A Model of Risk Reduction for Older Adults Vulnerable to Nursing Home Placement

Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries

Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.

Barriers to Aging in Place for Rural, Institutionalized Older Adults: A Qualitative Exploration

OBJECTIVES

Although the majority of older adults wish to "age in place" in their communities, rural contexts pose challenges to maintaining long-term independence. The purpose of this study was to develop an understanding of the experiences of rural older adults who live in Skilled Nursing Facilities (SNFs) and thus have not aged in place. By retrospectively analyzing their pre-institution care situation, we aim to generate foundational knowledge on the barriers to aging in place in rural settings.

METHODS

A series of individual and group interviews was conducted in SNFs across seven rural communities. A grounded, thematic analysis was used to interpret interview findings, and coding was informed by the socio-ecological model (SEM).

RESULTS

Participants were 32 adults with a mean age of 72 years (SD = 5.7 years) and an average SNF residence of 3.9 years. Two themes emerged as primary barriers to successful aging in place: (1) Caregiver-related support issues and (2) Present focus, or lack of advanced care-planning.

CONCLUSIONS

Findings suggest the importance of specifically supporting caregivers, to ease burden and allow for increased agency for rural older adults. A lack of access to caregiver supports and other services limits the ability of community-dwelling rural older adults to age in place or plan for the future.

CLINICAL IMPLICATIONS

Existing networks of rural community resources and innovative solutions should be leveraged to improve access to services for older adults and their informal caregivers.

Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia

OBJECTIVES

To examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time.

DESIGN

Retrospective cohort study based on secondary data analyses.

SETTING

New York State Medicare beneficiaries who were admitted to an SNF in 2014.

PARTICIPANTS

Total of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home.

MEASUREMENTS

We used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics.

RESULTS

Among SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD.

CONCLUSION

Newly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.

Patients discharged from higher-quality skilled nursing facilities spend more days at home

OBJECTIVE

To evaluate the association of skilled nursing facility (SNF) quality with days spent alive in nonmedical settings ("home time") after SNF discharge to the community.

DATA SOURCES

Secondary data are from Medicare claims for New York State (NYS) Medicare beneficiaries, the Area Health Resources File, and Nursing Home Compare.

STUDY DESIGN

We estimate home time in the 30- and 90-day periods following SNF discharge. Two-part zero-inflated negative binomial regression models characterize the association of SNF quality with home time.

DATA EXTRACTION METHODS

We use Medicare claims data to identify 25 357 NYS fee-for-service Medicare beneficiaries aged 65 years and older with an SNF admission for postacute care who were subsequently discharged to home in 2014.

PRINCIPAL FINDINGS

Following 30 and 90 days after SNF discharge, the average home time is 28.0 (SD = 6.1) and 81.6 (SD = 20.2) days, respectively. A number of patient- and SNF-level factors are associated with home time. In particular, within 30 and 90 days of discharge, respectively, patients discharged from 2- to 5-star SNFs spend 1.2-1.5 (P < .001) and 3.2-4.3 (P < .001) more days at home than those discharged from 1-star (lowest quality) SNFs.

CONCLUSIONS

Improved understanding of what is contributing to differences in home time could help guide efforts into optimizing post-SNF discharge outcomes.

Skilled Nursing Facility Patients Discharged to Home Health Agency Services Spend More Days at Home

OBJECTIVES

To investigate the association of the utilization of Medicare-certified home health agency (CHHA) services with post-acute skilled nursing facility (SNF) discharge outcomes that included home time, rehospitalization, SNF readmission, and mortality.

DESIGN

Retrospective cohort study.

SETTING

New York State fee-for-service Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care and discharged to the community in 2014.

PARTICIPANTS

A total of 25,357 older adults.

MEASUREMENTS

The outcomes included days spent alive in the community ("home time"), rehospitalization, SNF readmission, and mortality within 30- and 90-day post-SNF discharge periods. The primary independent variables were SNF five-star overall quality rating and receipt of CHHA services within 7 days of SNF discharge. Zero-inflated negative binomial regression and logistic regression models characterized the association of CHHA linkage with home time and other outcomes, respectively.

RESULTS

Following SNF discharge, 17,657 (69.6%) patients received CHHA services. In analyses that adjusted for patient-, market-, and other SNF-level factors, older adults discharged from higher quality SNFs were more likely to receive CHHA services. In analyses that adjusted for patient- and market-level factors, receipt of post-SNF CHHA services was associated with 2.03 and 4.17 (P < .001) more days in the community over 30- and 90-day periods. Receiving CHHA services was also associated with decreased odds for rehospitalization (odds ratio [OR] = .68; P < .001; OR = .91; P = .008), SNF readmission (OR = .36; P < .001; OR = .62; P < .001), and death (OR = .34; P < .001; OR = .63; P < .001) over 30- and 90-day periods, respectively.

CONCLUSION

Among older adults discharged from a post-acute SNF stay, those who received CHHA services had better discharge outcomes. They were less likely to experience admissions to institutional care settings and had a lower mortality risk. Future efforts that examine how the type and intensity of CHHA services affect outcomes would build on this work. J Am Geriatr Soc 68:1573-1578, 2020.

Long-Term Care Admissions Following Hospitalization: The Role of Social Vulnerability

We sought to understand the association between social vulnerability and the odds of long-term care (LTC) placement within 30 days of discharge following admission to an acute care facility and whether this association varied based on age, sex, or pre-admission frailty. Patients admitted to hospital with acute respiratory illness were enrolled in the Canadian Immunization Research Network's Serious Outcomes Surveillance Network during the 2011/2012 influenza season. Participants (N = 475) were 65 years or older (mean = 78.6, SD = 7.9) and over half were women (58.9%). Incident LTC placement was rare (N = 15); therefore, we used penalized likelihood logistic regression analysis. Social vulnerability and frailty indices were built using a deficit accumulation approach. Social vulnerability interacted with frailty and age, but not sex. At age 70, higher social vulnerability was associated with lower odds of LTC placement at high levels of frailty (frailty index (FI) = 0.35; odds ratio (OR) = 0.32, 95% confidence interval (CI) = 0.09-0.94), but not at lower levels of frailty. At age 90, higher social vulnerability was associated with greater odds of LTC placement at lower levels of frailty (FI = 0.05; OR = 14.64, 95%CI = 1.55, 127.21 and FI = 0.15; OR = 7.26, 95%CI = 1.06, 41.84), but not at higher levels of frailty. Various sensitivity analyses yielded similar results. Although younger, frailer participants may need LTC, they may not have anyone advocating for them. In older, healthier patients, social vulnerability was associated with increased odds of LTC placement, but there was no difference among those who were frailer, suggesting that at a certain age and frailty level, LTC placement is difficult to avoid even within supportive social situations.

Rehabilitation Providers' Prediction of the Likely Success of the SNF-to-Home Transition Differs by Discipline

OBJECTIVES

Our article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

One hundred-twelve English-speaking adults aged 65 years and older admitted to 2 SNF rehabilitation units.

MEASURES

Our outcome is time to "failed transition to home," which identified SNF rehabilitation patients who did not successfully transition from the SNF to home during the study. Our primary independent variable consisted of the prediction of medical providers, occupational therapists, physical therapists, and social workers about the likely success of their patients' SNF-to-home transition. We also examined the association of sociodemographic factors and physical, mental, and social health with a failed transition to home.

RESULTS

The predictions of occupational and physical therapists were associated with whether patients successfully transitioned from the SNF to their homes in bivariate [hazard ratio (HR) = 4.96, P = .014; HR = 10.91, P = .002, respectively] and multivariate (HR = 5.07, P = .036; HR = 53.33, P = .004) analyses. The predictions of medical providers and social workers, however, were not associated with our outcome in either bivariate (HR = 1.44, P = .512; HR = 0.84, P = .794, respectively) or multivariate (HR = 0.57, P = .487; HR = 0.54, P = .665) analyses. Living alone, more medical conditions, lower physical functioning scores, and greater depression scores were also associated with time to failed transition to home.

CONCLUSIONS/IMPLICATIONS

These findings suggest that occupational and physical therapists may be better able to predict post-SNF discharge outcomes than are other rehabilitation providers. Why occupational and physical therapists' predictions are associated with the SNF-to-home outcome whereas the predictions of medical providers and social workers are not is uncertain. A better understanding of the factors informing the postdischarge predictions of occupational and physical therapists may help identify ways to improve the SNF-to-home discharge planning process.

Patient-Reported Outcomes in Functioning Following Nursing Home or Inpatient Rehabilitation

OBJECTIVES

Our study examines factors associated with patient-reported outcomes in functioning among Medicare beneficiaries who reported receiving rehabilitation services in a nursing home or inpatient (ie, hospital or rehabilitation facility) setting in the prior year.

DESIGN

Data are from the 2015 and 2016 rounds of the National Health and Aging Trends Study (NHATS), a longitudinal study of a nationally representative sample of Medicare beneficiaries aged 65 years and older.

SETTING AND PARTICIPANTS

A total of 479 participants in the 2016 sample who reported receiving rehabilitation services in a nursing home or inpatient setting in the past year.

MEASURES

Bivariate and logistic regression analyses examined the association of demographic, socioeconomic status, and health variables (from the 2015 interview) and rehabilitation characteristics (from the 2016 interview) with patient-reported improvement in "functioning and ability to do activities" while receiving rehabilitation services in the past year.

RESULTS

Among Medicare beneficiaries who received rehabilitation services in nursing home or inpatient settings, 33.4% (weighted percent) reported no improvement in functioning while they were receiving rehabilitation. In a regression analysis that accounted for demographics, those with a high school education or less (compared with those with a college degree), instrumental activities of daily living impairments, certain primary conditions for rehabilitation, less than 1-month total duration of rehabilitation services, and no outpatient rehabilitation services had greater odds of reporting no improvement.

CONCLUSIONS/IMPLICATIONS

Our weighted sample represents approximately 2.3 million Medicare beneficiaries who received rehabilitation services in nursing home or inpatient settings. In this sample, 1 in 3 reported no improvement in functioning, with differences in patient-reported outcomes across socioeconomic status, health status, and rehabilitation characteristics domains. Consideration of characteristics across these domains may be clinically pertinent, but investigation as to why these differences are present and whether services can be optimized to further improve patient-reported outcomes is warranted.