Advancing the science of population-based measures of home-time

Trajectories of care and outcomes of Veterans receiving home-based primary care

BACKGROUND

Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described.

METHODS

We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps.

RESULTS

We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care.

CONCLUSIONS

HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.

Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries

BACKGROUND

Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation.

OBJECTIVE

To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries.

RESEARCH DESIGN

We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data.

PARTICIPANTS

North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017.

MEASURES

We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS).

RESULTS

Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older.

CONCLUSIONS

Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.

Informing a home time measure reflective of quality of life: A data driven investigation of time frames and settings of health care utilization

OBJECTIVE

To evaluate short- and long-term measures of health care utilization-days in the emergency department (ED), inpatient (IP) care, and rehabilitation in a post-acute care (PAC) facility-to understand how home time (i.e., days alive and not in an acute or PAC setting) corresponds to quality of life (QoL).

DATA SOURCES

Survey data on community-residing veterans combined with multipayer administrative data on health care utilization.

STUDY DESIGN

VA or Medicare health care utilization, quantified as days of care received in the ED, IP, and PAC in the 6 and 18 months preceding survey completion, were used to predict seven QoL-related measures collected during the survey. Elastic net machine learning was used to construct models, with resulting regression coefficients used to develop a weighted utilization variable. This was then compared with an unweighted count of days with any utilization.

PRINCIPAL FINDINGS

In the short term (6 months), PAC utilization emerged as the most salient predictor of decreased QoL, whereas no setting predominated in the long term (18 months). Results varied by outcome and time frame, with some protective effects observed. In the 6-month time frame, each weighted day of utilization was associated with a greater likelihood of activity of daily living deficits (0.5%, 95% CI: 0.1%-0.9%), as was the case with each unweighted day of utilization (0.6%, 95% CI: 0.3%-1.0%). The same was true in the 18-month time frame (for both weighted and unweighted, 0.1%, 95% CI: 0.0%-0.3%). Days of utilization were also significantly associated with greater rates of instrumental ADL deficits and fair/poor health, albeit not consistently across all models. Neither measure outperformed the other in direct comparisons.

CONCLUSIONS

These results can provide guidance on how to measure home time using multipayer administrative data. While no setting predominated in the long term, all settings were significant predictors of QoL measures.

Hospital at Home as a Treatment Strategy for Worsening Heart Failure

Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

The Program of All-Inclusive Care for the Elderly: An Update after 25 Years of Permanent Provider Status

PACE is the gold standard for community-based integrated care. Over the 25 years as permanent provider status by Centers for Medicare and Medicaid Services, it has evolved in design and grown in numbers served. We review the evidence base, history, and future direction of PACE.

An evaluation of the outcome metric 'days alive and at home' in older patients after hip fracture surgery

'Days alive and at home' is a validated measure that estimates the time spent at home, defined as the place of residence before admission to hospital. We evaluated this metric in older adults after hip fracture surgery and assessed two follow-up durations, 30 and 90 days. Patients aged ≥ 70 years who underwent hip fracture surgery were identified retrospectively via hospital admission and government mortality records. Patients who successfully returned home and were still alive within 90 days of surgery were distinguished from those who were not. Regression models were used to examine which variables were associated with failure to return home and number of days at home among those who did return, within 90 days of surgery. We analysed the records of 825 patients. Median (IQR [range]) number of days at home within 90 days (n = 788) was 54 (0-76 [0-88]) days and within 30 days (n = 797) it was 2 (0-21 [0-28]) days. Out of these, 274 (35%) patients did not return home within 90 days and 374 (47%) within 30 days after surgery. Known peri-operative risk-factors such as older age, pre-operative anaemia and postoperative acute renal impairment were associated with failure to return home. This study supports days alive and at home as a useful patient-centred outcome measure in older adults after hip fracture surgery. We recommend that this metric should be used in clinical trials and measured at 90, rather than 30, postoperative days. As nearly half of this patient population did not return home within 30 days, the shorter time-period catches fewer meaningful events.

Using a home time measure to differentiate ACO performance for seriously ill populations

BACKGROUND

Alternative Payment Models (APMs) piloted by the Centers for Medicare and Medicaid Services (CMS) such as ACO Realizing Equity, Access and Community Health (REACH) seek to improve care and quality of life among seriously ill populations (SIP). Days at Home (DAH) was proposed for use in this model to evaluate organizational performance. It is important to assess the utility and feasibility of person-centered outcomes measures, such as DAH, as CMS seeks to advance care models for seriously ill beneficiaries. We leverage existing Accountable Care Organization (ACO) contracts to evaluate the feasibility of ACO-level DAH measure and examine characteristics associated with ACOs with more DAH.

METHODS

We calculated DAH for Medicare fee-for-service beneficiaries aged 68 and over who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. We then aggregated to the ACO level DAH for each ACO's seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, we evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics.

RESULTS

ACOs' seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32-351.53). Beneficiaries of ACOs are composed of a less racially diverse beneficiary cohort, opting for two-sided risk models, and operating in markets with fewer hospital and Skilled Nursing Facility beds had more DAH.

CONCLUSIONS

Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.

A Comparison of Home Health Utilization, Outcomes, and Cost Between Medicare Advantage and Traditional Medicare

BACKGROUND

Home health use is rising rapidly in the United States as the population ages, the prevalence of chronic disease increases, and older Americans express their desire to age at home. Enrollment in Medicare Advantage (MA) plans rather than Traditional Medicare (TM) has grown as well, from 13% of total Medicare enrollment in 2004 to 39% in 2020. Despite these shifts, little is known about outcomes and costs following home health in MA as compared with TM.

OBJECTIVE

The objective of this study was to measure the association of MA enrollment with outcomes and costs for patients using home health.

DESIGN

This was a retrospective cohort study.

PARTICIPANTS

Patients enrolled in plans offered by 1 large, national MA organization and patients enrolled in TM, with at least 1 home health visit between January 1, 2017, and June 30, 2018.

EXPOSURE

MA enrollment.

MAIN MEASURES

We compared the intensity of home health services and types of care delivered. The main outcome measures were hospitalization, the proportion of days in the home, and total allowed costs during the 180-day period following the first qualifying home health visit during the study period.

KEY RESULTS

Among patients who used home health, our models demonstrated enrollment in MA was associated with 14%, and 6% decreased odds of 60- and 180-day hospitalization, respectively, a 12.8% and 14.7% decrease in medical costs exclusive and inclusive of home health costs, respectively, and a 0.27% increase in the proportion of days at home during the 180-day follow-up, equivalent to an additional half-day at home. There were few differences in home health care delivered for MA and TM [mean number of visits in the first episode of care (17.1 vs. 17.3) and mean visits per week (3.2 vs. 3.3)]. The mean number of visits by visit type and percent of patients with each type was similar between MA and TM as well.

CONCLUSIONS

Compared with enrollment in TM, enrollment in MA was associated with improved patient-centered outcomes and lower cost and utilization, despite few differences in the way home health was delivered. These findings might be explained by structural components of MA that encourage better care management, but further investigation is needed to clarify the mechanisms by which MA enrollment may lead to higher value home health care.

Developing a person-centered, population based measure of "home time": Perspectives of older patients and unpaid caregivers

Measuring "home time," number of days not in facility-based care, with medical claims is a promising approach to assess person-centered outcomes on a population level. Generally, spending more time at home matches long-term care preferences and improves quality of life. However, existing "home time" measures have not incorporated key stakeholder perspectives. We sought to understand how patients and family caregivers value time spent in diverse facility-based health care settings (Emergency Department, Nursing Home, Post-Acute Care/Skilled Nursing, Inpatient Hospital) to help determine whether various settings have different effects on quality of life and thus merit different weighting in a "home time" measure. We conducted three focus groups among patients and family caregivers within the U.S. Veterans Health Care System. We identified themes pertaining to patients' quality of life in each of the four facility-based care settings. Discussions about both emergency department and post-acute/skilled nursing care reflected loss of personal control, counterbalanced by temporary stay. Inpatient hospital care evoked discussion about greater loss of personal control due to the intensity of care. Nursing homes ultimately signified decline. These findings illuminate differences in quality of life across health-care settings and help justify the need for different weights in a measure of "home time."

Hospital-free Days: A Pragmatic and Patient-centered Outcome for Trials Among Critically and Seriously Ill Patients

Hospital-free days (HFDs), alternatively known as "days alive and outside the hospital," is increasingly used as a primary or secondary outcome in randomized trials among critically and seriously ill patients. This novel outcome measure addresses an existing gap in the availability of patient-centered, reliably obtained outcome measures among patients with acute respiratory failure, advanced lung diseases, lung transplantation, and other serious and critical illnesses. Traditional outcomes such as mortality, organ-failure-free days, and longitudinal patient-reported measures have distinct drawbacks that limit their suitability as endpoints in trials of patients with serious illness, particularly those trials with pragmatic designs. By contrast, HFDs provides a summary measure of important health events and is easily calculated from administrative or electronic health record data, thereby balancing the goals of patient-centeredness and pragmatic measurement. However, before HFDs can be widely adopted as an endpoint in trials of patients with respiratory and critical illnesses, several questions must be addressed regarding the optimal definition, measurement, and analysis of HFDs. In this perspective, we outline important considerations relevant to the use of HFDs as a trial endpoint and suggest directions for further development of the measure.