments in acute hospital care. METHODS The analyses use baseline data of the ongoing multisite, longitudinal, randomized controlled intervention trial intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with Intersectoral Care Management), which recruited 402 participants at baseline. We assessed sociodemographic aspects, cognitive status, functional status, frailty, comorbidities, level of impairment, formal diagnosis of dementia, geriatric diagnoses, delirium, depression, pharmacological treatment, utilization of health care services and health care related needs. RESULTS The sample under examination had been on average mildly cognitively impaired (MMSE M = 22.3) and had a mild to moderate functional impairment (Barthel Index M = 50.4; HABAM M = 19.1). The Edmonton Frail Scale showed a mean of 7.4 and half of the patients (52.3%) had been assigned a care level. About 46.9% had a geriatric diagnosis, 3.0% had a diagnosis of dementia. According to DSM-V 19.2% of the patients had at least one main symptom of depression. The mean number of regularly taken drugs per patient was 8.2. Utilization of health care services prior to the hospital stay was rather low. On average, the sample showed 4.38 care related needs in general, of which 0.60 needs were unaddressed at the time of assessment. CONCLUSIONS Descriptive analyses highlight an in-depth insight into impairments and different care needs of people with cognitive impairments. The results emphasize the need for gender-specific analyses as well as an increased attention to the heterogeneity of needs of people with cognitive impairments related to specific wards, settings and regions where they are admitted. Our results indicate also that people with cognitive impairments represent a high proportion of older patients in acute hospital care. TRIAL REGISTRATION The intersec-CM trial is registered at ClinicalTrials.gov ( NCT03359408 ).
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Affiliation(s)
- F Kracht
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany.
| | - M Boekholt
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany.
| | - F Schumacher-Schönert
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany
| | - A Nikelski
- Evangelisches Klinikum Bethel, Campus Bielefeld-Bethel, Division of Geriatric Psychiatry, Universitätsklinikum OWL der Universität Bielefeld, Bielefeld, Germany
| | - N Chikhradze
- Institute of General Practice and Family Medicine (AM RUB), Faculty of Medicine, Ruhr University Bochum (RUB), Bochum, Germany
| | - P Lücker
- Institute for Community Medicine, Section of Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany
| | - H C Vollmar
- Institute of General Practice and Family Medicine (AM RUB), Faculty of Medicine, Ruhr University Bochum (RUB), Bochum, Germany
| | - W Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany
- Institute for Community Medicine, Section of Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany
| | - S H Kreisel
- Evangelisches Klinikum Bethel, Campus Bielefeld-Bethel, Division of Geriatric Psychiatry, Universitätsklinikum OWL der Universität Bielefeld, Bielefeld, Germany
| | - J R Thyrian
- German Center for Neurodegenerative Diseases (DZNE), site Rostock/ Greifswald, Greifswald, Germany.
- Institute for Community Medicine, Section of Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany.
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Knox S, Downer B, Haas A, Ottenbacher KJ. Mobility and Self-Care are Associated With Discharge to Community After Home Health for People With Dementia. J Am Med Dir Assoc 2021; 22:1493-1499.e1. [PMID: 33476569 PMCID: PMC8496773 DOI: 10.1016/j.jamda.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/17/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES A priority health outcome for patients, families, and the Centers for Medicare & Medicaid Services (CMS) is a patient's ability to return home and remain in the community without adverse events following discharge from post-acute care services. Successful discharge to community (DTC) is defined as being discharged to the community and not experiencing a readmission or death within 30 days of discharge. The objective of this study was to determine the association between patient factors and successful DTC after home health for individuals with Alzheimer's disease and related dementias (ADRD). DESIGN This retrospective study derived data from 100% national CMS data files from October 1, 2016, through September 30, 2017. SETTINGS AND PARTICIPANTS Criteria from the Home Health Quality Reporting program were used to identify a cohort of 790,439 Medicare home health beneficiaries, 143,164 (18.0%) with ADRD. MEASURES Successful DTC rates with associated 95% confidence intervals (CIs) were calculated for each patient characteristic. Multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC after home health, by ADRD diagnosis, mobility, self-care, caregiver support, and medication management, adjusted for patient demographics and clinical characteristics. RESULTS Overall, 79.4% of beneficiaries had a successful DTC. Beneficiaries with ADRD had a significantly lower odds of successful DTC than those without ADRD (RR=0.947, 95% CI=0.944-0.950). This association remained significant after adjustment for caregiver support, assistance with medications, independence in mobility, and level of self-care. Greater need for caregiver support, greater need for assistance with medications, greater dependence in mobility, and greater self-care dependence were all associated with decreased risk of successful DTC. CONCLUSIONS AND IMPLICATIONS Older adults with ADRD receiving home health had decreased RR of successful DTC. To have a successful DTC, older adults with ADRD need sufficient support from caregivers and independence in functioning.
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Affiliation(s)
- Sara Knox
- Division of Physical Therapy, Medical University of South Carolina, Charleston, SC, USA.
| | - Brian Downer
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Allen Haas
- Department of Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Kenneth J Ottenbacher
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, USA
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Welberry HJ, Jorm LR, Barbieri S, Hsu B, Brodaty H. The impact of dementia on aged care service transitions in the last five years of life. Age Ageing 2021; 50:1159-1165. [PMID: 33270824 DOI: 10.1093/ageing/afaa254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To investigate the impact of dementia on aged care service use at end-of-life. METHODS Our retrospective data linkage study in New South Wales, Australia, used survey data from participants in the 45 and Up Study who died between July 2011-June 2014 linked to routinely collected administrative data for 2006-2014. We investigated movement between aged care "states" (No Services, Home Care including Home Support and Low-and High-Level Home Care and Residential Care) in the last five years of life. The dementia cohort comprised decedents with a dementia diagnosis recorded in hospital records, death certificates or who had claims for dementia-specific medicines prior to death (n = 2,230). The comparison cohort were decedents with no dementia diagnosis, matched 1:1 on age-at-death, sex, income and location. RESULTS Compared to those without dementia, people with dementia were more likely to: use home care (67 versus 60%, P < 0.001), enter residential care (72 versus 30%, P < 0.001) and stay longer in residential care (median 17.9 versus 12.7 months, P < 0.001). Five years before death, more people with dementia were within residential care (6 versus 4%; RR = 1.61, 95%CI = 1.23-2.10) and these rates diverged at the end-of-life (69 versus 28%, RR = 2.48, 95%CI = 2.30-2.66). Use of home-based care was higher among people with dementia five years from death (20 versus 17%; RR = 1.15, 95%CI = 1.02-1.30) but lower at end-of-life (13 versus 24%, RR = 0.55, 95%CI = 0.49-0.63). CONCLUSION Dementia-specific aged care trajectories were dominated by residential care. Home care use declined towards end-of-life for people with dementia and may not be meeting their needs.
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Affiliation(s)
- Heidi J Welberry
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Sebastiano Barbieri
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Benjumin Hsu
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Henry Brodaty
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
- Dementia Centre for Research Collaboration, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
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Burke RE, Xu Y, Ritter AZ. Outcomes of post-acute care in skilled nursing facilities in Medicare beneficiaries with and without a diagnosis of dementia. J Am Geriatr Soc 2021; 69:2899-2907. [PMID: 34173231 DOI: 10.1111/jgs.17321] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND More than 600,000 Medicare beneficiaries with a diagnosis of dementia are discharged to skilled nursing facilities (SNFs) after hospitalization annually. However, it is unclear how their risks and benefits of a SNF stay compare to beneficiaries without a diagnosis of dementia. DESIGN Retrospective analysis comparing SNF outcomes for Medicare beneficiaries with and without a diagnosis of dementia. SETTING One hundred percent sample of Medicare beneficiaries from 2015 to 2016. PARTICIPANTS Dementia was identified using validated diagnosis codes. In beneficiaries who had an acute hospitalization followed by SNF stay, we used propensity score matching to balance demographics, comorbidities, characteristics of the index hospital stay, prior hospital and SNF utilization, and cognitive status on SNF admission. MEASUREMENTS Outcomes included unplanned hospital readmission, community discharge rate, and mortality during the SNF stay. Multivariate models were adjusted for hospital and SNF characteristics. RESULTS Our sample included 2,418,853 Medicare beneficiaries discharged from hospital to SNF; 830,524 (34.3%) carried a diagnosis of dementia. Overall, 14.7% of the sample had a hospital readmission, 5.0% died, and 61.5% were successfully discharged to the community. In the propensity-matched cohort, beneficiaries with a diagnosis of dementia had a lower odds ratio of mortality (OR 0.87; 95% confidence interval [CI] 0.86-0.89), similar odds of hospital readmission (OR 0.99; 95% CI 0.98-1.00), and reduced odds of discharge to the community (OR 0.92; 95% CI 0.91-0.93). However, these findings varied by the severity of cognitive impairment on SNF admission: in beneficiaries with no impairment, those with a diagnosis of dementia had higher odds of adverse outcomes. In beneficiaries with severe impairment, beneficiaries with a diagnosis of dementia had lower odds of adverse outcomes. CONCLUSIONS Cognitive dysfunction on SNF admission is a stronger predictor of outcomes than a diagnosis of dementia, suggesting the need to individualize decisions about the benefits and risks of SNF care in populations with cognitive impairment.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yao Xu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashley Z Ritter
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rodriguez K, Fugard M, Amini S, Smith G, Marasco D, Shatzer J, Guerrero M, Garvan C, Davis J, Price C. Caregiver Response to an Online Dementia and Caregiver Wellness Education Platform. J Alzheimers Dis Rep 2021; 5:433-442. [PMID: 34368629 PMCID: PMC8293668 DOI: 10.3233/adr-200292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Web-based educational interventions are emerging as a potential solution to improve caregiver dementia knowledge and overall well-being. OBJECTIVE To assess the feasibility of delivering a web-based intervention for dementia caregivers by examining: 1) engagement with the online platform, 2) skill implementation, and 3) changes on outcome metrics over the 30-day study period. METHODS Enrolled participants were onboarded by a trained research coordinator and provided 24/7 access to the platform over 30 days. At study onset and completion, caregivers completed assessments of care recipient dementia severity and neuropsychiatric symptoms along with instruments which measured dementia knowledge, caregiver burden, and carer experience. RESULTS Of 84 referrals, 60 caregivers met study inclusion criteria and 55 completed pre and post study measures. Caregivers completed an average of 8 hours of learning over the 30-day web-based intervention, with 84.4%of participants reporting using at least one skill they learned from the online platform. Eighty-nine percent of participants reported high satisfaction with the web-based educational intervention. There were small effect sizes for decreases in NPIQ neuropsychiatric symptom severity and caregiver distress scores from pre- to post-intervention. Small effect sizes were observed for changes in caregiver burden from pre- to post-intervention among caregivers who perceived their care recipient as having high global deterioration. CONCLUSION Findings show online educational programs are feasible for informal family caregivers of dementia and have perceived value. Future studies should address caregiver response to online education in less severe versus more severe care recipients, and explore the value of caregiver online platforms in diverse caregiver samples.
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Affiliation(s)
- Katie Rodriguez
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
| | | | - Shawna Amini
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Glenn Smith
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | | | | | | | - Cynthia Garvan
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
| | | | - Catherine Price
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Perioperative Cognitive Anesthesia Network for Alzheimer’s Disease and Related Dementias, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
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Sternberg SA, Shinan-Altman S, Volicer L, Casarett DJ, van der Steen JT. Palliative Care in Advanced Dementia: Comparison of Strategies in Three Countries. Geriatrics (Basel) 2021; 6:44. [PMID: 33922208 PMCID: PMC8167764 DOI: 10.3390/geriatrics6020044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/18/2022] Open
Abstract
Palliative care including hospice care is appropriate for advanced dementia, but policy initiatives and implementation have lagged, while treatment may vary. We compare care for people with advanced dementia in the United States (US), The Netherlands, and Israel. We conducted a narrative literature review and expert physician consultation around a case scenario focusing on three domains in the care of people with advanced dementia: (1) place of residence, (2) access to palliative care, and (3) treatment. We found that most people with advanced dementia live in nursing homes in the US and The Netherlands, and in the community in Israel. Access to specialist palliative and hospice care is improving in the US but is limited in The Netherlands and Israel. The two data sources consistently showed that treatment varies considerably between countries with, for example, artificial nutrition and hydration differing by state in the US, strongly discouraged in The Netherlands, and widely used in Israel. We conclude that care in each country has positive elements: hospice availability in the US, the general palliative approach in The Netherlands, and home care in Israel. National Dementia Plans should include policy regarding palliative care, and public and professional awareness must be increased.
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Affiliation(s)
| | - Shiri Shinan-Altman
- The Louis and Gabi Weisfeld School of Social Work, Faculty of Social Sciences, Bar Ilan University, Ramat Gan 5290002, Israel;
| | - Ladislav Volicer
- School of Aging Studies, University of South Florida, Tampa, FL 33620, USA;
- Third Faculty of Medicine, Charles University, 100 00 Prague, Czech Republic
| | | | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Department of Primary and Community Care, Radboud university medical center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Re-imagining care transitions for people with dementia and complex support needs in residential aged care: using co-designed sensory objects and a focused ethnography to recognise micro transitions. AGEING & SOCIETY 2021. [DOI: 10.1017/s0144686x2100043x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
The concept of transition is often used in health and lifecourse research to understand a significant movement from one state or place to another. While people with dementia experience more major transitions than their peers, they are often excluded from transitional care research. This study set out to develop meaningful transitional supports for people with dementia and complex support needs who were undertaking a significant planned geographical transition from their current residential aged care facility to a new purpose-built facility. Using the language of complex support needs acknowledges that participants in this study have a breadth and depth of need, including cognitive, physical, psycho-social and communication impairments and social and cultural disadvantage associated with ageing, institutionalisation and social isolation. To support their move, Participatory Action Research was used to support the co-creation of transitional objects (personalised scarves and blankets) with 15 people with dementia, their families and care staff. Whilst these objects were useful in supporting transition, it was not in the way we imagined. Whilst our initial focus had been on supporting a significant geographical transition, rather it was four types of micro transitions in which the transitional objects were used: small physical transitions (from one place to another); social transitions (entering or exiting personal interactions); activity transitions (moving between activities); and time travel (moving between different times). Reimagining transitions from the perspective of people with dementia and complex support needs involves the recognition of the need for supports for micro as well as macro transitions. Personalised objects to support these everyday micro transitions have the potential to make the lives of people with dementia and complex support needs more manageable, meaningful and comprehensible. Reimagining transitions in dementia in this way helps us reimagine dementia itself, as a constantly fluid, dynamic and responsive series of moments which also has implications for the re-imagination of dementia care.
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Wild K, Sharma N, Mattek N, Karlawish J, Riley T, Kaye J. Application of In-Home Monitoring Data to Transition Decisions in Continuing Care Retirement Communities: Usability Study. J Med Internet Res 2021; 23:e18806. [PMID: 33439144 PMCID: PMC7840292 DOI: 10.2196/18806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/23/2020] [Accepted: 09/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Continuous in-home monitoring of older adults can provide rich and sensitive data capturing subtle behavioral and cognitive changes. Our previous work has identified multiple metrics that describe meaningful trends in daily activities over time. The continuous, multidomain nature of this technology may also serve to inform caregivers of the need for higher levels of care to maintain the health and safety of at-risk older adults. Accordingly, care decisions can be based on objective, systematically assessed real-time data. OBJECTIVE This study deployed a suite of in-home monitoring technologies to detect changing levels of care needs in residents of independent living units in 7 retirement communities and to assess the efficacy of computer-based tools in informing decisions regarding care transitions. METHODS Continuous activity data were presented via an interactive, web-based tool to the staff identified in each facility who were involved in decisions regarding transitions in care among residents. Comparisons were planned between outcomes for residents whose data were shared and those whose data were not made available to the staff. Staff use of the data dashboard was monitored throughout the study, and exit interviews with the staff were conducted to explicate staff interaction with the data platform. Residents were sent weekly self-report questionnaires to document any health- or care-related changes. RESULTS During the study period, 30 of the 95 residents (32%) reported at least one incidence of new or increased provision of care; 6 residents made a permanent move to a higher level of care within their communities. Despite initial enthusiasm and an iterative process of refinement of measures and modes of data presentation based on staff input, actual inspection and therefore the use of resident data were well below expectation. In total, 11 of the 25 staff participants (44%) logged in to the activity dashboard throughout the study. Survey data and in-depth interviews provided insight into the mismatch between intended and actual use. CONCLUSIONS Most continuous in-home monitoring technology acceptance models focus on perceived usefulness and ease of use and equate the intent to use technology with actual use. Our experience suggests otherwise. We found that multiple intervening variables exist between perceived usefulness, intent to use, and actual use. Ethical, institutional, and social factors are considered in their roles as determinants of use.
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Affiliation(s)
- Katherine Wild
- Department of Neurology, Oregon Center for Aging and Technology, Oregon Health and Science University, Portland, OR, United States
| | - Nicole Sharma
- Department of Neurology, Oregon Center for Aging and Technology, Oregon Health and Science University, Portland, OR, United States
| | - Nora Mattek
- Department of Neurology, Oregon Center for Aging and Technology, Oregon Health and Science University, Portland, OR, United States
| | - Jason Karlawish
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Thomas Riley
- Department of Neurology, Oregon Center for Aging and Technology, Oregon Health and Science University, Portland, OR, United States
| | - Jeffrey Kaye
- Department of Neurology, Oregon Center for Aging and Technology, Oregon Health and Science University, Portland, OR, United States
- Department of Biomedical Engineering, Oregon Center for Aging and Technology, Oregon Health and Science University, Portland, OR, United States
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Kraal AZ, Massimo L, Fletcher E, Carrión CI, Medina LD, Mungas D, Gavett BE, Farias ST. Functional reserve: The residual variance in instrumental activities of daily living not explained by brain structure, cognition, and demographics. Neuropsychology 2021; 35:19-32. [PMID: 33393797 PMCID: PMC8753970 DOI: 10.1037/neu0000705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Cognitive reserve is a concept that explains individual differences in resilience to brain pathology and susceptibility to poor late-life cognitive outcomes. We evaluate the analogous concept of "Functional Reserve," defined as the difference between observed functional abilities and those predicted by brain structure, cognitive performance, and demographics. This study aims to validate the construct of functional reserve by testing its utility in predicting clinical outcomes and exploring its predictors. METHOD Longitudinal data collected annually for up to 7 years from 1,084 older adults (ndementia = 163; nMCI = 333; nCN = 523) were analyzed. Functional reserve was operationalized as the residual variance in the Lawton-Brody Instrumental Activities of Daily Living (IADL) Scale after accounting for demographics (sex/gender, race, ethnicity, education), neuropathology (gray matter, hippocampal, and white matter hyperintensity volumes), and cognition (executive function, verbal episodic memory, semantic memory, and spatial function). Structural equation models estimated (a) functional reserve's associations with 7-year changes in clinical diagnosis and disease severity and (b) predictors of functional reserve. RESULTS Functional reserve was lower in dementia versus cognitively normal individuals. Higher baseline functional reserve was associated with lower concurrent dementia severity and slower clinical progression and attenuated the association of cognition with concurrent dementia severity. Physical function and apathy were the strongest predictors of functional reserve. CONCLUSIONS Results provide preliminary validation of functional reserve for explaining individual differences in susceptibility to IADL dysfunction independent of neuropathology, cognition, and demographics. Physical functioning and apathy are promising modifiable intervention targets to enhance functional reserve in the context of brain atrophy and cognitive decline. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | | | - Evan Fletcher
- Department of Neurology, University of California, Davis
| | | | | | - Dan Mungas
- Department of Neurology, University of California, Davis
| | - Brandon E Gavett
- Department of Psychological Science, University of Western Australia
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Sharma RK, Kim H, Gozalo PL, Sullivan DR, Bunker J, Teno JM. The Black and White of Invasive Mechanical Ventilation in Advanced Dementia. J Am Geriatr Soc 2020; 68:2106-2111. [PMID: 32710813 PMCID: PMC7722138 DOI: 10.1111/jgs.16635] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/20/2020] [Accepted: 05/08/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/OBJECTIVES Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation. DESIGN Retrospective cohort study. SETTING Acute-care hospitals in the United States. PARTICIPANTS Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race. MEASUREMENT Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV. RESULTS Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51). CONCLUSION IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.
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Affiliation(s)
- Rashmi K. Sharma
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Hyosin Kim
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon
| | - Pedro L. Gozalo
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island
| | - Donald R. Sullivan
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Jennifer Bunker
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon
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Khemai C, Janssen DJA, Schols JMGA, Naus L, Kemper S, Jole I, Bolt SR, Meijers JMM. Nurses' needs when collaborating with other healthcare professionals in palliative dementia care. Nurse Educ Pract 2020; 48:102866. [PMID: 32950940 DOI: 10.1016/j.nepr.2020.102866] [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: 10/31/2019] [Revised: 07/10/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
Adequate interprofessional collaboration is essential to provide high quality palliative dementia care across different settings. Within interprofessional collaboration, nurses are the frontline healthcare professionals (HCPs), who interact closely with people with dementia, their loved ones, and other HCPs. A survey was conducted to explore the needs of nurses regarding interprofessional collaboration in home care (HC) organisations, nursing homes (NHs) and during NH admissions. The survey identified the perceived quality of and preferred needs regarding interprofessional collaboration. In total, 384 participants (53.9% home care nurses) completed the survey. The most frequently reported collaboration needs in HC organisations and NH were optimal communication content e.g. information transfer and short communication lines (being able to easily contact other disciplines), and coordination e.g. one contact person, and clear task division and responsibilities). During NH admissions, it was important to create transparency about agreements concerning end-of-life wishes, optimize nurse-to-nurse handover during NH admissions (through performing visits prior to admissions, and receiving practical information on how to guide relatives), and improve coordination (e.g. one contact person). In conclusion, the key collaboration needs were organising central coordination, establishing optimal communication, and creating transparency on end-of-life care agreements.
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Affiliation(s)
- C Khemai
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands.
| | - D J A Janssen
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands; Department of Research and Development, CIRO, Hornerheide 1, 6085, NM Horn, the Netherlands
| | - J M G A Schols
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands
| | - L Naus
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands
| | - S Kemper
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands
| | - I Jole
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands
| | - S R Bolt
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands
| | - J M M Meijers
- Department of Health Services Research, CAPHRI (Care and Public Health Research Institute), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, the Netherlands; Zuyderland Care, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162, BG Sittard-Geleen, the Netherlands
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Orsulic‐Jeras S, Whitlatch CJ, Powers SM, Johnson J. A dyadic perspective on assessment in Alzheimer's dementia: Supporting both care partners across the disease continuum. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12037. [PMID: 32885021 PMCID: PMC7453780 DOI: 10.1002/trc2.12037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
Written from a dyadic strength-based perspective, this article first provides a brief overview of the Education, Information, and Support section of the 2018 Alzheimer's Disease Dementia Care Practice Recommendations.1 Subsequent sections present a comprehensive overview of available valid and reliable psychosocial measures that assess a selection of important domains for dementia care planning that can be used by families from early stage until end-of-life. Measures selected for the purposes of this article will focus on concepts that are strength-based and most relevant to care dyads as they navigate the difficult disease trajectory: readiness, knowledge, coping, dyadic relationship, care values and preferences. We will also highlight measures that have traditionally targeted the family care partner but can potentially be considered for use with the care partner with dementia, with adjustments, beyond the early stages. Part of this discussion will include various strategies for including persons with dementia in all aspects of their own care using a strength-based perspective, potentially enabling them to answer questions more reliably across disease stages. Last, gaps in existing measures will be identified to provide options to better assess areas of need most meaningful to families, and in ways that positively contribute to the successful aging of those living with dementia and their care partners.
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Bronskill SE, Maclagan LC, Walker JD, Guan J, Wang X, Ng R, Rochon PA, Yates EA, Vermeulen MJ, Maxwell CJ. Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study. BMJ Open 2020; 10:e037485. [PMID: 32709654 PMCID: PMC7380876 DOI: 10.1136/bmjopen-2020-037485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time. DESIGN Population-based cohort study using health administrative data. SETTING Ontario, Canada from 1 April 2007 to 31 March 2014. PARTICIPANTS 62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity. MAIN OUTCOME MEASURES Rates of health service use, long-term care placement and mortality over time. RESULTS After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI -0.6 to 1.9 increase per year). CONCLUSIONS While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.
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Affiliation(s)
- Susan E Bronskill
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences & Hurvitz Brain Sciences Research Programs, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Jennifer D Walker
- ICES, Toronto, Ontario, Canada
- School of Northern and Rural Health, Laurentian University, Sudbury, Ontario, Canada
| | | | | | - Ryan Ng
- ICES, Toronto, Ontario, Canada
| | - Paula A Rochon
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | - Colleen J Maxwell
- ICES, Toronto, Ontario, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
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Gaugler JE, Statz TL, Birkeland RW, Louwagie KW, Peterson CM, Zmora R, Emery A, McCarron HR, Hepburn K, Whitlatch CJ, Mittelman MS, Roth DL. The ResidentialCare Transition Module: a single-blinded randomized controlled evaluation of a telehealth support intervention for family caregivers of persons with dementia living in residential long-term care. BMC Geriatr 2020; 20:133. [PMID: 32293314 PMCID: PMC7158110 DOI: 10.1186/s12877-020-01542-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Families do not fully disengage from care responsibilities following relatives' admissions to residential long-term (RLTC) care settings such as nursing homes. Caregiver stress, depression, or other key outcomes remain stable or sometimes increase following a relative's RLTC entry. Some interventions have attempted to increase family involvement after institutionalization, but few rigorous studies have demonstrated whether these interventions are effective in helping families navigate the potential emotional and psychological upheaval presented by relatives' transitions to RLTC environments. The Residential Care Transition Module (RCTM) provides six formal sessions of consultation (one-to-one and family sessions) over a 4-month period to family caregivers who have admitted a relative to a RLTC setting. METHODS In this embedded mixed methods randomized controlled evaluation, family members who have admitted a cognitively impaired relative to a RLTC setting are randomly assigned to the RCTM (n = 120) or a usual care control condition (n = 120). Primary outcomes include reductions in family members' primary subjective stress and negative mental health outcomes; secondary role strains; and residential care stress. The mixed methods design will allow for an analysis of intervention action mechanisms by "embedding" qualitative components (up to 30 semi-structured interviews) at the conclusion of the 12-month evaluation. DISCUSSION This evaluation will fill an important clinical and research gap by evaluating a psychosocial intervention designed for families following RLTC admission that determines whether and how the RCTM can help families better navigate the emotional and psychological challenges of residential care transitions. TRIAL REGISTRATION ClinicalTrials.gov (NCT02915939, prospectively registered).
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Affiliation(s)
- Joseph E Gaugler
- Division of Health Policy and Management, School 8of Public Health, University of Minnesota, D351 Mayo (MMC 729), 420 Delaware Street S.E, Minneapolis, MN, 55455, USA.
| | - Tamara L Statz
- Division of Health Policy and Management, School 8of Public Health, University of Minnesota, D351 Mayo (MMC 729), 420 Delaware Street S.E, Minneapolis, MN, 55455, USA
| | - Robyn W Birkeland
- Division of Health Policy and Management, School 8of Public Health, University of Minnesota, D351 Mayo (MMC 729), 420 Delaware Street S.E, Minneapolis, MN, 55455, USA
| | - Katie W Louwagie
- Division of Health Policy and Management, School 8of Public Health, University of Minnesota, D351 Mayo (MMC 729), 420 Delaware Street S.E, Minneapolis, MN, 55455, USA
| | - Colleen M Peterson
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Rachel Zmora
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Ann Emery
- Division of Health Policy and Management, School 8of Public Health, University of Minnesota, D351 Mayo (MMC 729), 420 Delaware Street S.E, Minneapolis, MN, 55455, USA
| | - Hayley R McCarron
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kenneth Hepburn
- Nell Hodgson Woodruff School of Nursing, Emory University Alzheimer's Disease Research Center, Emory University, Atlanta, GA, USA
| | | | - Mary S Mittelman
- Department of Psychiatry, NYU School of Medicine, NYU Langone Health, New York, NY, USA
| | - David L Roth
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA
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Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, Hooper SM, Allen IE, Braley T, Bernstein A, Rosa TD, Harrison K, Begert-Hellings H, Kornak J, Kahn JG, Naasan G, Lanata S, Clark AM, Chodos A, Gearhart R, Ritchie C, Miller BL. Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial. JAMA Intern Med 2019; 179:1658-1667. [PMID: 31566651 PMCID: PMC6777227 DOI: 10.1001/jamainternmed.2019.4101] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Few health systems have adopted effective dementia care management programs. The Care Ecosystem is a model for delivering care from centralized hubs across broad geographic areas to caregivers and persons with dementia (PWDs) independently of their health system affiliations. OBJECTIVE To determine whether the Care Ecosystem is effective in improving outcomes important to PWDs, their caregivers, and payers beyond those achieved with usual care. DESIGN, SETTING, AND PARTICIPANTS A single-blind, randomized clinical trial with a pragmatic design was conducted among PWDs and their caregivers. Each PWD-caregiver dyad was enrolled for 12 months between March 20, 2015, and February 28, 2017. Data were collected until March 5, 2018. Study interventions and assessments were administered over the telephone and internet by clinical and research teams in San Francisco, California, and Omaha, Nebraska. Of 2585 referred or volunteer PWD-caregiver dyads in California, Iowa, or Nebraska, 780 met eligibility criteria and were enrolled. A total of 512 PWD-caregiver dyads were randomized to receive care through the Care Ecosystem and 268 dyads to receive usual care. All eligible PWDs had a dementia diagnosis; were enrolled or eligible for enrollment in Medicare or Medicaid; and spoke English, Spanish, or Cantonese. Analyses were intention-to-treat. INTERVENTION Telephone-based collaborative dementia care was delivered by a trained care team navigator, who provided education, support and care coordination with a team of dementia specialists (advanced practice nurse, social worker, and pharmacist). MAIN OUTCOMES AND MEASURES Primary outcome measure: Quality of Life in Alzheimer's Disease based on caregiver's rating of 13 aspects of PWD's well-being (including physical health, energy level, mood, living situation, memory, relationships, and finances) on a 4-point scale (poor to excellent). Secondary outcomes: frequencies of PWDs' use of emergency department, hospitalization, and ambulance services; caregiver depression (score on 9-Item Patient Health Questionnaire; higher scores indicate more severe depression); and caregiver burden (score on 12-Item Zarit Burden Interview; higher scores indicate more severe caregiver burden). RESULTS The 780 PWDs (56.3% female; mean [SD] age, 78.1 [9.9] years) and 780 caregivers (70.9% female; mean [SD] age, 64.7 [12.0] years) lived in California (n = 452), Nebraska (n = 284), or Iowa (n = 44). Of 780 dyads, 655 were still active at 12 months, and 571 completed the 12-month survey. Compared with usual care, the Care Ecosystem improved PWD quality of life (B, 0.53; 95% CI, 0.25-1.30; P = .04), reduced emergency department visits (B, -0.14; 95% CI, -0.29 to -0.01; P = .04), and decreased caregiver depression (B, -1.14; 95% CI, -2.15 to -0.13; P = .03) and caregiver burden (B, -1.90; 95% CI, -3.89 to -0.08; P = .046). CONCLUSIONS AND RELEVANCE Effective care management for dementia can be delivered from centralized hubs to supplement usual care and mitigate the growing societal and economic burdens of dementia. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02213458.
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Affiliation(s)
- Katherine L Possin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco.,Global Brain Health Institute, University of California, San Francisco
| | - Jennifer J Merrilees
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Stephen J Bonasera
- Home Instead Center for Successful Aging, Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Winston Chiong
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Kirby Lee
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Sarah M Hooper
- UCSF/UC Consortium on Law, Science & Health Policy, UC Hastings College of the Law, San Francisco
| | - Isabel Elaine Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Tamara Braley
- Home Instead Center for Successful Aging, Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Alissa Bernstein
- Global Brain Health Institute, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Talita D Rosa
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco.,Global Brain Health Institute, University of California, San Francisco
| | - Krista Harrison
- Global Brain Health Institute, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.,Division of Geriatrics, University of California, San Francisco
| | - Hailey Begert-Hellings
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - John Kornak
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Georges Naasan
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Serggio Lanata
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Amy M Clark
- Home Instead Center for Successful Aging, Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha.,Department of Social Work, Nebraska Wesleyan University, Lincoln
| | - Anna Chodos
- Division of Geriatrics, University of California, San Francisco
| | - Rosalie Gearhart
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Christine Ritchie
- Division of Geriatrics, University of California, San Francisco.,Center for Research on Aging, San Francisco Campus for Jewish Living, San Francisco, California
| | - Bruce L Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
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Dementia Severity Associated With Increased Risk of Potentially Preventable Readmissions During Home Health Care. J Am Med Dir Assoc 2019; 21:519-524.e3. [PMID: 31734120 DOI: 10.1016/j.jamda.2019.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Approximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST). DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Home health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013-June 1, 2015) diagnosed with dementia (ICD-9 codes). MEASURES 30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe). RESULTS The overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2. CONCLUSIONS AND IMPLICATIONS Dementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.
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