The residential history file: studying nursing home residents' long-term care histories(*)

Recent Health Care Use and Medicaid Entry of Medicare Beneficiaries

Purpose of the Study

To examine the relationship between Medicaid entry and recent health care use among Medicare beneficiaries.

Design and Methods

We identified Medicare beneficiaries without full Medicaid or use of hospital or nursing home services in 2008 (N = 2,163,387). A discrete survival analysis estimated beneficiaries' monthly likelihood of entry into the full Medicaid program between January 2009 and June 2010.

Results

During the 18-month study period, Medicaid entry occurred for 1.1% and 3.7% of beneficiaries who aged into Medicare or originally qualified for Medicare due to disability, respectively. Among beneficiaries who aged into Medicare, 49% of new Medicaid participants had no use of inpatient, skilled nursing facility, or nursing home services during the study period. Individuals who recently used inpatient, skilled nursing facility or nursing home services had monthly rates of 1.9, 14.0, and 38.1 new Medicaid participants per 1,000 beneficiaries, respectively, compared with 0.4 new Medicaid participants per 1,000 beneficiaries with no recent use of these services.

Implications

Although recent health care use predicted greater likelihood of Medicaid entry, half of new Medicaid participants used no hospital or nursing home care during the study period. These patterns should be considered when designing and evaluating interventions to reform health care delivery for dual-eligible beneficiaries.

First-dollar cost-sharing for skilled nursing facility care in medicare advantage plans

BACKGROUND

The initial days of a Medicare-covered skilled nursing facility (SNF) stay may have no cost-sharing or daily copayments depending on beneficiaries' enrollment in traditional Medicare or Medicare Advantage. Some policymakers have advocated imposing first-dollar cost-sharing to reduce post-acute expenditures. We examined the relationship between first-dollar cost-sharing for a SNF stay and use of inpatient and SNF services.

METHODS

We identified seven Medicare Advantage plans that introduced daily SNF copayments of $25-$150 in 2009 or 2010. Copays began on the first day of a SNF admission. We matched these plans to seven matched control plans that did not introduce first-dollar cost-sharing. In a difference-in-differences analysis, we compared changes in SNF and inpatient utilization for the 172,958 members of intervention and control plans.

RESULTS

In intervention plans the mean annual number of SNF days per 100 continuously enrolled inpatients decreased from 768.3 to 750.6 days when cost-sharing changes took effect. Control plans experienced a concurrent increase: 721.7 to 808.1 SNF days per 100 inpatients (adjusted difference-in-differences: -87.0 days [95% CI (-112.1,-61.9)]). In intervention plans, we observed no significant changes in the probability of any SNF service use or the number of inpatient days per hospitalized member relative to concurrent trends among control plans.

CONCLUSIONS

Among several strategies Medicare Advantage plans can employ to moderate SNF use, first-dollar SNF cost-sharing may be one influential factor.

TRIAL REGISTRATION

Not applicable.

Utilization of long-term care after decompressive hemicraniectomy for severe stroke among older patients

BACKGROUND

While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial.

AIMS

To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC.

METHODS

Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data.

RESULTS

Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC.

CONCLUSIONS

There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.

Increased healthcare facility use in veterans surviving sepsis hospitalization

PURPOSE

We sought to measure inpatient healthcare utilization among U.S. Veteran Affairs beneficiaries surviving sepsis hospitalization, and to examine how post-sepsis utilization varies by select patient characteristics.

MATERIALS AND METHODS

Retrospective cohort study of 26,561 Veterans who survived sepsis hospitalization in 2009. Using difference-in-differences analysis, we compared changes in healthcare utilization in one year before and one year after sepsis hospitalization by Veteran age, illness severity, and recent nursing facility use.

RESULTS

Median days in a healthcare facility increased from 5 to 10. Veterans with recent nursing facility use spent a median 65days (or 86% of days alive) in a healthcare facility in the year after sepsis. Older age, greater illness severity, and recent nursing home use were each associated with spending more days, and a greater proportion of days alive, in a healthcare facility during the year after sepsis. However, none of these characteristics was associated with a greater rise in utilization after sepsis.

CONCLUSIONS

Veterans surviving sepsis experience high rates of post-sepsis mortality and significant increases in healthcare facility use. Recent nursing facility use is strongly predictive of greater post-sepsis healthcare utilization.

Defining hip fracture with claims data: outpatient and provider claims matter

Medicare claims are commonly used to identify hip fractures, but there is no universally accepted definition. We found that a definition using inpatient claims identified fewer fractures than a definition including outpatient and provider claims. Few additional fractures were identified by including inconsistent diagnostic and procedural codes at contiguous sites.

INTRODUCTION

Medicare claims data is commonly used in research studies to identify hip fractures, but there is no universally accepted definition of fracture. Our purpose was to describe potential misclassification when hip fractures are defined using Medicare Part A (inpatient) claims without considering Part B (outpatient and provider) claims and when inconsistent diagnostic and procedural codes occur at contiguous fracture sites (e.g., femoral shaft or pelvic).

METHODS

Participants included all long-stay nursing home residents enrolled in Medicare Parts A and B fee-for-service between 1/1/2008 and 12/31/2009 with follow-up through 12/31/2011. We compared the number of hip fractures identified using only Part A claims to (1) Part A plus Part B claims and (2) Part A and Part B claims plus discordant codes at contiguous fracture sites.

RESULTS

Among 1,257,279 long-stay residents, 40,932 (3.2%) met the definition of hip fracture using Part A claims, and 41,687 residents (3.3%) met the definition using Part B claims. 4566 hip fractures identified using Part B claims would not have been captured using Part A claims. An additional 227 hip fractures were identified after considering contiguous fracture sites.

CONCLUSIONS

When ascertaining hip fractures, a definition using outpatient and provider claims identified 11% more fractures than a definition with only inpatient claims. Future studies should publish their definition of fracture and specify if diagnostic codes from contiguous fracture sites were used.

Constructing a Measure of Private-pay Nursing Home Days

BACKGROUND

Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population.

OBJECTIVES

To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity.

DESIGN

Retrospective descriptive analysis of US NHs in 2007-2009.

MEASURES

We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics.

RESULTS

Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities.

CONCLUSIONS

This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

Hospital Variation in Rates of New Institutionalizations Within 6 Months of Discharge

OBJECTIVES

Hospitalization in community-dwelling elderly is often accompanied by functional loss, increasing the risk for continued functional decline and future institutionalization. The primary objective of our study was to examine the hospital-level variation in rates of new institutionalizations among Medicare beneficiaries.

DESIGN

Retrospective cohort study.

SETTING

Hospitals and nursing homes.

PARTICIPANTS

Medicare fee-for-service beneficiaries discharged from 4,469 hospitals in 2013 (N = 4,824,040).

MEASUREMENTS

New institutionalization, defined as new long term care nursing home residence (not skilled nursing facility) of at least 90 days duration within 6 months of hospital discharge.

RESULTS

The overall observed rate of new institutionalizations was 3.6% (N = 173,998). Older age, white race, Medicaid eligibility, longer hospitalization, and having a skilled nursing facility stay over the 6 months before hospitalization were associated with higher adjusted odds. Observed rates ranged from 0.9% to 5.9% across states. The variation in rates attributable to the hospital after adjusting for case-mix and state was 5.1%. Odds were higher for patients treated in smaller (OR = 1.36, 95% CI: 1.27-1.45, ≤50 vs >500 beds), government owned (OR = 1.15, 95% CI: 1.09-1.21 compared to for-profit), limited medical school affiliation (OR = 1.13, 95% CI: 1.07-1.19 compared to major) hospitals and lower for patients treated in urban hospitals (OR = 0.79, 95% CI: 0.76-0.82 compared to rural). Higher Summary Star ratings (OR = 0.75, 95% CI: 0.67-0.93, five vs one stars) and Overall Hospital Rating (OR = 0.62, 95% CI: 0.57-0.67, ratings of 9-10 vs 0) were associated with lower odds of institutionalization.

CONCLUSION

Hospitalization may be a critical period for preventing future institutionalization among elderly patients. The variation in rates across hospitals and its association with hospital quality ratings suggest some of these institutionalizations are avoidable and may represent targets for care improvement.

Comparison of methods to identify long term care nursing home residence with administrative data

BACKGROUND

To compare different methods for identifying a long term care (LTC) nursing home stay, distinct from stays in skilled nursing facilities (SNFs), to the method currently used by the Center for Medicare and Medicaid Services (CMS). We used national and Texas Medicare claims, Minimum Data Set (MDS), and Texas Medicaid data from 2011-2013.

METHODS

We used Medicare Part A and B and MDS data either alone or in combination to identify LTC nursing home stays by three methods. One method used Medicare Part A and B data; one method used Medicare Part A and MDS data; and the current CMS method used MDS data alone. We validated each method against Texas 2011 Medicare-Medicaid linked data for those with dual eligibility.

RESULTS

Using Medicaid data as a gold standard, all three methods had sensitivities > 92% to identify LTC nursing home stays of more than 100 days in duration. The positive predictive value (PPV) of the method that used both MDS and Medicare Part A data was 84.65% compared to 78.71% for the CMS method and 66.45% for the method using Part A and B Medicare. When the patient population was limited to those who also had a SNF stay, the PPV for identifying LTC nursing home was highest for the method using Medicare plus MDS data (88.1%).

CONCLUSIONS

Using both Medicare and MDS data to identify LTC stays will lead to more accurate attribution of CMS nursing home quality indicators.

Implementing a Pilot Trial of an Infection Control Program in Nursing Homes: Results of a Matched Cluster Randomized Trial

BACKGROUND

Hand hygiene is the single-most important nursing home (NH) infection control measure. We piloted a multifaceted hand-washing/surface cleaning intervention in 5 NHs. Our aims were to assess the feasibility of implementing this intervention by assessing staff participation, satisfaction, hand-washing compliance, and whether the intervention was associated with reductions in infection rates, new antimicrobial orders, or overall hospitalization rates.

METHODS

We conducted a randomized, pair-matched pilot intervention in 10 Colorado NHs to reduce infections for all NH residents from October 1, 2015 through May 31, 2016. To evaluate process, we determined online education participation rates, recorded intervention fidelity through weekly reporting measures on microbial surface counts, hand-washing, and infection reporting, and conducted a survey of participating employees. To evaluate potential impacts on clinical outcomes, we collected information on monthly infection log data, new antibiotic orders, and hospitalizations.

RESULTS

Three of 5 sites had education participation rates >90%, the other 2 were poor (13% and 23%). The majority of participation survey respondents (58%) were promoters of the intervention. Directors of nursing reported hygiene hand-washing data for 19.6/24 (81.8%) weeks and microbial surface count data for 20.4/24 (85.1%) weeks. For the first 4 weeks of the study, the bacterial counts averaged 351.4 ± 497.5 relative light units, the mean value for the last 4 weeks was 127.7 ± 85.1 (P value = .12). The number of hand-washing occasions per NH resident was steady over time but differed by treatment facility (P = .03). We observed nonsignificant reductions for total infections (6.7%) and lower respiratory tract infections (19.9%) vs control NHs. There were no significant differences in antimicrobial orders or hospitalization rates pre-post intervention.

CONCLUSIONS

This multifaceted hand-washing and surface cleaning intervention was designed to reduce infection rates among NH residents. In our 10-facility randomized, matched pair pilot study, we observed program compliance and satisfaction along with reductions in surface bacterial counts, but did not observe a statistically significant reduction in infection rates, antimicrobial use, or hospitalizations.

End-of-Life Care Transition Patterns of Medicare Beneficiaries

OBJECTIVES

To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132).

DESIGN

Retrospective study.

SETTING

United States.

PARTICIPANTS

Medicare beneficiaries aged 66 and older who died from July to December 2011.

MEASUREMENTS

Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospice) in the last 6 months of life. A count variable for number of transitions was summarized, and Sankey diagrams were produced to illustrate the sequences of healthcare transitions. Multivariable analyses were used to identify factors associated with likelihood of having four or more transitions.

RESULTS

More than 80% decedents (n = 556,437) had at least one transition within the last 6 months of life; 218,731 had four or more transitions within the last 6 months of life. The most-frequent transition pattern (19.3% of all decedents; n = 127,435) was home to hospital, back to home or skilled nursing facility, to hospital again, and then to settings other than hospital, ending with four or more transitions. The average number of transitions in the last 6 months of life varied substantially across states, ranging from 1.8 in Alaska to 3.1 in New Jersey. Transitions became more intensive for decedents approaching death. In multivariable analyses, women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions (all P < .05).

CONCLUSION

Approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. Identifying interventions that can facilitate care transitions consistent with beneficiaries' preferences is warranted.

Waiving the three-day rule: admissions and length-of-stay at hospitals and skilled nursing facilities did not increase

The traditional Medicare program requires an enrollee to have a hospital stay of at least three consecutive calendar days to qualify for coverage of subsequent postacute care in a skilled nursing facility. This long-standing policy, implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner. To assess the implications of eliminating the three-day qualifying stay requirement, we compared hospital and postacute skilled nursing facility utilization among Medicare Advantage enrollees in matched plans that did or did not eliminate that requirement in 2006-10. Among hospitalized enrollees with a skilled nursing facility admission, the mean hospital length-of-stay declined from 6.9 days to 6.7 days for those no longer subject to the qualifying stay but increased from 6.1 to 6.6 days among those still subject to it, for a net decline of 0.7 day when the three-day stay requirement was eliminated. The elimination was not associated with more hospital or skilled nursing facility admissions or with longer lengths-of-stay in a skilled nursing facility. These findings suggest that eliminating the three-day stay requirement conferred savings on Medicare Advantage plans and that study of the requirement in traditional Medicare plans is warranted.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

Beta-Blocker Use in U.S. Nursing Home Residents After Myocardial Infarction: A National Study

OBJECTIVES

To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission.

MEASUREMENTS

The outcome was beta-blocker initiation within 30 days of NH readmission.

RESULTS

Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership.

CONCLUSION

Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.

Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?

OBJECTIVE

To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.

SETTINGS

Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.

STUDY DESIGN

We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.

PRINCIPAL FINDINGS

The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.

CONCLUSIONS

Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?

OBJECTIVE

To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.

SETTINGS

Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.

STUDY DESIGN

We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.

PRINCIPAL FINDINGS

The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.

CONCLUSIONS

Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

Medical Foster Homes: Can the Adult Foster Care Model Substitute for Nursing Home Care?

OBJECTIVE

To compare characteristics, healthcare use, and costs of care of veterans in the rapidly expanding Veterans Health Administration (VHA) medical foster home (MFH) with those of three other VHA long-term care (LTC) programs.

DESIGN

Descriptive, unmatched study.

SETTING

VHA MFHs, home-based primary care (HBPC), community living centers (CLCs), and community nursing homes (CNHs).

PARTICIPANTS

Veterans newly enrolled in one of the four LTC settings in calendar years 2010 or 2011.

MEASUREMENTS

Using VA and Medicare data from fiscal years 2010 and 2011, demographic characteristics, healthcare use, and costs of 388 veterans in MFHs were compared with 26,037 of those in HBPC, 5,355 in CLCs, and 5,517 in CNHs in the year before and the year after enrollment.

RESULTS

Veterans enrolled in the MFH program were more likely to be unmarried than those in other LTC programs and had higher levels of comorbidity and frailty than veterans receiving HBPC but had similar levels of comorbidity, frailty, and healthcare use as those in CLCs and CNHs. MFH veterans incurred lower costs than those in CNHs and CLCs.

CONCLUSION

MFHs served a distinct subset of veterans with levels of comorbidity and frailty similar to those of veterans cared for in CLCs and CNHs at costs that were comparable to or lower than those of the VHA. Propensity-matched comparisons will be necessary to confirm these findings.

Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol

BACKGROUND

The program "Implementing Goals of Care Conversations with Veterans in VA LTC Settings" is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.

METHODS

Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives-meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans' preferences expressed and documented, and acted on-to support action planning to improve performance.

DISCUSSION

We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.

Racial Differences in Hospitalizations of Dying Medicare-Medicaid Dually Eligible Nursing Home Residents

OBJECTIVES

To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents.

DESIGN

National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status.

SETTING

Nursing homes in the United States.

PARTICIPANTS

Dually eligible Medicare-Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948).

MEASUREMENTS

Racial difference in EOL hospitalizations from a NH.

RESULTS

End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status.

CONCLUSION

Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.

Geographic Variation in Hip Fracture Among United States Long-Stay Nursing Home Residents

INTRODUCTION

Despite high rates of hip fracture among United States (US) nursing home (NH) residents, little is known about geographic variation in hip fracture incidence. We used nationally representative data to identify geographic variation in hip fracture among US NH residents.

DESIGN AND SETTING

Retrospective cohort study using Part A claims for a 100% of Medicare enrollees in 15,289 NHs linked to NH minimum data set and Online Survey, Certification, and Reporting databases.

PARTICIPANTS

A total of 891,085 long-stay (continuous residence of ≥100 days) NH residents ≥65 years old.

MEASUREMENTS

Medicare Part A claims documenting a hip fracture. Mean incidence rates of hip fracture for long-stay NH residents were calculated for each state and US Census Division from 2007 to 2010.

RESULTS

The age-, sex-, and race-adjusted incidence rate of hip fracture ranged from 1.49 hip fractures/100 person-years (Hawaii) to 3.60 hip fractures/100 person-years (New Mexico), with a mean of 2.38 (standard deviation 0.43) hip fractures/100 person-years. The mean incidence of hip fracture was 1.7-fold greater in the highest quintile than the lowest.

CONCLUSIONS

We observed modest US state and regional variation in hip fracture incidence among long-stay NH residents. Future studies should assess whether state policies or NH characteristics explain the variation.

Incidence of Hip Fracture in U.S. Nursing Homes

BACKGROUND

Hip fractures are associated with significant morbidity and mortality in the nursing home. Our objective was to describe the incidence rate (IR) of hip fracture according to age, sex, and race in a nationwide sample of long-stay nursing home residents.

METHODS

Using 2007-2010 Medicare claims data linked with the Minimum Data Set, we identified 892,837 long-stay residents (≥100 days in the same nursing facility) between May 1, 2007 and April 30, 2008. Hip fractures were defined using Part A diagnostic codes (ICD-9). Residents were followed from the date they became a long-stay resident until the first event of death, discharge, hip fracture, or 2 years of follow-up.

RESULTS

Mean age was 84 years (range 65-113 years), and 74.5% were women. 83.9% were white and 12.0% were black. The overall IR of hip fracture was 2.3/100 person years. The IR was similar in men and women across age groups. The IR of hip fracture was highest in Native Americans aged 85 years or older (3.7/100 person years), in whites (2.6/100 person years), and during the first 100 days of institutionalization (2.7/100 person years). IRs of hip fracture were lowest in blacks (1.3/100 person years).

CONCLUSIONS

In nursing home residents surviving 100 days or more in a facility, the incidence of hip fracture is high, particularly among older white, Native American, and newly admitted residents. This is the first nationwide study to provide sex- and age-specific estimates among U.S. nursing home residents, and it underscores the magnitude of the problem.

Do Nursing Home Chain Size and Proprietary Status Affect Experiences With Care?

BACKGROUND

In 2012, over half of nursing homes were operated by corporate chains. Facilities owned by the largest for-profit chains were reported to have lower quality of care. However, it is unknown how nursing home chain ownerships are related with experiences of care.

OBJECTIVES

To study the relationship between nursing home chain characteristics (chain size and profit status) with patients' family member reported ratings on experiences with care.

DATA SOURCES AND STUDY DESIGN

Maryland nursing home care experience reports, the Online Survey, Certification, And Reporting (OSCAR) files, and Area Resource Files are used. Our sample consists of all nongovernmental nursing homes in Maryland from 2007 to 2010. Consumer ratings were reported for: overall care; recommendation of the facility; staff performance; care provided; food and meals; physical environment; and autonomy and personal rights. We identified chain characteristics from OSCAR, and estimated multivariate random effect linear models to test the effects of chain ownership on care experience ratings.

RESULTS

Independent nonprofit nursing homes have the highest overall rating score of 8.9, followed by 8.6 for facilities in small nonprofit chains, and 8.5 for independent for-profit facilities. Facilities in small, medium, and large for-profit chains have even lower overall ratings of 8.2, 7.9, and 8.0, respectively. We find similar patterns of differences in terms of recommendation rate, and important areas such as staff communication and quality of care.

CONCLUSIONS

Evidence suggests that Maryland nursing homes affiliated with large-for-profit and medium-for-profit chains had lower ratings of family reported experience with care.

An Examination of the First 30 Days After Patients are Discharged to the Community From Hip Fracture Postacute Care

BACKGROUND

Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients' success in staying home after discharge or differences on this outcome across PAC providers.

OBJECTIVES

Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome.

RESEARCH DESIGN

Retrospective observational study.

SUBJECTS

Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006.

MEASURES

Successful community discharge, sites of readmission after PAC discharge.

RESULTS

Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82-0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%-66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile.

CONCLUSIONS

Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

Volume Matters: Returning Home After Hip Fracture

OBJECTIVES

To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant's fracture) and other facility characteristics on outcomes.

DESIGN

Prospective observational study.

SETTING

U.S. skilled nursing facilities (SNFs) admitting individuals discharged from the hospital after treatment for hip fracture between 2000 and 2007 (N = 15,439).

PARTICIPANTS

Community-dwelling fee-for-service Medi-care beneficiaries aged 75 and older admitted to U.S. hospitals for their first hip fracture and discharged to a SNF for postacute care from 2000 to 2007 (N = 512,967).

MEASUREMENTS

Successful discharge from SNF to community, defined as returning to the community within 30 days of hospital discharge to the SNF and remaining in the community without being institutionalized for at least 30 days, was examined using Medicare administrative data, propensity score matching, and instrumental variables.

RESULTS

The overall rate of successful discharge to the community was 31%. Of the 15,439 facilities, the facility interquartile range varied from 0% (25th percentile) to 42% (75th percentile). An important determinant of variation in discharge rate was SNF volume of hip fracture admissions. Unadjusted successful discharge from SNF to community was 43.7% in high-volume facilities (>24 admissions/year), versus 18.8% in low-volume facilities (1-6 admissions/year). This facility volume effect persisted after adjusting for participant and facility characteristics associated with outcomes (e.g., adjusted odds ratio = 2.06, 95% confidence interval = 1.91-2.21 for volume of 25 vs 3 admissions per year).

CONCLUSION

In community-dwelling persons with their first hip fracture, successful return to the community varies substantially according to SNF provider volume and staffing characteristics.

The Impact of Medicaid Payer Status on Hospitalizations in Nursing Homes

OBJECTIVES

To examine the association between payer status (Medicaid vs. private-pay) and the risk of hospitalizations among long-term stay nursing home (NH) residents who reside in the same facility.

DATA AND STUDY POPULATION

The 2007-2010 National Medicare Claims and the Minimum Data Set were linked. We identified newly admitted NH residents who became long-stayers and then followed them for 180 days.

ANALYSES

Three dichotomous outcomes-all-cause, discretionary, and nondiscretionary hospitalizations during the follow-up period-were defined. Linear probability model with facility fixed-effects and robust SEs were used to examine the within-facility difference in hospitalizations between Medicaid and private-pay residents. A set of sensitivity analyses were performed to examine the robustness of the findings.

RESULTS

The prevalence of all-cause hospitalization during a 180-day follow-up period was 23.3% among Medicaid residents compared with 21.6% among private-pay residents. After accounting for individual characteristics and facility effects, the probability of any all-cause hospitalization was 1.8-percentage point (P<0.01) higher for Medicaid residents than for private-pay residents within the same facility. We also found that Medicaid residents were more likely to be hospitalized for discretionary conditions (5% increase in the likelihood of discretionary hospitalizations), but not for nondiscretionary conditions. The findings from the sensitivity analyses were consistent with the main analyses.

CONCLUSIONS

We observed a higher hospitalization rate among Medicaid NH residents than private-pay residents. The difference is in part driven by the financial incentives NHs have to hospitalize Medicaid residents.

Estimating the Effect of Influenza Vaccination on Nursing Home Residents' Morbidity and Mortality

OBJECTIVES

To estimate the effect of influenza vaccination on hospitalization and mortality in nursing home (NH) residents.

DESIGN

Retrospective cohort study.

SETTING

Medicare claims data linked to NH Minimum Data Set assessments and Centers for Disease Control and Prevention (CDC) surveillance data from 122 U.S. cities.

PARTICIPANTS

More than 1 million Medicare fee-for-service, long-stay NH residents between 2000 and 2009.

MEASUREMENTS

Weekly facility outcome aggregates of NH resident pneumonia and influenza (P&I) hospitalizations and all-cause mortality and city-level P&I mortality as reported by the CDC were created. The seasonal vaccine match rate for influenza A/H1N1, A/H3N2, and B strains was calculated, and each outcome was compared in seasons of high and low match rates using facility fixed-effects regression models separately for full-year and nonsummer months.

RESULTS

Average weekly all-cause mortality varied across seasons from 3.74 to 4.13 per 1,000 NH residents per week, and hospitalization for P&I varied from 2.05 to 2.43. Vaccine match rates were invariably high for H1N1 but variable across seasons for the other two types. The association between vaccine match and reduction in overall mortality and P&I hospitalizations was strongest for A/H3N2, the influenza strain typically responsible for the most-severe influenza cases. Given the approximately 130,000 deaths and 77,000 P&I hospitalizations of long-stay NH residents during the 32 nonsummer weeks, the model estimated that a 50-percentage-point increase in the A/H3N2 match rate (from <25% to >75%) reduced long-stay NH resident deaths by 2.0% and P&I hospitalizations by 4.2%.

CONCLUSION

Well-matched influenza vaccine prevents P&I hospitalizations and mortality in NH residents.

What happens to patients when they fracture their hip during a skilled nursing facility stay?

OBJECTIVES

To characterize outcomes of patients experiencing a fall and subsequent hip fracture while in a nursing home receiving skilled nursing facility (SNF) services.

DESIGN

Observational study.

PARTICIPANTS

Short-stay fee-for-service Medicare beneficiaries who experienced their first hip fracture during an SNF stay.

MEASUREMENTS

Outcomes measured in the 90 days after the hip fracture hospitalization included community discharge (with a stay in the community <30 days), successful community discharge (in the community ≥30 days), death, and institutionalization.

RESULTS

Between 1999 and 2007, 27,305 hip fractures occurred among short-stay nursing home patients receiving SNF care. After surgical repair of the hip fracture, 83.9% of these patients were discharged from the hospital back to an SNF, with most (99%) returning to the facility where the hip fracture occurred. In the first 90 days after hospitalization, 24.1% of patients died, 7.3% were discharged to the community but remained fewer than 30 days, 14.0% achieved successful community discharge, and 54.6% were still in a health care institution with almost 46.4% having transitioned to long-term care.

CONCLUSION

SNF care aims to maximize the short-stay patient's independence and facilitate a safe community transition. However, experiencing a fall and hip fracture during the SNF stay was a sentinel event that limited the achievement of this goal. There is an urgent need to ensure the integration of fall prevention into the patient's plan of care. Further, falls among SNF patients may serve as indicator of quality, which consumers and payers can use to make informed health care decisions.

Influence of hospital and nursing home quality on hospital readmissions

OBJECTIVES

To determine whether the quality of the hospital and of the nursing home (NH) to which a patient was discharged were related to the likelihood of rehospitalization.

STUDY DESIGN

Retrospective cohort study of 1,382,477 individual hospitalizations discharged to 15,356 NHs from 3683 hospitals between 2006 and 2008.

METHODS

Data come from Medicare claims and enrollment records, Minimum Data Set, Online Survey Certification and Reporting Dataset, Hospital Compare, and the American Hospital Association Database. Cross-classified random effects models were used to test the association of hospital and NH quality measures and the likelihood of 30-day rehospitalization.

RESULTS

Patients discharged from higher-quality hospitals (as indicated by higher scores on their accountability process measures and high nurse staffing levels) and patients who received care in higher-quality NHs (as indicated by high nurse staffing levels and lower deficiency scores) were less likely to be rehospitalized within 30 days.

CONCLUSIONS

The passage of the Affordable Care Act changed the accountability of hospitals for patients' outcomes after discharge. This study highlights the joint accountability of hospitals and NHs for rehospitalization of patients.

The origin and disposition of Medicare observation stays

BACKGROUND

Growing use of hospital observation care continues unabated despite growing concerns from Medicare beneficiaries, patient advocacy groups, providers, and policy makers. Unlike inpatient stays, outpatient observation stays are subject to 20% coinsurance and do not count toward the 3-day stay required for Medicare coverage of skilled nursing facility (SNF) care. Despite the policy relevance, we know little about where patients originate or their discharge disposition following observation stays, making it difficult to understand the scope of unintended consequences for beneficiaries, particularly those needing postacute care in a SNF.

OBJECTIVE

To determine Medicare beneficiaries' location immediately preceding and following an observation stay.

RESEARCH DESIGN

We linked 100% Medicare Inpatient and Outpatient claims data with the Minimum Data Set for nursing home resident assessments. We then flagged observation stays and conducted a descriptive claims-based analysis of where beneficiaries were immediately before and after their observation stay.

RESULTS

Most patients came from (92%) and were discharged to (90%) the community. Of >1 million total observation stays in 2009, just 7537 (0.75%) were at risk for high out-of-pocket expenses related to postobservation SNF care. Beneficiaries with longer observation stays were more likely to be discharged to SNF.

CONCLUSIONS

With few at risk for being denied Medicare SNF coverage due to observation care, high out-of-pocket costs resulting from Medicare outpatient coinsurance requirements for observation stays seem to be of greater concern than limitations on Medicare coverage of postacute care. However, future research should explore how observation stay policy might decrease appropriate SNF use.

Surveying multiple health professional team members within institutional settings: an example from the nursing home industry

Quality improvement and cost containment initiatives in health care increasingly involve interdisciplinary teams of providers. To understand organizational functioning, information is often needed from multiple members of a leadership team since no one person may have sufficient knowledge of all aspects of the organization. To minimize survey burden, it is ideal to ask unique questions of each member of the leadership team in areas of their expertise. However, this risks substantial missing data if all eligible members of the organization do not respond to the survey. Nursing home administrators (NHA) and directors of nursing (DoN) play important roles in the leadership of long-term care facilities. Surveys were administered to NHAs and DoNs from a random, nationally representative sample of U.S. nursing homes about the impact of state policies, market forces, and organizational factors that impact provider performance and residents' outcomes. Responses were obtained from a total of 2,686 facilities (response rate [RR] = 66.6%) in which at least one individual completed the questionnaire and 1,693 facilities (RR = 42.0%) in which both providers participated. No evidence of nonresponse bias was detected. A high-quality representative sample of two providers in a long-term care facility can be obtained. It is possible to optimize data collection by obtaining unique information about the organization from each provider while minimizing the number of items asked of each individual. However, sufficient resources must be available for follow-up to nonresponders with particular attention paid to lower resourced, lower quality facilities caring for higher acuity residents in highly competitive nursing home markets.

Does the introduction of nursing home culture change practices improve quality?

OBJECTIVES

To understand whether nursing home (NH) introduction of culture change practices is associated with improved quality.

DESIGN

NH-level panel study using multivariate fixed-effects statistical modeling to estimate the effect of culture change introduction on quality outcomes.

SETTING

Eight hundred twenty-four U.S. NHs with culture change practice involvement beginning between 2005 and 2010.

PARTICIPANTS

Directors of nursing and nursing home administrators.

MEASUREMENTS

A culture change practice score (derived from a 2009/10 national NH survey) was used to stratify NHs according to practice implementation (high (scores in the top quartile; n = 217) vs other (n = 607)). NH-level outcomes included prevalence of seven care practices and three resident outcomes, health-related and quality-of-life weighted survey deficiencies, and average number of hospitalizations per resident year.

RESULTS

For NHs with high practice implementation, introduction of culture change was associated with a significant decrease in prevalence of restraints, tube feeding, and pressure ulcers; an increase in the proportion of residents on bladder training programs; and a small decrease in the average number of hospitalizations per resident year (coefficient -0.04, standard error (SE) 0.02, P = .06). For NHs with lower practice implementation (practice scores in lower three quartiles), introduction was associated with fewer health-related (coefficient -5.26, SE 3.05; P = .09) and quality-of-life (coefficient -0.10, SE 0.05; P = .04) survey deficiencies, although these NHs also had small statistically significant increases in the prevalence of residents with urinary tract infections and in average hospitalizations per resident year (coefficient 0.03, SE 0.01, P = .02).

CONCLUSION

The introduction of NH culture change appears to result in significant improvements in some care processes and outcomes in NHs with high practice implementation. For other NHs, culture change introduction results in fewer survey deficiencies.

Trends in family ratings of experience with care and racial disparities among Maryland nursing homes

BACKGROUND

Providing equitable and patient-centered care is critical to ensuring high quality of care. Although racial/ethnic disparities in quality are widely reported for nursing facilities, it is unknown whether disparities exist in consumer experiences with care and how public reporting of consumer experiences affects facility performance and potential racial disparities.

METHODS

We analyzed trends of consumer ratings publicly reported for Maryland nursing homes during 2007-2010, and determined whether racial/ethnic disparities in experiences with care changed during this period. Multivariate longitudinal regression models controlled for important facility and county characteristics and tested changes overall and by facility groups (defined based on concentrations of black residents). Consumer ratings were reported for: overall care; recommendation of the facility; staff performance; care provided; food and meals; physical environment; and autonomy and personal rights.

RESULTS

Overall ratings on care experience remained relatively high (mean=8.3 on a 1-10 scale) during 2007-2010. Ninety percent of survey respondents each year would recommend the facility to someone who needs nursing home care. Ratings on individual domains of care improved among all nursing homes in Maryland (P<0.01), except for food and meals (P=0.827 for trend). However, site-of-care disparities existed in each year for overall ratings, recommendation rate, and ratings on all domains of care (P<0.01 in all cases), with facilities more predominated by black residents having lower scores; such disparities persisted over time (P>0.2 for trends in disparities).

CONCLUSIONS

Although Maryland nursing homes showed maintained or improved consumer ratings during the first 4 years of public reporting, gaps persisted between facilities with high versus low concentrations of minority residents.

Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer?

OBJECTIVE

To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies.

DATA SOURCES/COLLECTION

We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.

STUDY DESIGN

We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.

PRINCIPAL FINDINGS

Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.

CONCLUSIONS

Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.

Are dual eligibles admitted to poorer quality skilled nursing facilities?

BACKGROUND

Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries.

OBJECTIVES

To determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities (SNFs) compared with Medicare-only beneficiaries.

RESEARCH DESIGN

Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual-eligibility status.

SUBJECTS

A total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005.

MEASURES

Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality.

RESULTS

Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home.

CONCLUSIONS

Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility.

Dual Eligibility, Selection of Skilled Nursing Facility, and Length of Medicare Paid Postacute Stay

Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients' SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.

Hospice referral after inpatient psychiatric treatment of individuals with advanced dementia from a nursing home

This report addresses the discharge disposition following inpatient psychiatric treatment for advanced dementia. The total population included 685 305 Medicare fee-for-service decedents with advanced cognitive and functional impairment, with a mean age of 85.9 years who had resided in a nursing home. In the last 90 days of life, 1027 (0.15%) persons received inpatient psychiatry treatment just prior to the place of care where the individual died. Discharge dispositions included 132 (12.9%) persons to a medical hospital, 728 (70.9%) to nursing home without hospice services, 73 (7.1%) to hospice services in a nursing home, 32 (3.1%) to home without hospice services, and 16 (1.6%) to hospice services at home. Overall, the rate of referral to hospice services for advanced dementia was relatively low.

Medical staff involvement in nursing homes: development of a conceptual model and research agenda

Medical staff (physicians, nurse practitioners, physicians' assistants) involvement in nursing homes (NH) is limited by professional guidelines, government policies, regulations, and reimbursements, creating bureaucratic burden. The conceptual NH Medical Staff Involvement Model, based on our mixed-methods research, applies the Donabedian "structure-process-outcomes" framework to the NH, identifying measures for a coordinated research agenda. Quantitative surveys and qualitative interviews conducted with medical directors, administrators and directors of nursing, other experts, residents and family members and Minimum Data Set, the Online Certification and Reporting System and Medicare Part B claims data related to NH structure, process, and outcomes were analyzed. NH control of medical staff, or structure, affects medical staff involvement in care processes and is associated with better outcomes (e.g., symptom management, appropriate transitions, satisfaction). The model identifies measures clarifying the impact of NH medical staff involvement on care processes and resident outcomes and has strong potential to inform regulatory policies.

Trends in the utilization and outcomes of Medicare patients hospitalized for hip fracture, 2000-2008

OBJECTIVE

This study examines temporal trends in hip fracture related utilization and outcomes among elderly fee-for-service Medicare beneficiaries.

METHOD

The study uses claims data for a 5% sample of Medicare beneficiaries with an incident hip fracture hospitalization between 2000 and 2008. We present annual mean patient characteristics, health services utilization, and outcomes and use ordinary least squares regressions to examine adjusted trends in utilization and outcomes after controlling for changes in patient characteristics.

RESULTS

We observe a statistically significant temporal decline in inpatient acute days and a statistically significant increase in inpatient post-acute days following hip fractures. In models that control for patient characteristics, we observe statistically significant declines in 1-year hip fracture readmission and mortality rates. Rates of nursing home residence 1-year following fracture were unchanged and remain high.

DISCUSSION

Hip fractures remain highly debilitating events and pose significant challenges for the financing of public health insurance programs.

Effect of hospital-SNF referral linkages on rehospitalization

OBJECTIVE

To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage.

DATA SOURCES/COLLECTION

We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006.

STUDY DESIGN

We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument.

PRINCIPAL FINDINGS

Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge.

CONCLUSIONS

Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs.

Association between proportion of provider clinical effort in nursing homes and potentially avoidable hospitalizations and medical costs of nursing home residents

OBJECTIVES

To assess potential avoidable hospitalizations of nursing home (NH) residents as a function of the percentage of clinical effort their primary care provider (PCP) devotes to NH practice.

DESIGN

Retrospective cohort study.

SETTING

NHs in Texas.

PARTICIPANTS

Residents newly admitted to long-term NHs in 2006 to 2008 were identified by linking the Minimum Data Set to 100% Texas Medicare claims data (N = 12,249).

MEASUREMENTS

The care that residents received over successive 6-month periods was measured as a time-dependent covariate. Potentially avoidable hospitalizations and Medicare costs were assessed over 6 to 48 months.

RESULTS

Seventy percent of NH residents had a physician as their major PCP, 25% had an advance practice nurse (APN), and 5% had a physician assistant (PA). Physician PCPs who derived less than 20% of their Medicare billings from NH residents cared for 36% of all NH residents. Most NH residents with APN or PA PCPs had providers with 85% or more of Medicare billings generated in NHs. Residents with PCPs who devoted less than 5% of their clinical effort to NH care were at 52% higher risk of potentially avoidable hospitalization than those whose PCPs devoted 85% or more of their clinical effort to NHs (hazard ratio = 1.52, 95% confidence interval = 1.25-1.83) and had $2,179 higher annual Medicare spending, controlling for PCP discipline.

CONCLUSION

The percentage of clinical effort that providers devote to NHs is associated with risk of avoidable hospitalization.

Trends in postacute care and staffing in US nursing homes, 2001-2010

OBJECTIVE

The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010.

DESIGN

We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities.

SETTING

All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims.

MEASUREMENTS

We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff.

RESULTS

In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities.

CONCLUSION

There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.

Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents

IMPORTANCE

It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents.

OBJECTIVE

To conduct a case-crossover study to estimate the association between nonbenzodiazepine hypnotic drug use (zolpidem tartrate, eszopiclone, or zaleplon) and the risk for hip fracture among a nationwide sample of long-stay nursing home residents, overall and stratified by individual and facility-level characteristics.

DESIGN AND SETTING

Case-crossover study performed in an academic research setting.

PARTICIPANTS

The study participants included 15,528 long-stay US nursing home residents 50 years or older with a hip fracture documented in Medicare Part A and Part D fee-for-service claims between July 1, 2007, and December 31, 2008.

MAIN OUTCOME MEASURES

Odds ratios (ORs) of hip fracture were estimated using conditional logistic regression models by comparing the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods). Analyses were stratified by individual and facility-level characteristics.

RESULTS

Among the study participants, 1715 (11.0%) were dispensed a nonbenzodiazepine hypnotic drug before the hip fracture, with 927 exposure-discordant pairs included in the analyses. The mean (SD) age of participants was 81.0 (9.7) years, and 77.6% were female. The risk for hip fracture was elevated among users of a nonbenzodiazepine hypnotic drug (OR, 1.66; 95% CI, 1.45-1.90). The association between nonbenzodiazepine hypnotic drug use and hip fracture was somes greater in new users (OR, 2.20; 95% CI, 1.76-2.74) and in residents with mild vs moderate to severe impairment in cognition (OR, 1.86 vs 1.43; P = .06), with moderate vs total or severe functional impairment (OR, 1.71 vs 1.16; P = .11), with limited vs full assistance required with transfers (OR, 2.02 vs 1.43; P = .02), or in a facility with fewer Medicaid beds (OR, 1.90 vs 1.46; P = .05).

CONCLUSIONS AND RELEVANCE

The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents.

Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009

IMPORTANCE

A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care.

OBJECTIVE

To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life.

MAIN OUTCOME MEASURES

Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life).

RESULTS

Our random 20% sample included 848,303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%).

CONCLUSION AND RELEVANCE

Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

The relationship between older Americans Act Title III state expenditures and prevalence of low-care nursing home residents

OBJECTIVE

To test the relationship between older Americans Act (OAA) program expenditures and the prevalence of low-care residents in nursing homes (NHs). DATA SOURCES AND COLLECTION: Two secondary data sources: State Program Reports (state expenditure data) and NH facility-level data downloaded from LTCfocUS.org for 16,030 US NHs (2000-2009).

STUDY DESIGN

Using a two-way fixed effects model, we examined the relationship between state spending on OAA services and the percentage of low-care residents in NHs, controlling for facility characteristics, market characteristics, and secular trends.

PRINCIPAL FINDINGS

Results indicate that increased spending on home-delivered meals was associated with fewer residents in NHs with low-care needs.

CONCLUSIONS

States that have invested in their community-based service networks, particularly home-delivered meal programs, have proportionally fewer low-care NH residents.

The impact of hospital-based skilled nursing facility closures on rehospitalizations

OBJECTIVE

To examine the effect of reductions in hospital-based (HB) skilled nursing facility (SNF) bed supply on the rate of rehospitalization of patients discharged to any SNF from zip codes that lost HB beds.

DATA SOURCE

We used Medicare enrollment records, Medicare hospital and SNF claims, and nursing home Minimum Dataset assessments and characteristics (OSCAR) to examine nearly 10 million Medicare fee-for-service hospital discharges to SNFs between 1999 and 2006.

STUDY DESIGN

We calculated the number of HB and freestanding (FS) SNF beds within a 22 km radius from the centroid of all zip codes in which Medicare beneficiaries reside in all years. We examined the relationship between HB and FS bed supply and the rehospitalization rates of the patients residing in corresponding zip codes in different years using zip code fixed effects and instrumental variable methods including extensive sensitivity analyses.

PRINCIPAL FINDINGS

Our estimated coefficients suggest that closure of 882 HB homes during our study period resulted in 12,000-18,000 extra rehospitalizations within 30 days of discharge. The effect was largely concentrated among the most acutely ill, high-need patients.

CONCLUSIONS

SNF patient-based prospective payment resulted in closure of higher cost HB facilities that had served most postacute patients. As other, less experienced SNFs replaced HB facilities, they were less able to manage high acuity patients without rehospitalizing them.

Effect of forced transitions on the most functionally impaired nursing home residents

OBJECTIVES

To examine the hospitalization rate and mortality associated with forced mass transfer of nursing home (NH) residents with the highest levels of functional impairment.

DESIGN

Retrospective cohort study.

SETTING

One hundred nineteen Texas and Louisiana NHs identified as being at risk for evacuation for Hurricane Gustav.

PARTICIPANTS

Six thousand four hundred sixty-four long-stay residents residing in at-risk NHs for at least three consecutive months before landfall of Hurricane Gustav.

MEASUREMENTS

Using Medicare claims and instrumental variable analysis, the mortality (death at 30 and 90 days) and hospitalization rates (at 30 and 90 days) of the most functionally impaired long-stay residents who were evacuated for Hurricane Gustav were compared with those of the most functionally impaired residents who did not evacuate.

RESULTS

The effect of evacuation was associated with 8% more hospitalizations by 30 and 90 days for the most functionally impaired residents. Evacuation was not significantly related to mortality.

CONCLUSION

The most functionally impaired NH residents experience more hospitalizations but not mortality as a consequence of forced mass transfer. With the inevitability of NH evacuations for many different reasons, harm mitigation strategies focused on the most impaired residents are needed.

Decision making and outcomes of a hospice patient hospitalized with a hip fracture

CONTEXT

Hospice patients are at risk for falls and hip fracture with little clinical information to guide clinical decision making.

OBJECTIVES

To examine whether surgery is done and survival of hip fracture surgery among persons receiving hospice services.

METHODS

This was an observational cohort study from 1999 to 2007 of Medicare hospice beneficiaries aged 75 years and older with incident hip fracture. We studied outcomes among hospice beneficiaries who did and did not have surgical fracture repair. Main outcomes included the trends in the proportion of those undergoing surgery, the site of death, and six-month survival.

RESULTS

Between 1999 and 2007, approximately 1% (n=14,400) of patients aged 75 years and older admitted with a diagnosis of their first hip fracture were receiving hospice services in the 30 days before that admission and 83.4% underwent surgery. Among patients on hospice at the time of the hip fracture, 8.8% died during the initial hospitalization and an additional two-thirds died within the first six months on hospice. The median survival from hospital admission was 25.9 days for those forgoing surgery compared with 117 days for those who had surgery, adjusted for age, race, and other covariates (P<0.001).

CONCLUSION

Despite being on hospice services, the majority underwent surgery with improved survival. Sixty-six percent of all individuals on hospice at the time of the fracture died in the first six months, with the majority returning to hospice services.

The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents

PURPOSE

Individuals receiving postacute care in skilled nursing facilities often require complex, skilled care provided by licensed nurses. It is believed that a stable set of nursing personnel is more likely to deliver better care. The purpose of this study was to determine the relationships among licensed nurse retention, turnover, and a 30-day rehospitalization rate in nursing homes (NHs).

DESIGN AND METHODS

We combined two data sources: NH facility-level data (including characteristics of the facility, the market, and residents) and the Florida Nursing Home Staffing Reports (which provide staffing information for each NH) for 681 Florida NHs from 2002 to 2009. Using a two-way fixed effects model, we examined the relationships among licensed nurse turnover rates, retention rates, and 30-day rehospitalization rates.

RESULTS

Results indicate that an NH's licensed nurse retention rate is significantly associated with the 30-day rehospitalization rate (est. = -.02, p = .04) controlling for demographic characteristics of the patient population, residents' preferences for hospitalization, and the ownership characteristics of the NH. The NHs experiencing a 10% increase in their licensed nurse retention had a 0.2% lower rehospitalization rate, which equates to 2 fewer hospitalizations per NH annually. Licensed nurse turnover is not significantly related to the 30-day rehospitalization rate.

IMPLICATIONS

These findings highlight the need for NH administrators and policy makers to focus on licensed nurse retention, and future research should focus on the measures of staff retention for understanding the staffing/quality relationship.