Post‐acute care transitions and outcomes among medicare beneficiaries in assisted living communities

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

OBJECTIVE

To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services.

DESIGN

Nested case-control study.

SETTING AND PARTICIPANTS

Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December 31, 2019. New residents of assisted living were matched on age, sex, and initiation date of home care ( ± 7 days) to community-dwelling home care recipients in a 1:4 ratio.

METHODS

Clinical and functional status, health service use, sociodemographic variables, and community-level characteristics were examined; conditional logistic regression was used to model associations with a transition to an assisted living facility.

RESULTS

There were 2427 new residents of assisted living who were matched to 9708 home care recipients (mean [SD] age 85.5 [6.02] years, 72% female). Most of the new residents were concentrated in urban communities and communities with higher income quintiles. New residents had an increased rate of physician-diagnosed dementia (adjusted hazard ratio [aHR], 1.28; 95% CI, 1.14-1.43), mood disorders (aHR, 1.17; 95% CI, 1.05-1.29), and cardiac arrhythmias (aHR, 1.19; 95% CI, 1.07-1.32). They also had higher rates of mild cognitive impairment (aHR, 1.43; 95% CI, 1.24-1.66), 2 or more falls (aHR, 1.29; 95% CI, 1.11-1.51), participation in activities of long-standing interest in the past 7 days (aHR, 1.29; 95% CI, 1.11-1.50), and a lower rate of a spouse or partner unpaid caregiver vs a child (aHR, 0.66; 95% CI, 0.56-0.79).

CONCLUSIONS AND IMPLICATIONS

New residents of assisted living were mostly women, were cognitively impaired, had clinical comorbidities that could increase their risk of injuries, and had caregivers who were their children. These findings stress the importance of upscaling memory and dementia care in assisted living to address the needs of this population.

Assisted living residents with dementia: Disparities in mental health services pre and during COVID-19

BACKGROUND

Little is known about mental health among Medicare beneficiaries with Alzheimer's disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL residents with ADRD, pre and during the COVID pandemic, focusing on race/ethnicity and Medicare/Medicaid dual status.

METHODS

A CY2018 cohort of AL residents with ADRD was identified. Outcome was any quarterly in-person or telemedicine mental health visit based on national CY2019-2020 Medicare claims. Key independent variables were individual race/ethnicity and dual status and the AL-level proportion of dual residents. We estimated a linear probability model with random effects and robust standard errors. Quarterly indicators captured service use before and after the onset of the pandemic.

RESULTS

The study included 102,758 fee-for-service Medicare beneficiaries with ADRD in 13,400 ALs. One in five residents had any mental health visits prior to the COVID-19 pandemic. Black residents, and those with dual Medicare/Medicaid eligibility, were significantly less likely to use mental health services prior to and during the pandemic. There were no significant differences in visits via telemedicine by race/ethnicity or individual dual status. Residents in AL communities with a higher proportion of duals had a lower likelihood of visits before and during the pandemic.

CONCLUSIONS/IMPLICATIONS

Mental health service use among AL residents with ADRD was low and declining prior to the pandemic. Telehealth allowed for mental health visits to continue during the pandemic, albeit at a lower level. Residents in ALs with a higher proportion of duals were less likely to have in-person or telehealth visits. The results suggest that some ALs may find it difficult to assure mental health service provision to this vulnerable population.

Minimal Clinically Important Difference (MCID) in the Functional Status Measures in Patients with Stroke: Inverse Probability Treatment Weighting

This study proposed to evaluate the temporal trend, define the minimal clinically important difference (MCID) for five functional status measures, and identify risk factors for reaching deterioration in the MCID. This prospective cohort study analyzed 680 patients with ischemic stroke and 151 patients with hemorrhagic stroke at six hospitals between April 2015 and October 2021. All patients completed the functional status measures before rehabilitation (baseline), and at the 12th week and 2nd year after rehabilitation. Patients in the post-acute care (PAC) group exhibited significantly larger improvements for the functional status measures compared to those in the non-PAC group (p < 0.05). Patients with hemorrhagic stroke also displayed larger improvements in the functional status measures when compared to patients with ischemic stroke. Furthermore, the improvement in MCID ranged from 0.01 to 16.18 points when comparing baseline and the 12th week after rehabilitation, but the deterioration in MCID ranged from 0.38 to 16.12 points. Simultaneously, assessing the baseline and the second year after rehabilitation, the improvement in MCID ranged from 0.01 to 18.43 points, but the deterioration in MCID ranged from 0.68 to 17.26 points. Additionally, the PAC program, age, education level, body mass index, smoking, readmission within 30 days, baseline functional status score, use of Foley catheter and nasogastric tube, as well as a history of previous stroke are significantly associated with achieving deterioration in MCID (p < 0.05). These findings suggest that if the mean change scores of the functional status measures have reached the thresholds, the change scores can be perceived by patients as clinically important.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

OBJECTIVE

We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662).

METHODS

We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics.

RESULTS

End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death.

CONCLUSIONS AND IMPLICATIONS

There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

OBJECTIVES

Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018.

DESIGN

We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data Set (MDS).

SETTING AND PARTICIPANTS

A total of 412,723 Medicare beneficiaries who lived in ZIP+4 codes associated with an AL were identified as residents. Approximately 28% of the 16,682 ALs in which these beneficiaries resided were smaller communities (<25 beds).

METHODS

For each AL, we identified ZIP+4 codes associated with its address. Using this ZIP+4 file, we searched through the Medicare EDB to identify beneficiaries who lived in each ZIP+4 code. The MBSF and MDS were used to exclude beneficiaries who died before 2018 and those whose AL and nursing home stays overlapped. We identified 3 cohorts of Medicare beneficiaries: (1) residents of a specific AL (one AL address per ZIP+4), (2) most likely AL residents, and (3) not likely AL residents. Comparisons across these cohorts were used to examine construct validity of our approach. Additional comparisons were made to AL residents based on the National Survey of Long-Term Care Providers (NSLTCP) and to fee-for-service (FFS) Medicare community-dwelling and long-stay nursing home residents.

RESULTS

The cohorts of beneficiaries identified as AL residents exhibited good construct validity. AL residents also showed similarity in demographic characteristics to the 2018 sample from the NSLTCP, and as expected were different from FFS community and nursing home beneficiaries.

CONCLUSION AND IMPLICATIONS

We developed a methodology for identifying Medicare beneficiaries who reside in ALs. As this residential setting continues to grow, future studies will need effective approaches for identifying AL residents in order to evaluate the quality of care they receive.

Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status

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.

The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

Background

The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood.

Objectives

Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic.

Research design

Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020.

Subjects

Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses.

Measures

Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset.

Results

During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (-3.9%, CI [-5.2%, -2.7%]) or to home (-2.8% CI [-4.4%, -1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics.

Conclusions

Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.