Successful Discharge to Community Gap of FFS Medicare Beneficiaries With and Without ADRD Narrowed

Impact of dementia special care units for short-stay nursing home patients

BACKGROUND

Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients.

METHODS

We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool.

RESULTS

The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode.

CONCLUSIONS

Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.

"Definitely a Dark Time:" professional and ethical issues in post-acute care physical therapy during the COVID-19 pandemic

BACKGROUND

Disproportionate effects of the SARS-CoV-2 (COVID-19) pandemic on older adults in post-acute care settings created many professional and ethical challenges for patients and healthcare providers.

OBJECTIVE

The purpose of this study was to examine the professional and ethical issues of physical therapists (PTs) and physical therapist assistants (PTAs) in providing facility-based post-acute care in residential settings (skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals) during the COVID-19 pandemic.

METHODS

A qualitative descriptive research design was used to explore professional and ethical issues during the COVID-19 pandemic. PTs and PTAs described their experiences during semi-structured interviews conducted virtually. Interview data was analyzed with reflexive thematic analysis.

RESULTS

Thematic analysis produced 4 themes: facility-wide battle against infection and death, doing the best you can to provide care amidst COVID-19 constraints, promoting ethical good and doing the right thing, and a dark intense time.

CONCLUSIONS

Professional and ethical constraints on providing care faced by PTs and PTAs during the COVID-19 pandemic can inform current and future clinical practice. Although some of the challenges faced by PTs and PTAs were unique to COVID-19, many problems represent preexisting systemic and organizational issues that were exacerbated by the pandemic.

Accountable Care Organization Attribution and Post-Acute Skilled Nursing Facility Outcomes for People Living With Dementia

OBJECTIVES

Under the Accountable Care Organization (ACO) model, reductions in healthcare spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. We examined SNF length of stay (LOS) and outcomes among ACO-attributed and non-ACO-attributed ADRD patients.

DESIGN

Observational serial cross-sectional study.

SETTING AND PARTICIPANTS

Twenty percent national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676).

METHODS

Our primary covariate of interest was ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for 3 time periods (<30, 31-90, and 91-180 days) following hospital discharge. We used 2-stage least squares regression to predict LOS as a function of ACO attribution, and patient and facility characteristics.

RESULTS

ACO-attributed ADRD patients have shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post-hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). No significant association was found between LOS and readmission, with small effects on mortality favoring ACOs in fully adjusted models.

CONCLUSIONS AND IMPLICATIONS

Being an ACO-attributed patient is associated with shorter SNF LOS but is not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.

The Role of Individual-Level Socioeconomic Status on Nursing Home Placement Accounting for Neighborhood Characteristics

OBJECTIVE

Independent living is desirable for many older adults. Although several factors such as physical and cognitive functions are important predictors for nursing home placement (NHP), it is also reported that socioeconomic status (SES) affects the risk of NHP. In this study, we aimed to examine whether an individual-level measure of SES is associated with the risk of NHP after accounting for neighborhood characteristics.

DESIGN

A population-based study (Olmsted County, Minnesota, USA).

SETTING AND PARTICIPANTS

Older adults (age 65+ years) with no prior history of NHP.

METHODS

Electronic health records (EHR) were used to identify individuals with any NHP between April 1, 2012 (baseline date) and April 30, 2019. Association between the (HOUsing-based index of SocioEconomic Status (HOUSES) index, an individual-level SES measure based on housing characteristics of current residence, and risk of NHP was tested using random effects Cox proportional hazard model adjusting for area deprivation index (ADI), an aggregated SES measure that captures neighborhood characteristics, and other pertinent confounders such as age and chronic disease burden.

RESULTS

Among 15,031 older adults, 3341 (22.2%) experienced NHP during follow-up period (median: 7.1 years). At baseline date, median age was 73 years old with 55% female persons, 91% non-Hispanic Whites, and median number of chronic conditions of 4. Accounting for pertinent confounders, the HOUSES index was strongly associated with risk of NHP (hazard ratio 1.89; 95% confidence interval 1.66‒2.15 for comparing the lowest vs highest quartiles), which was not influenced by further accounting for ADI.

CONCLUSIONS AND IMPLICATIONS

This study demonstrates that an individual-level SES measure capturing current individual-specific socioeconomic circumstances plays a significant role for predicting NHP independent of neighborhood characteristics where they reside. This study suggests that older adults who are at higher risk of NHP can be identified by utilizing the HOUSES index and potential individual-level intervention strategies can be applied to reduce the risk for those with higher risk.

The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review

Background

Older adults with cognitive impairment are frequently hospitalized and discharged to facility-based transitional care programs (TCPs). However, it is unknown whether TCPs are effective in improving their functional status and promoting discharge home rather than to long-term care. The aims of this systematic review were to examine the effectiveness of facility-based TCPs on functional status, patient and health services outcomes for older adults (≥ 65 years) with cognitive impairment and to determine what proportion post TCP are discharged home compared to long-term care.

Methods

The Joanna Briggs Institute Critical Appraisal Manual for Evidence Synthesis was used to guide the methodology for this review. The protocol was published in PROSPERO (registration number CRD42021257870). MEDLINE, CINAHL, PsycINFO, the Cochrane Library, and EMBASE databases, and ClinicalTrials.gov and the World Health Organization Trials Registry were searched for English publications. Studies that met the following criteria were included: community-dwelling older adults ≥ 65 years who participated in facility-based TCPs and included functional status and/or discharge destination outcomes. Studies with participants from nursing homes and involved rehabilitation programs or transitional care in the home or in acute care, were excluded. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Results are in narrative form.

Results

Twenty-two studies (18 cohort and four cross sectional studies) involving 4,013,935 participants met inclusion criteria. The quality of the studies was mostly moderate to good. Improvement in activities of daily living (ADLs) was reported in eight of 13 studies. Between 24.4%-68% of participants were discharged home, 20–43.9% were hospitalized, and 4.1–40% transitioned to long-term care. Review limitations included the inability to perform meta-analysis due to heterogeneity of outcome measurement tools, measurement times, and patient populations.

Conclusions

Facility-based TCPs are associated with improvements in ADLs and generally result in a greater percentage of participants with cognitive impairment going home rather than to long-term care. However, gains in function were not as great as for those without cognitive impairment. Future research should employ consistent outcome measurement tools to facilitate meta-analyses. The level of evidence is level III-2 according to the National Health and Medical Research Council for cohort and cross-sectional studies.

Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study

OBJECTIVES

The purpose of the study was to describe unique care needs of people with dementia (PWD) and their caregivers during transitions from skilled nursing facilities (SNF) to home.

DESIGN

A qualitative study using focus groups, semistructured interviews, and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

The study was set in one state, in 4 SNFs where staff had experience using a standardized transitional care protocol. The sample included 22 SNF staff, 4 home health nurses, 10 older adults with dementia, and their 10 family caregivers of whom 39 participated in focus groups and/or interviews.

METHODS

Data collection included 4 focus groups with SNF staff and semistructured interviews with home health nurses, SNF staff, PWD, and their family caregivers. Standardized focus group and interview guides were used to elicit participant perceptions of transitional care. We used the framework analytic approach to qualitative analysis. A steering committee participated in interpretation of findings.

RESULTS

Participants described 4 unique care needs: (1) PWD and caregivers may not be ready to fully engage in dementia care planning while in the SNF, (2) caregivers are not prepared to manage dementia symptoms at home, (3) SNF staff have difficulty connecting PWD and caregivers to community supports, and (4) caregivers receive little support to address their own needs.

CONCLUSIONS AND IMPLICATIONS

Based on findings, recommendations are offered for adapting transitional care to address the needs of PWD and their caregivers. Further research is needed (1) to confirm these findings in larger, more diverse samples and (2) to adapt and test interventions to support successful community discharge of PWD and their caregivers.

Successful Discharge of Short Stay Veterans from VA Community Living Centers

The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.