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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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Sahni NR, Marine C, Cutler DM, Medford-Davis LN, Mezue M, Kattan O, Levine E, Joynt Maddox KE. Potential US Health Care Savings Based on Clinician Views of Feasible Site-of-Care Shifts. JAMA Netw Open 2024; 7:e2426857. [PMID: 39141386 PMCID: PMC11325203 DOI: 10.1001/jamanetworkopen.2024.26857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
Importance Shifting care to alternative sites when clinically appropriate may be associated with reduced US health care spending, improved access, and, in some cases, improved care outcomes. Objective To fill 2 main gaps in the current literature on site-of-care shifts: (1) understanding the clinician perspective on appropriateness of alternative care sites, given the central role they play in referrals and patient trust and (2) considering all potential sites where care could shift and calculating net savings potential. Design, Setting, and Participants In this survey study, physicians (MDs and DOs), nurse practitioners, physician assistants, nurse anesthetists, radiology and imaging technicians, and psychologists were surveyed from September 17 to November 22, 2021, about potential shifts of care from the hospital setting to alternative sites. Participants were selected by the survey firm Intellisurvey to provide broad representation across all specialties of interest. A minimum of 34 clinicians responded to each question. Data were analyzed from April 2022 through October 2023. Exposure More than 5000 individual diagnostic and procedural codes were reviewed and sorted into 312 distinct care activities by an expert panel of physicians. Survey respondents were then provided with the 2019 claims-based distribution across sites of care for each care activity and were asked, "based on your clinical judgment, what portion of [care activity] could safely occur in each of the following sites of care, without compromising clinical outcomes?" Main Outcomes and Measures Based on clinician-reported distributions, the total potential shift of volume from hospital-based settings to alternative sites and the associated net savings were estimated. Results Survey respondents included 1069 practicing clinicians (386 female [36.1%]; mean [SD] years since residency of physicians, 21.0 [9.7] years; mean [SD] age of nonphysicians, 45.3 [9.4] years) across specialties, all of whom practiced more than 20 clinical hours per week. There were 794 physicians (74.3%), and the remaining 275 respondents were midlevel professionals, such as physician assistants. Among 312 care activities surveyed, respondents indicated that 10.3 percentage points (95% CI, 10.0-10.5 percentage points) of commercial and 10.9 percentage points (95% CI, 10.7-11.1 percentage points) of Medicare volume currently taking place in hospital-based settings could shift to alternative sites with today's technology without compromising clinical outcomes. Across the entire US health care system, these shifts could be associated with a reduction in overall health care consumption spending ($3 562 339 000 000 000) by approximately $113.8 billion ($113 767 446 087 174 [3.2%]) to $147.7 billion ($147 661 672 284 263 [4.1%]) annually. Conclusions and relevance In this study, a substantial net savings opportunity was estimated. However, realizing this potential will require ongoing alignment among organizations, clinicians, and policymakers to overcome barriers to these shifts.
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Affiliation(s)
- Nikhil R Sahni
- Department of Economics, Harvard University, Cambridge, Massachusetts
- Center for US Healthcare Improvement, McKinsey and Company, Boston, Massachusetts
| | - Crosbie Marine
- Center for US Healthcare Improvement, McKinsey and Company, Boston, Massachusetts
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Melvin Mezue
- Center for US Healthcare Improvement, McKinsey and Company, Boston, Massachusetts
| | - Omar Kattan
- Center for US Healthcare Improvement, McKinsey and Company, Boston, Massachusetts
| | - Ed Levine
- Center for US Healthcare Improvement, McKinsey and Company, Boston, Massachusetts
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Center for Advancing Health Services, Policy and Economics Research, Institute for Public Health, Washington University, St Louis, Missouri
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Huan T, Intrator O, Simning A, Boockvar K, Grabowski DC, Cai S. Mental Health Treatment Among Nursing Home Residents With Alzheimer's Disease and Related Dementias. J Am Med Dir Assoc 2024; 25:105088. [PMID: 38885931 DOI: 10.1016/j.jamda.2024.105088] [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: 02/15/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To examine the prevalence of mental health treatment among nursing home (NH) long-stay residents with Alzheimer's disease and related dementias (ADRD) and explore factors associated with utilization. DESIGN Retrospective cohort study. Minimum Data Set data (April 2017-September 2018), Medicare Master Beneficiary Summary File, Part B Carrier file and Part D prescription file were used to identify mental illness and ADRD diagnoses, patient characteristics, and mental health treatment. SETTING AND PARTICIPANTS All US Medicare- or Medicaid-certified NHs. Fee-for-service Medicare beneficiaries aged 65 and older who had a quarterly or annual Minimum Data Set assessment with ADRD and were enrolled in Medicare Parts B and D. Two cohorts: residents with both ADRD and psychiatric disorders; residents with ADRD only. METHODS Primary outcomes: receipt of (1) any mental health treatment (medication or psychotherapy); (2) any psychotherapy in a calendar quarter. SECONDARY OUTCOMES antipsychotics, antidepressants, hypnotics, antiepileptics, short-session ( ≤ 30 minutes), long-session ( ≥ 45 minutes), and family/group psychotherapy. Covariates included predisposing, enabling characteristics, and needs factors. Generalized Estimating Equation models of quarterly data, nested within patients, were estimated for each outcome among each cohort. RESULTS Analyses included 1,913,945 resident-quarter observations from 503,077 unique NH long-stay residents. Overall, 68.5% of NH long-stay residents with ADRD have psychiatric disorders; of these, 85% received mental health treatment. African American or Hispanic residents were less likely to use antidepressants. African American residents or residents living in rural locations were less likely to receive long-session psychotherapy. Hispanic residents were more likely to receive long-session psychotherapy. Residents in minority groups were more likely to receive group/family psychotherapy. CONCLUSIONS AND IMPLICATIONS Most of NH long-stay residents with ADRD had psychiatric disorders and most of them received treatment. Antidepressants or long-session psychotherapy were less likely to be provided to African American residents. Factors that determine the efficacy of mental health treatment and reasons for the racial disparities require further exploration.
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Affiliation(s)
- Tianwen Huan
- Department of Public Health Sciences, University of Rochester, Rochester, NY, USA; Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester, Rochester, NY, USA; Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Adam Simning
- Department of Public Health Sciences, University of Rochester, Rochester, NY, USA; Department of Psychiatry, University of Rochester, Rochester, NY, USA
| | - Kenneth Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, AL, USA; Geriatrics Research, Education, and Clinical Center, Birmingham VA Health Care System, Birmingham, AL, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester, Rochester, NY, USA; Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA
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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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Jung D, Song S, Ma C. Where Patients Live Matter in Emergency Department Visits in Home Health Care: Rural/Urban Status and Neighborhood Socioeconomic Status. J Appl Gerontol 2024; 43:933-944. [PMID: 37991851 DOI: 10.1177/07334648231216644] [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] [Indexed: 11/24/2023] Open
Abstract
An increasing body of evidence highlights the importance of an individual's place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural-urban disparities and improving home health care.
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Affiliation(s)
- Daniel Jung
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Suhang Song
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Chenjuan Ma
- Rory Meyers College of Nursing, New York University, New York, NY, USA
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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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Thompson MP, Hou H, Likosky DS, Pagani FD, Falvey J, Bowles KH, Wadhera RK, Sterling MR. Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2024; 17:e010459. [PMID: 38770653 PMCID: PMC11251853 DOI: 10.1161/circoutcomes.123.010459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting. METHODS Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers. RESULTS A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge. CONCLUSIONS A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.
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Affiliation(s)
- Michael P. Thompson
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Hechuan Hou
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kathryn H. Bowles
- University of Pennsylvania School of Nursing, Philadelphia, PA
- VNS Health, New York, NY
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Jones T, Luth EA, Cleland CM, Brody AA. Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults. J Am Med Dir Assoc 2024; 25:104983. [PMID: 38604244 PMCID: PMC11139601 DOI: 10.1016/j.jamda.2024.03.003] [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: 11/20/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVES Medicare Home Health Care (HHC) services are integral to the care of homebound seriously ill older adults requiring ongoing specialized medical care. Although disparities in health outcomes are well documented in inpatient and primary care, disparities experienced by historically marginalized racial and ethnic groups underrepresented in HHC are understudied. This study aimed to examine the relationship between individual characteristics and differences in HHC health outcomes for seriously ill older adults. DESIGN Secondary data analysis, repeated measure. SETTING AND PARTICIPANTS Seriously ill older adults who received HHC in 2016 in the HHC Outcome and Assessment Information Set (OASIS). METHODS Start of care and discharge data from the 2016 HCC OASIS were used to examine the relationship between individual characteristics and differences in HHC health outcomes identified by the Centers for Medicare and Medicaid Services as key indicators of quality in HHC, including dyspnea, pain frequency, cognitive functioning, and presence of unhealed pressure ulcer stage II or higher. A generalized ordered logit model with partial proportional odds was used for the ordinal categorical outcomes and a logistic regression was used for the binary dependent variable. RESULTS Findings indicated that of 227,402 seriously ill individuals with an HHC episode in 2016, those from underrepresented racial and ethnic groups had between 14% and 57% higher odds of worse health outcomes compared with non-Hispanic white patients with the exception of pain frequency. CONCLUSIONS AND IMPLICATIONS For people living with serious illness, there are significant differences in Medicare HHC health outcomes when comparing underrepresented racial or ethnic beneficiaries with white counterparts. More research is needed to understand how health care processes such as referral patterns or time to care initiation, and structural factors such as HHC agency quality and neighborhood social deprivation are related to health differences observed in the population.
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Affiliation(s)
- Tessa Jones
- Division of General Internal Medicine and the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Elizabeth A Luth
- Institute for Health, Health Care Policy, and Aging Research, Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, Rutgers University, Rutgers, NJ, USA
| | - Charles M Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Abraham A Brody
- HIGN, New York University Rory Meyers College of Nursing, and Division of Geriatric Medicine and Palliative Care, New York University Grossman School of Medicine, New York, NY, USA
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Goyal A, Taylor S. Health equity and Hospital at Home programs. J Hosp Med 2024; 19:435-439. [PMID: 38488219 DOI: 10.1002/jhm.13326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Anupama Goyal
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephanie Taylor
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Chen AC, Fu CX, Grabowski DC. Claims-Based vs Agency-Reported Patient Outcomes Among Home Health Agencies, 2013-2019. JAMA Netw Open 2024; 7:e245692. [PMID: 38598240 PMCID: PMC11007578 DOI: 10.1001/jamanetworkopen.2024.5692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/11/2024] [Indexed: 04/11/2024] Open
Abstract
Importance Given the growth of home health agency (HHA) care, it is important to understand whether quality reporting programs, such as star ratings, are associated with improved patient outcomes. Objective To assess the immediate and long-term association of the introduction of HHA star ratings with patient-level quality outcomes, comparing claims-based and agency-reported measures. Design, Setting, and Participants This cross-sectional study used Medicare HHA claims and agency-reported assessments to identify sequential patient episodes (ie, spells) among US adults with traditional Medicare who received HHA care (2013-2019). An interrupted time series (ITS) model was used to measure changes in trends and levels before and after the introduction of star ratings. Statistical analysis was performed from November 2022 to September 2023. Exposure The exposure was the introduction of HHA star ratings. The postexposure period was set as starting January 1, 2016, to account for the period when both star ratings (quality of patient care and patient satisfaction rating) were publicly reported. Main Outcomes and Measures The main outcomes included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge) and agency-reported functional measures, such as improvement in ambulation, bathing, and bed transferring. There was also a measure to capture timely initiation of care among post-acute care HHA users, defined as HHA care initiated within 2 days of inpatient discharge. Results This study identified 22 958 847 patient spells to compare annual changes over time; 9 750 689 patient spells were included during the pre-star ratings period from January 1, 2013, to December 31, 2015 (6 067 113 [62.2%] female; 1 100 145 [11.3%] Black, 512 487 [5.3%] Hispanic, 7 845 197 [80.5%] White; 2 656 124 [27.2%] dual eligible; mean [SD] patient spell duration, 70.9 [124.9] days; mean [SD] age, 77.4 [12.0] years); 13 208 158 patient spells were included during the post-star ratings period from January 1, 2016, to December 31, 2019 (8 104 69 [61.4%] female; 1 385 180 [10.5%] Black, 675 536 [5.1%] Hispanic, 10 664 239 [80.7%] White; 3 318 113 [25.1%] dual eligible; mean [SD] patient spell duration, 65.3 [96.2] days; mean [SD] age, 77.7 [11.6] years). Results from the ITS models found that the introduction of star ratings was associated with an acceleration in the mean [SE] hospitalization rate during the spell (0.39% [0.05%] per year) alongside functional improvements in ambulation (2.40% [0.29%] per year), bed transferring (3.95% [0.48%] per year) and bathing (2.34% [0.19%] per year) (P < .001). This occurred alongside a 1.21% (0.12%) per year reduction in timely initiation of care (P < .001). Conclusions and Relevance This cross-sectional study found an observed improvement in agency-reported functional measures, which contrasted with slower increases in more objective measures such as hospitalization rates and declines in timely initiation of care. These findings suggest a complex picture of HHA quality of care after the introduction of star ratings.
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Affiliation(s)
- Amanda C. Chen
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Harvard Graduate School of Arts and Sciences, Boston, Massachusetts
| | - Christina Xiang Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Fashaw‐Walters SA, Rahman M, Jarrín OF, Gee G, Mor V, Nkimbeng M, Thomas KS. Getting to the root: Examining within and between home health agency inequities in functional improvement. Health Serv Res 2024; 59:e14194. [PMID: 37356822 PMCID: PMC10915486 DOI: 10.1111/1475-6773.14194] [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] [Indexed: 06/27/2023] Open
Abstract
OBJECTIVE To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). DATA SOURCES 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. DATA COLLECTION/EXTRACTION METHODS Not Applicable. STUDY DESIGN We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. PRINCIPAL FINDINGS Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. CONCLUSIONS Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.
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Affiliation(s)
- Shekinah A. Fashaw‐Walters
- Division of Health Policy and Management, School of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Momotazur Rahman
- Center for Gerontology and Healthcare Research, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
| | - Olga F. Jarrín
- Division of Nursing Science, School of Nursing, RutgersThe State University of New JerseyNew BrunswickNew HampshireUSA
| | - Gilbert Gee
- Department of Community Health Sciences, Fielding School of Public HealthUniversity of California at Los AngelesLos AngelesCaliforniaUSA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Center of Innovation in Long‐Term Services and SupportsU.S. Department of Veterans Affairs Medical CenterProvidenceRhode IslandUSA
| | - Manka Nkimbeng
- Division of Health Policy and Management, School of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Center of Innovation in Long‐Term Services and SupportsU.S. Department of Veterans Affairs Medical CenterProvidenceRhode IslandUSA
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Hinton L, Tran D, Peak K, Meyer OL, Quiñones AR. Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review. Alzheimers Dement 2024; 20:3000-3020. [PMID: 38265164 PMCID: PMC11032576 DOI: 10.1002/alz.13612] [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: 03/28/2023] [Revised: 08/25/2023] [Accepted: 11/25/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers. METHODS We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings. RESULTS Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life. DISCUSSION Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.
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Affiliation(s)
- Ladson Hinton
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Duyen Tran
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Kate Peak
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
| | - Oanh L. Meyer
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Ana R. Quiñones
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
- OHSU‐PSU School of Public HealthOregon Health & Science UniversityPortlandOregonUSA
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13
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Osakwe ZT, Calixte R, Peterson ML, Young SG, Ikhapoh I, Pierre K, McIntosh JT, Senteio C, Girardin JL. Association of Hospice Agency Location and Neighborhood Socioeconomic Disadvantage in the U.S. Am J Hosp Palliat Care 2024; 41:309-317. [PMID: 37644697 DOI: 10.1177/10499091231195319] [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] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Despite the growing increase in the utilization of hospice in the U.S, disparities exist in the utilization of hospice. Accumulating evidence has shown that neighborhood characteristics have an impact on availability of hospice agencies. OBJECTIVE To assess the association between neighborhood social vulnerability and hospice agency availability. METHODS Using the Medicare Post-Acute Care and Hospice Provider Utilization and Payment Public Use Files (PAC PUF) for 2019. Hospice agency addresses were geocoded to the census tract level. Multivariable Poisson regression models were used to assess the association between socioeconomic status SVI theme and hospice agency availability adjusting for number of home health agencies, primary care health profession shortage, per cent Black, and Percent Hispanic at the census tract level and rurality. RESULTS The socioeconomic status SVI subtheme was associated with decreased likelihood of hospice agency availability (adjusted IRR (aIRR), .56; 95% CI, .50- .63; P < .001). Predominantly Black, and predominantly Hispanic neighborhoods had lower rates of hospice agency availability (aIRR, .48; 95% CI, .39-.59; P < .001 and aIRR, .29; 95% CI, .24-.36; P < .001), respectively. CONCLUSION Neighborhood socioeconomic disadvantage was associated with lower availability of hospice agencies. Policies aimed at increasing access to hospice should be cognizant of neighborhood socioeconomic disadvantage.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Rose Calixte
- Department of Epidemiology and Biostatistics, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mandi-Leigh Peterson
- North Dakota Healthcare Workforce Group, University of North Dakota, Grand Forks, ND, USA
| | - Sean G Young
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
| | - Izuagie Ikhapoh
- School of Engineering and Applies Sciences, University of Buffalo, Buffalo, NY, USA
| | - Kaydeen Pierre
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Jennifer T McIntosh
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
- Yale University School of Nursing, Orange, CT, USA
| | - Charles Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - Jean-Louis Girardin
- Department of Psychiatry and Neurology at the Miller School of Medicine, University of Miami, Miami, FL, USA
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14
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Bigger SE, Hemphill JC, Njoroge T, Doyon K, Glenn L. Black Americans, hospitalization, and advance care planning: Structural vulnerability in Home Health Value-Based Purchasing. Am J Hosp Palliat Care 2024; 41:140-149. [PMID: 37192103 DOI: 10.1177/10499091231176281] [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] [Indexed: 05/18/2023] Open
Abstract
Skilled home health (HH) is the largest long-term care setting and the fastest-growing site of healthcare in the United States (U.S.). Home Health Value-Based Purchasing (HHVBP) is a structure of Medicare that penalizes U.S. HH agencies for high hospitalization rates. Prior studies have shown inconsistent evidence about associations of race with hospitalization rates in HH. Evidence supports that Black or African Americans are less likely to participate in advance care planning (ACP), or to complete written advance directives, which could affect their potential for hospitalization when nearing end of life. In this quasi-experimental study, we used Medicare administrative datasets, the Weighted Acute Care Services Use Rates (WACSUR) score, and the Advance Care Planning Protocol (ACPP) score to determine whether the proportion of Black HH patients in the U.S. was correlated with acute care use rates and the robustness of agency protocols on ACP. We used primary and secondary data from the U.S. from 2016-2020. We included Medicare-certified HH agencies. Spearman's correlation coefficient was used. We found a statistical trend showing that the greater proportion of Black patients enrolled in a HH agency, the greater tendency to have a high hospitalization rate. Our findings suggest that HHVBP may encourage patient selection and exacerbate health disparities. Our findings support recommendations for alternative measures of quality in HH to include measures of goal-concordant care coordination when patients are denied admission to HH.
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FABIUS CHANEED, OKOYE SAFIYYAHM, WU MINGCHEMJ, JOPSON ANDREWD, CHYR LINDAC, BURGDORF JULIAG, BALLREICH JEROMIE, SCERPELLA DANNY, WOLFF JENNIFERL. The Role of Place in Person- and Family-Oriented Long-Term Services and Supports. Milbank Q 2023; 101:1076-1138. [PMID: 37503792 PMCID: PMC10726875 DOI: 10.1111/1468-0009.12664] [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: 12/22/2022] [Revised: 06/13/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions. CONTEXT Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them. METHODS We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status. FINDINGS We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations. CONCLUSIONS We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.
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16
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Lin SC, Hammond G, Esposito M, Majewski C, Foraker RE, Joynt Maddox KE. Segregated Patterns of Hospital Care Delivery and Health Outcomes. JAMA HEALTH FORUM 2023; 4:e234172. [PMID: 37991783 PMCID: PMC10665978 DOI: 10.1001/jamahealthforum.2023.4172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/29/2023] [Indexed: 11/23/2023] Open
Abstract
Importance Residential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care. Objective To characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes. Design, Setting, and Participants This cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023. Exposures Dissimilarity index and isolation index for HRRs. Main Outcomes and Measures Health outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes. Results This study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients. Conclusions and Relevance This cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.
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Affiliation(s)
- Sunny C. Lin
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Gmerice Hammond
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
| | | | - Cassandra Majewski
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Randi E. Foraker
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | - Karen E. Joynt Maddox
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
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Karmarkar AM, Roy I, Lane T, Shaibi S, Baldwin JA, Kumar A. Home health services for minorities in urban and rural areas with Alzheimer's and related dementia. Home Health Care Serv Q 2023; 42:265-281. [PMID: 37128943 DOI: 10.1080/01621424.2023.2206368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.
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Affiliation(s)
- Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
- Research Department, Sheltering Arms Institute, Richmond, Virginia, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Taylor Lane
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Stefany Shaibi
- Physical Therapy Department, Creighton University, Phoenix, Arizona, USA
| | - Julie A Baldwin
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Amit Kumar
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
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18
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Fashaw-Walters SA, McGuire CM. Proposing A Racism-Conscious Approach To Policy Making And Health Care Practices. Health Aff (Millwood) 2023; 42:1351-1358. [PMID: 37782862 DOI: 10.1377/hlthaff.2023.00482] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Racial and ethnic health inequities are driven by multiple social and political factors. Race-neutral policies that overlook the role of racism in policy and in disparities may also contribute to inequities. In response, one broad policy-making approach has been to craft race-based policies that attempt to improve outcomes explicitly for specific racial groups. However, race-based policies can be politically infeasible. We propose a racism-conscious approach to policy making and health care practices that addresses racism and advances health equity. Using postacute and long-term care policies as a backdrop, we identify five key steps to creating racism-conscious policies that rest on continuous community engagement and policy evaluation. The proposed racism-conscious framework can be used to develop a new health policy or to redesign an existing policy, and it can work for federal, state, local, and organizational policies, practices, or both.
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Jung D, Rajbhandari-Thapa J, Chen Z. Disparities in Successful Discharge to the Community Following Use of Medicare Home Health by Level of Neighborhood Socioeconomic Disadvantage. J Appl Gerontol 2023; 42:2119-2128. [PMID: 37104640 DOI: 10.1177/07334648231172677] [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] [Indexed: 04/29/2023] Open
Abstract
Considering the importance of social and structural support and resources in recovering health, where people reside could lead to differences in health outcome in Medicare home health care. We used the 2019 Outcome and Assessment Information Set and Area Deprivation Index to examine the association between neighborhood context and successful discharge to community among older Medicare home health care users. Based on the multivariable logistic regression (OR: 0.84; 95% CI, 0.83-0.85) and conditional logistic regression models stratified by home health agency (OR: 0.95; 95% CI, 0.94-0.95), patients living in the most disadvantaged neighborhoods were less likely to experience successful discharge to community than others. Furthermore, the predicted probability of successful discharge to community decreased as the percentage of patients from the most disadvantaged neighborhoods within a home health agency increased. Policymakers should consider using area-level interventions and supports to reduce disparities in Medicare home health care.
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Affiliation(s)
- Daniel Jung
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Janani Rajbhandari-Thapa
- Department of Health Policy and Management, College of Public Health, 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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Li J, Ha J, Hoffman G. Unaddressed functional difficulty and care support among White, Black, and Hispanic older adults in the last decade. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad041. [PMID: 38274860 PMCID: PMC10809881 DOI: 10.1093/haschl/qxad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Unaddressed functional difficulties contribute to disparities in healthy aging. While the Affordable Care Act (ACA) is believed to have reshaped long-term care, little is known how it has collectively altered the prevalence of older adults with functional difficulties and their use of family and formal care. This study uses nationally representative data from the Health and Retirement Study (2008 - 2018) to describe racial-ethnic differences in prevalence of community-dwelling older adults who had difficulty with, but lacked assistance for self-care, mobility, and household activities before and after the ACA. Individuals with functional difficulties accounted for about a third of Black and Hispanic, compared to one-fifth of White people. Prevalence of Black and Hispanic people with functional difficulties lacking corresponding care support was consistently 1.5 times higher than of White people. Racial-ethnic differences disappeared only for low-income households where unaddressed difficulties were uniformly high. While formal care quantity was similar, Black and Hispanic people with functional difficulties received nearly 50 percent more family care than White people. These gaps between White, Black, and Hispanic older adults were persistent over time. These findings suggest that racial-ethnic gaps in aging needs and supports remain despite major health care reforms in the past decade.
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Affiliation(s)
- Jun Li
- Department of Public Administration and International Affairs, Maxwell School of Citizenship & Public Affairs, Syracuse University
| | - Jinkyung Ha
- Institute of Health Policy and Innovation, University of Michigan
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21
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Karmarkar AM, Roy I, Rivera-Hernandez M, Shaibi S, Baldwin JA, Lane T, Kean J, Kumar A. Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD). Alzheimers Dement 2023; 19:4037-4045. [PMID: 37204409 PMCID: PMC10730234 DOI: 10.1002/alz.13139] [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: 12/07/2022] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD). METHODS Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge. RESULTS Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA. DISCUSSION Black patients are more likely to experience a delay in home health care initiation than White patients.
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Affiliation(s)
- Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
- Research Department, Sheltering Arms Institute, Richmond, Virginia, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Stefany Shaibi
- Physical Therapy Department, Creighton University, Phoenix, Arizona, USA
| | - Julie A Baldwin
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Taylor Lane
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Jacob Kean
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Amit Kumar
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
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Fong MC, Russell D, Gao O, Franzosa E. Contextual Forces Shaping Home-Based Health Care Services Between 2010 and 2020: Insights From the Social-Ecological Model and Organizational Theory. THE GERONTOLOGIST 2023; 63:1117-1128. [PMID: 35921664 PMCID: PMC9384634 DOI: 10.1093/geront/gnac113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 12/02/2022] Open
Abstract
Demands for home-based care have surged alongside population aging, preferences for aging in place, policy-driven reforms incentivizing lower hospital utilization, and public concerns around coronavirus disease 2019 transmissions in institutional care settings. However, at both macro and micro levels, sociopolitical, and infrastructural contexts are not aligned with the operational needs of home health care organizations, presenting obstacles to home health care equity. We integrate the social-ecological model and organizational theory to highlight contextual forces shaping the delivery of home-based care services between 2010 and 2020. Placing home-based health care organizations at the center of observation, we discuss patterns and trends of service delivery as systematic organizational behaviors reflecting the organizations' adaptations and responses to their surrounding forces. In this light, we consider the implications of provision and access to home care services for health equity, discuss topics that are understudied, and provide recommendations for home-based health care organizations to advance home health care equity. The article represents a synthesis of recent literature and our research and industry experiences.
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Affiliation(s)
- Mei-Chia Fong
- Business Intelligence and Analytics, VNS Health, New York, New York, USA
| | - David Russell
- Center for Home Care Policy & Research, VNS Health, New York, USA
- Department of Sociology, Appalachian State University, Boone, North Carolina, USA
| | - Oude Gao
- Business Intelligence and Analytics, VNS Health, New York, New York, USA
| | - Emily Franzosa
- Geriatric Research Education and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med 2023; 26:1100-1108. [PMID: 37010377 PMCID: PMC10440673 DOI: 10.1089/jpm.2023.0011] [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] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, 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
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Krista L. Harrison
- Global Brain Health Institute, 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
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer E. James
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra K. Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
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24
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Chen AC, Grabowski DC. Nursing Homes Underreport Antipsychotic Use but Overreport Diagnoses Qualifying for Appropriate Use. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad022. [PMID: 38322323 PMCID: PMC10846688 DOI: 10.1093/haschl/qxad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Antipsychotic drug use in U.S. nursing homes remains a priority concern, but less is understood about the characteristics associated with reporting. Using linked Medicare claims and Minimum Data Set (MDS) assessments for long-stay nursing home residents from January 2018 to December 2019, we assessed the consistency of antipsychotic drug reporting and diagnosis of conditions (schizophrenia, Tourette's syndrome, and Huntington's disease) which qualify as appropriate drug use across data sources by calculating reporting rates in facility-reported MDS and Medicare claims. The antipsychotic reporting outcome is conditional on claims reporting while the condition reporting outcomes are conditional on MDS reporting. We found underreporting (87% reporting rate) in facility-reported antipsychotic use relative to Medicare claims. In contrast, we found overreporting of the qualifying conditions with a number of facility-reported diagnoses unsupported by a corresponding claims diagnosis. Only 54.8% of schizophrenia, 46.5% of Tourette's syndrome, and 72.4% of Huntington's disease diagnoses reported in the MDS had a claims diagnosis. There was also variation in reporting odds for antipsychotic drug use by dual-eligibility status and race, with higher odds for dual-eligible and lower odds for Black residents These findings suggest CMS should continue investigating the source of reporting discrepancies in antipsychotic drug use and qualifying diagnoses.
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Affiliation(s)
| | - David C Grabowski
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health
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25
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FASHAW‐WALTERS SHEKINAHA, RAHMAN MOMOTAZUR, GEE GILBERT, MOR VINCENT, RIVERA‐HERNANDEZ MARICRUZ, FORD CERON, THOMAS KALIS. Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access. Milbank Q 2023; 101:527-559. [PMID: 36961089 PMCID: PMC10262386 DOI: 10.1111/1468-0009.12616] [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: 05/31/2022] [Revised: 11/14/2022] [Accepted: 01/03/2023] [Indexed: 03/25/2023] Open
Abstract
Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated. CONTEXT Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors. METHODS We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design. FINDINGS After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use. CONCLUSIONS Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.
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Affiliation(s)
| | - MOMOTAZUR RAHMAN
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
| | - GILBERT GEE
- Fielding School of Public HealthUniversity of California at Los Angeles
| | - VINCENT MOR
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
- US Department of Veterans Affairs Medical CenterCenter of Innovation in Long‐Term Services and Supports
| | - MARICRUZ RIVERA‐HERNANDEZ
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
| | - CERON FORD
- School of Public HealthUniversity of Minnesota
| | - KALI S. THOMAS
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
- US Department of Veterans Affairs Medical CenterCenter of Innovation in Long‐Term Services and Supports
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26
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Bankole AO, Girdwood T, Leeman J, Womack J, Toles M. Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study. Geriatr Nurs 2023; 51:293-302. [PMID: 37031581 PMCID: PMC10247499 DOI: 10.1016/j.gerinurse.2023.03.015] [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: 12/05/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/11/2023]
Abstract
Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home.
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Affiliation(s)
- Ayomide Okanlawon Bankole
- University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, Campus Box #7460, Chapel Hill, NC 27599-7460, USA.
| | | | - Jennifer Leeman
- University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, Campus Box #7460, Chapel Hill, NC 27599-7460, USA
| | - Jennifer Womack
- Appalachian State University, Beaver College of Health Sciences, Boone, NC, USA
| | - Mark Toles
- University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, Campus Box #7460, Chapel Hill, NC 27599-7460, USA
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27
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Fabius CD, Millar R, Geil E, Stockwell I, Diehl C, Johnston D, Gallo JJ, Wolff JL. The Role of Dementia and Residential Service Agency Characteristics in the Care Experiences of Maryland Medicaid Home and Community-Based Service Participants and Family and Unpaid Caregivers. J Appl Gerontol 2023; 42:627-638. [PMID: 36200297 PMCID: PMC9991935 DOI: 10.1177/07334648221128286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2022] Open
Abstract
In Maryland, residential service agencies deliver Medicaid Home and Community-Based Services (HCBS) to older adults with disabilities through direct care workers (e.g., personal care aides). Leveraging survey data from residential service agency administrators, linked to interRAI Home Care assessments for 1144 participants, we describe agency characteristics, and participant and family caregiver experiences by participant dementia status. Most (61.7%) participants experienced low social engagement, and roughly 10.0% experienced a hospitalization or emergency room visit within 90 days. Few (14.4%) participants were served by agencies requiring dementia-specific direct care worker training, and most were served by agencies offering supplemental services, or in which direct care workers helped with health information technology (81.2% and 72.8%, respectively). Few caregivers reported negative care experiences. Participants with dementia and those served by agencies with training and support more often reported negative care experiences. Findings lay the foundation for future longitudinal and embedded interventions within Medicaid HCBS.
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Affiliation(s)
- Chanee D Fabius
- 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Erick Geil
- 51575The Hilltop Institute, Baltimore, MD, USA
| | | | | | | | - Joseph J Gallo
- 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer L Wolff
- 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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28
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Albrecht JS, Kumar A, Falvey JR. Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries. JAMA Surg 2023; 158:350-358. [PMID: 36696119 PMCID: PMC9878433 DOI: 10.1001/jamasurg.2022.7081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023]
Abstract
Importance Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. Objective To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. Design, Setting, and Participants This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Exposures Black or White race. Main Outcomes and Measures Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Results Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). Conclusions and Relevance This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City
| | - Jason R. Falvey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
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29
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Osakwe ZT. Understanding the Questions of Race and Ethnicity during a Home Visit. Home Healthc Now 2023; 41:119. [PMID: 36867489 PMCID: PMC9993427 DOI: 10.1097/nhh.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Zainab Toteh Osakwe
- Zainab Toteh Osakwe, PhD, MSN, RN, NP is an Assistant Professor, College of Nursing and Public Health, Adelphi University, Garden City, New York, New York
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30
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Franzosa E, Wyte-Lake T, Tsui EK, Reckrey JM, Sterling MR. Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies. J Am Med Dir Assoc 2022; 23:1990-1996. [PMID: 36343702 PMCID: PMC9634621 DOI: 10.1016/j.jamda.2022.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Geriatric Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, USA,Address correspondence to Emily Franzosa DrPH, Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY
| | - Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Emma K. Tsui
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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31
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Jain S, Hauschildt K, Scheunemann LP. Social determinants of recovery. Curr Opin Crit Care 2022; 28:557-565. [PMID: 35993295 DOI: 10.1097/mcc.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy. RECENT FINDINGS Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery. SUMMARY Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.
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