Expanding outpatient benefits package can reduce diabetes-related avoidable hospitalizations

Objective

To evaluate the policy effect of replacing hospitalization service with outpatient service and reducing diabetes-related avoidable hospitalizations by improving outpatient benefits package.

Methods

A database of hospital discharge from 2015 to 2017 in City Z was used. All diabetic inpatient cases enrolled in Urban Employee Basic Medical Insurance were selected as the intervention group, and diabetic inpatient cases enrolled in Urban and Rural Resident Basic Medical Insurance were selected as the control group. The Difference-in-Difference model was used to analyze the effect of improving outpatient benefits package level of diabetes from 1800 yuan (about $252.82) to 2400 yuan (about $337.09) per capita per year on avoidable hospitalization rate, average hospitalization cost and average length of stay.

Results

The avoidable hospitalization rate of diabetes mellitus decreased by 0.21 percentage points (P < 0.01), the average total cost of hospitalization increased by 7.89% (P < 0.01), and the average length of stay per hospitalization increased by 5.63% (P < 0.01).

Conclusions

Improving the outpatient benefits package of diabetes can play a role in replacing hospitalization service with outpatient service, reducing diabetes-related avoidable hospitalizations, and reducing the disease burden and financial burden.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions

BACKGROUND

Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations.

OBJECTIVE

We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating.

METHODS

Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating.

RESULTS

We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees.

CONCLUSIONS

Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.

Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México

OBJECTIVES

To estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010-2017.

METHODS

Secondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression.

RESULTS

For the period 2010-2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015-2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina.

CONCLUSIONS

AH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.

Describing Transfers Originating Out-of-Facility for Nursing Home Residents

OBJECTIVES

Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers).

DESIGN

Secondary data analysis with multivariable model for community transfer risk factors.

SETTING AND PARTICIPANTS

Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016.

METHODS

Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis.

RESULTS

Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement.

CONCLUSIONS AND IMPLICATIONS

Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.

Racial Disparities in Avoidable Hospitalizations in Traditional Medicare and Medicare Advantage

IMPORTANCE

Compared with traditional Medicare (TM), Medicare Advantage (MA) has the potential to reduce racial disparities in hospitalizations for ambulatory care sensitive conditions (ACSC). As racial disparities may be partly attributable to unequal treatment based on where people live, this suggests the need of examining geographic variations in racial disparities.

OBJECTIVE

The aim of this study was to examine differences in ACSC hospitalizations between White and Black beneficiaries in TM and MA and examine geographic variations in racial differences in ACSC hospitalizations in TM and MA.

METHODS

We analyzed the 2015-2016 Medicare Provider Analysis and Review files. We used propensity score matching to account for differences in characteristics between TM and MA beneficiaries. Then, we conducted linear regression and estimated adjusted outcomes for TM and MA beneficiaries by race. Also, we estimated racial differences in adjusted outcomes by insurance and hospital referral region (HRR).

RESULTS

While White beneficiaries in TM and MA had similar rates of ACSC hospitalizations (163.7 vs. 162.2/10,000 beneficiaries), Black beneficiaries in MA had higher rates of ACSC hospitalizations than Black beneficiaries in TM (221.2 vs. 209.3/10,000 beneficiaries). However, the racial differences were greater in MA than TM (59.0 vs. 45.6/10,000 beneficiaries). Racial differences in ACSC hospitalizations in MA were prevalent across almost all HRRs. 95.5% of HRRs had higher rates of ACSC hospitalizations among Black beneficiaries than White beneficiaries in MA relative to just 54.2% of HRRs in TM.

CONCLUSION

Our findings provide evidence of racial disparities in access to high-quality primary care, especially in MA.

Financial and Work-flow Benefits of Reducing Avoidable Hospitalizations of Nursing Home Residents

OBJECTIVES

1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes.

DESIGN

A CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012-2020).

SETTING AND PARTICIPANTS

Setting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region.

METHODS

Financial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis.

RESULTS

There was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015-2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014-2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes.

CONCLUSIONS

Reducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization.

IMPLICATIONS

Focusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Results of the Missouri Quality Initiative in Sustaining Changes in Nursing Home Care: Six-Year Trends of Reducing Hospitalizations of Nursing Home Residents

OBJECTIVES

The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents.

DESIGN

A CMS funded demonstration project analyzed over 6-years using a single group design.

SETTING AND PARTICIPANTS

The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019.

MEASURES

Resident data were analyzed using descriptive methods of aggregate facilities' hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described.

INTERVENTION

Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents.

RESULTS

Total transfers for 2014-2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified.

CONCLUSIONS/IMPLICATIONS

The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN's daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations' support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative

BACKGROUND/OBJECTIVES

Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated.

DESIGN

We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status.

SETTING

Participating NFs during fiscal years 2017 to 2018.

PARTICIPANTS

There were 47,202 long-stay NF residents from 260 facilities in seven states.

INTERVENTION

CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform.

MEASUREMENTS

Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions.

RESULTS

Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital.

CONCLUSION

Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Assessment of appropriateness of hospitalisations in Ukraine: analytical framework, method and findings

OBJECTIVES

This article reviews the applicability of a customised version of the Appropriateness Evaluation Protocol (AEP) to evaluate the magnitude of inappropriate hospitalisations in two regions of Ukraine.

DATA AND METHODS

The original AEP was modified to develop a customised tool, which included criteria for the appropriateness of hospitalisation and duration of inpatient stay. The customisation of the tool followed the Delphi procedure. We randomly selected 381 medical records to test the feasibility and reliability of the method and 800 medical records to evaluate the scope of inappropriate hospitalisations. We used descriptive and analytical statistics, receiver operating characteristic curve analysis and Cohen's kappa to check the consistency between the findings of primary reviewers and experts.

RESULT

We observed high levels of agreement in conclusions of primary reviewers (reference standard) and experts during testing of the reliability and validity of the method. The external validity check showed that the use of the tool by different experts provided high accuracy: 95.1 sensitivity, 76.6 specificity and area under ROC-curve (AUC)=0.948 (р<0.001) for analysis of the appropriateness of admissions; 95.3 sensitivity, 84.7 specificity and AUC=0.900 (р=0.001) for the duration of hospitalisations. Cohen's kappa coefficient (κ) indicated agreement in expert evaluations of 0.915 (95% СІ 0.799 to 1.000) and 0.812 (95% СІ 0.749 to 0.875), respectively.We found that over one-third of admissions (38.1%; 95% СІ 33.9 to 43.5) and over half of total bed-days were unnecessary (57.4%; 95% СІ 56.4 to 58.5). The highest levels of stay were observed in hospitals' general medicine departments (64.6%; 95% СІ 63.0 to 66.3)compared with other departments included in the analysis.

CONCLUSION

The proposed method is robust in assessing the appropriateness of hospitalisations and duration of inpatient stays. The quantified levels of unnecessary hospital care indicate the need for improving efficiency and quality of care and optimising the excessive hospital capacities in Ukraine.

The Complexity of Determining Whether a Nursing Home Transfer Is Avoidable at Time of Transfer

OBJECTIVES

To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores).

DESIGN

As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross-tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed-effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death.

SETTING

Indiana nursing facilities (N=19).

PARTICIPANTS

Long-stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016.

MEASUREMENTS

Participant symptoms, transfers, risk factors, and hospital diagnoses.

RESULTS

We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two-thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions.

CONCLUSION

Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining "avoidability" at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses.

An Innovative Day Hospital Dedicated to Nursing Home Resident: A Descriptive Study of 1306 Residents Referred by their Physicians

BACKGROUND

The transfer rate of residents from nursing homes (NH) to emergency rooms is high. These transfers are often inappropriate but also potentially avoidable. Recent studies have shown that in terms of methods for training NH teams, proposals for improvement of the healthcare sector must be organized. Given this observation, Gérontopôle de Toulouse (France) opened in October 2015, a responsive day hospital dedicated to NH residents (DH NH). This day hospital is characterized by its vocation, exclusively dedicated to NH residents and its ability to provide patient care within a short period of time.

OBJECTIVES

The purpose of this day hospital is twofold: (1) decrease the rate of inappropriate transfers for NH residents by offering general practitioners and NH teams quick access to expert advice, blood tests and radiological examinations during hospitalizations and care adapted to the characteristics of NH residents; (2) potentially reduce avoidable transfers to emergency rooms and hospitalizations by taking action to prevent acute decompensation in residents, but also for the education and training of NH healthcare teams. This manuscript aims to describe the arrangements put in place and the characteristics of the residents collected after two years of activity.

DESIGN

Retrospective descriptive study.

SETTING

Gérontopôle of Toulouse, France.

PARTICIPANTS

1306 residents have been consulted at the DH NH.

MEASUREMENTS

Referring physicians (treating physicians, coordinating physician or emergency room physicians) send a standardized hospitalization request form to the day hospital by fax or email indicating the reason for the request, specialist opinion(s) desired and additional required examination(s). A gerontological assessment was conducted and anamnesis data was collected for each resident, on the very day of their coming to the DH NH.

RESULTS

In 2 years, 1306 residents from 120 NHs were sent to the DH NH. The mean age was 86.23 ± 7.05 years and the majority of patients were women (n=941, 72.22%), dependent (median ADL at 2.75, [1.25-4.5]) and malnourished (821, 63.25%). In the 3 months prior to their visit to the day hospital, 668 (57.14%) residents had been hospitalized, and one-quarter (n=336, 25.72%) had been transferred to emergency rooms. The main reasons for hospitalization included assessment of cognitive disorders (n=336, 17.52%), assistance in managing behavioral disorders (n=297, 15.48%) and bedsores and slow wound healing (n=223, 11.63%).

CONCLUSION

Our experience over a 2-year period suggests that the DH NH could be a practical response to the problem of inappropriate and avoidable transfers of NH residents to emergency rooms. This innovation could easily be utilized in other hospitals.

Hospitalization for ambulatory care sensitive conditions among urban Métis adults

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are potentially preventable, but may be required if these conditions are not managed well. National-level information about ACSC hospitalizations is available for Canada, but not for Aboriginal groups. This study describes ACSC hospitalizations among urban Métis adults relative to their non-Aboriginal counterparts.

DATA AND METHODS

The 2006/2007-to-2008/2009 Discharge Abstract Database, which contains hospitalization records from all acute care facilities (excluding Quebec), was linked to the 2006 Census to obtain Aboriginal identity information. Age-standardized ACSC hospitalization rates (ASHRs) per 100,000 population and rate ratios were calculated for Métis aged 18 to 74 relative to non-Aboriginal people of the same ages. Odds of ACSC hospitalizations were estimated using logistic regression models, adjusting for demographic, geographic, and socioeconomic characteristics.

RESULTS

The ASHR for ACSCs among urban Métis adults was twice that among non-Aboriginal adults (393 versus 184 per 100,000 population). Even when demographic, geographic, and socioeconomic characteristics were taken into account, Métis had higher odds of ACSC hospitalizations overall (OR 1.5). Most commonly, these hospitalizations were for diabetes (OR 1.8) or chronic obstructive pulmonary disease (OR 1.5). Modelled factors partly reduced differences between Métis and non-Aboriginal adults, but variations between the groups remained after all adjustments.

INTERPRETATION

Rates of ACSC hospitalizations were higher among Métis than among non-Aboriginal adults who lived in urban areas. Further research using other data sources is warranted to assess the roles of factors not available for this analysis, such as primary care, co-morbidity, and health behaviours.

Impact of Advanced Practice Registered Nurses on Quality Measures: The Missouri Quality Initiative Experience

PURPOSE

The purpose of this article is to review the impact of advanced practice registered nurses (APRNs) on the quality measure (QM) scores of the 16 participating nursing homes of the Missouri Quality Initiative (MOQI) intervention. The MOQI was one of 7 program sites in the US, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services Innovations Center. While the goals of the MOQI for long-stay nursing home residents did not specifically include improvement of the QM scores, it was anticipated that improvement most likely would occur. Primary goals of the MOQI were to reduce the frequency of avoidable hospital admissions and readmissions; improve resident health outcomes; improve the process of transitioning between inpatient hospitals and nursing facilities; and reduce overall healthcare spending without restricting access to care or choice of providers.

METHODS

A 2-group comparison analysis was conducted using statewide QMs; a matched comparison group was selected from facilities in the same counties as the intervention homes, similar baseline QM scores, similar size and ownership. MOQI nursing homes each had an APRN embedded full-time to improve care and help the facility achieve MOQI goals. Part of their clinical work with residents and staff was to focus on quality improvement strategies with potential to influence healthcare outcomes. Trajectories of QM scores for the MOQI intervention nursing homes and matched comparison group homes were tested with nonparametric tests to examine for change in the desired direction between the 2 groups from baseline to 36 months. A composite QM score for each facility was constructed, and baseline to 36-month average change scores were examined using nonparametric tests. Then, adjusting for baseline, a repeated measures analysis using analysis of covariance as conducted.

RESULTS

Composite QM scores of the APRN intervention group were significantly better (P = .025) than the comparison group. The repeated measures analysis identified statistically significant group by time interaction (P = .012). Then group comparisons were made at each of the 6-month intervals and statistically significant differences were found at 24 months (P = .042) and 36 months (P = .002), and nearly significant at 30 months (P = .11).

IMPLICATIONS

APRNs working full time in nursing homes can positively influence quality of care, and their impact can be measured on improving QMs. As more emphasis is placed on quality and outcomes for nursing home services, providers need to find successful strategies to improve their QMs. Results of these analyses reveal the positive impact on QM outcomes for the majority of the MOQI nursing homes, indicating budgeting for APRN services can be a successful strategy.

Successfully Reducing Hospitalizations of Nursing Home Residents: Results of the Missouri Quality Initiative

PURPOSE

The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health outcomes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce overall healthcare spending without restricting access to care or choice of providers. The MOQI was one of 7 program sites in the United States, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services (CMS) Innovations Center.

DESIGN AND METHODS

A prospective, single group intervention design, the MOQI included an advanced practice registered nurse (APRN) embedded full-time within each nursing home (NH) to influence resident care outcomes. Data were collected continuously for more than 3 years from an average of 1750 long-stay Medicare, Medicaid, and private pay residents living each day in 16 participating nursing homes in urban, metro, and rural communities within 80 miles of a major Midwestern city in Missouri. Performance feedback reports were provided to each facility summarizing their all-cause hospitalizations and potentially avoidable hospitalizations as well as a support team of social work, health information technology, and INTERACT/Quality Improvement Coaches.

RESULTS

The MOQI achieved a 30% reduction in all-cause hospitalizations and statistically significant reductions in 4 single quarters of the 2.75 years of full implementation of the intervention for long-stay nursing home residents.

IMPLICATIONS

As the population of older people explodes in upcoming decades, it is critical to find good solutions to deal with increasing costs of health care. APRNs, working with multidisciplinary support teams, are a good solution to improving care and reducing costs if all nursing home residents have access to APRNs nationwide.

What Are Nursing Facilities Doing to Reduce Potentially Avoidable Hospitalizations?

OBJECTIVES

Hospitalizations among nursing facility residents are frequent and often potentially avoidable. A number of initiatives and interventions have been developed to reduce excessive hospitalizations; however, little is known about the specific approaches nursing facilities use to address this issue. The objective of this study is to better understand which types of interventions nursing facilities have introduced to reduce potentially avoidable hospitalizations of long-stay nursing facility residents.

DESIGN

Cross-sectional survey.

SETTING

236 nursing facilities from 7 states.

PARTICIPANTS

Nursing facility administrators.

MEASUREMENTS

Web-based survey to measure whether facilities introduced any policies or procedures designed specifically to reduce potentially avoidable hospitalizations of long-stay nursing facility residents between 2011 and 2015. We surveyed facilities about seven types of interventions and quality improvement activities related to reducing avoidable hospitalizations, including use of Interventions to Reduce Acute Care Transfers (INTERACT) and American Medical Directors Association tools.

RESULTS

Ninety-five percent of responding nursing facilities reported having introduced at least one new policy or procedure to reduce nursing facility resident hospitalizations since January 2011. The most common practice reported was hospitalization rate tracking or review, followed by standardized communication tools, such as Situation, Background, Assessment, Recommendation (SBAR). We found some variation in the extent and types of these reported interventions.

CONCLUSIONS

Nearly all facilities surveyed reported having introduced a variety of initiatives to reduce potentially avoidable hospitalizations, likely driven by federal, state, and corporate initiatives to decrease hospital admissions and readmissions.

The VA Medical Foster Home Program, Ambulatory Care Sensitive Conditions, and Avoidable Hospitalizations

This quality control study analyzes whether the Veterans Administration Medical Foster Home (VA MFH) program has been successful in improving access and effectiveness of ambulatory care. Individuals hospitalized for one or more of 22 adult ambulatory care sensitive conditions were identified. Pre and post comparisons of a specified population of participants in the program were conducted to determine rates of avoidable hospitalizations for 6 months prior to and following MFH enrollment. The overall rate of avoidable hospitalizations declined from 18.5 to 14.9 per 100 enrollees following enrollment. The number of bed days used declined by 39%, as did the cost associated with avoidable hospitalizations. Enrollment in the VA MFH program resulted in an overall reduction in the rate of avoidable hospitalizations, resource utilization, and costs. Studies are needed comparing these results with other matched cohorts of nursing home eligible veterans.

Inequities in ambulatory care and the relationship between socioeconomic status and respiratory hospitalizations: a population-based study of a canadian city

PURPOSE

Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations.

METHODS

Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease-related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient's usual physician (eg, payment mechanism, sex, years in practice).

RESULTS

We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93).

CONCLUSIONS

In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care-sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.

Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations

BACKGROUND

As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.

OBJECTIVE

We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.

DESIGN

Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.

PARTICIPANTS

2,853,030 patients from 814 VHA primary care clinics

MAIN MEASURES

Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.

KEY RESULTS

The overall mean home builder score in the study clinics was 88 (SD = 13) or 69%. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3% (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).

CONCLUSION

Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.

Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions

PURPOSE

Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are seen as potentially avoidable with optimal primary care. Little is known, however, about how primary care physicians rate these hospitalizations and whether and how they could be avoided. This study explores the complex causality of such hospitalizations from the perspective of primary care physicians.

METHODS

We conducted semistructured interviews with 12 primary care physicians from 10 primary care clinics in Germany regarding 104 hospitalizations of 81 patients with ACSCs at high risk of rehospitalization.

RESULTS

Participating physicians rated 43 (41%) of the 104 hospitalizations to be potentially avoidable. During the interviews the cause of hospitalization fell into 5 principal categories: system related (eg, unavailability of ambulatory services), physician related (eg, suboptimal monitoring), medical (eg, medication side effects), patient related (eg, delayed help-seeking), and social (eg, lack of social support). Subcategories frequently associated with physicians' rating of hospitalizations for ACSCs as potentially avoidable were after-hours absence of the treating physician, failure to use ambulatory services, suboptimal monitoring, patients' fearfulness, cultural background and insufficient language skills of patients, medication errors, medication nonadherence, and overprotective caregivers. Comorbidities and medical emergencies were frequent causes attributed to ACSC-based hospitalizations that were rated as being unavoidable.

CONCLUSIONS

Primary care physicians rated a significant proportion of hospitalizations for ACSCs to be potentially avoidable. Strategies to avoid these hospitalizations may target after-hours care, optimal use of ambulatory services, intensified monitoring of high-risk patients, and initiatives to improve patients' willingness and ability to seek timely help, as well as patients' medication adherence.