Changes in the use of postacute care during the initial Medicare payment reforms

Experiences and Perceptions of Hospitalization and Recovery of Older Adults and Their Caregivers Following Traumatic Brain Injury: "Not Knowing"

The purpose of the current study is to describe the experience and perceptions of older adults and their caregivers following hospitalization for mild or moderate traumatic brain injury (TBI). Qualitative analysis of data obtained in individual semi-structured interviews with older adults and their caregivers (N = 11, five dyads and one individual) was performed to capture the perceptions and experiences of the survivor and their caregivers about the acute injury, hospitalization, and recovery. Data were collected over a 2-month period following discharge from the hospital. Open coding and constant comparative analysis generated codes that were revised throughout the analysis and reformulated into thematic descriptions. As a result, seven interrelated themes were identified. These findings can be used to implement interventions focused on recovery, communication, teaching, patient outcomes, and satisfaction. [Res Gerontol Nurs. 2019; 12(5):227-238].

Remuneración a los proveedores de servicios de salud en Bogotá

Objetivo Revisar los conceptos, desarrollos y efectos de los mecanismos de pago utilizados en diversos países, con el fin de proponer una metodología de pago aplicable para los hospitales de Bogotá.Método Se efectuó una revisión bibliográfica de tres aspectos de interés: conceptos esenciales, desarrollos alcanzados y efectos derivados de los mecanismos de pago utilizados en diversos países. Luego se efectuaron sesiones de trabajo entre los autores y con diversos grupos y equipos de la secretaria de salud de Bogotá, los hospitales, la academia y las autoridades nacionales en salud, para el diseño metodológico de un esquema de pago aplicable a los hospitales de la red adscrita de salud en Bogotá.Resultados La revisión bibliográfica permitió establecer los ejes de trabajo para un esquema de pago prospectivo por red con incentivos de desempeño, basado en optimización de la eficiencia técnica (provisión de servicios de salud a menor costo) y locativa (optimización de la mezcla de los servicios de salud) y en mejores resultados de atención.Discusión El esquema de reconocimiento planteado debe ser un factor integrador del proceso de atención al paciente y redundar en una mejor operación del aseguramiento, la prestación de servicios y la gobernanza de la atención en salud, al tiempo que optimiza el flujo de recursos y la sostenibilidad local del sistema.

Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges From US Hospitals

BACKGROUND/OBJECTIVES

The number of patients discharged to postacute care (PAC) facilities after hospitalization increased by 50% nationally between 1996 and 2010. We sought to describe payors and patients most affected by this trend and to identify diagnoses for which PAC facility care may be substituting for continued hospital care.

DESIGN

Retrospective analysis of the National Hospital Discharge Survey from 1996 to 2010.

SETTING

Adult discharges from a national sample of non-Federal hospitals.

PARTICIPANTS/EXPOSURES

Adults admitted and discharged to a PAC facility between 1996 and 2010. Our analysis includes 2.99 million sampled discharges, representative of 386 million discharges nationally.

MEASUREMENTS

Patient demographic and hospitalization characteristics, including length of stay (LOS) and diagnoses treated.

RESULTS

More than half (50.7%) of all patients discharged to PAC facilities were 80 years old or older in 2010; 40% of hospitalizations in this age group ended with a PAC stay. Decreases in LOS and increases in PAC facility use were consistent across payors and patient demographics. PAC facilities may be substituting for continued inpatient care for patients with pneumonia, hip fracture, and sepsis as these diagnoses demonstrated the clearest trends of decreasing LOS and increasing discharges to PAC facilities.

CONCLUSIONS

The rise in discharges to PAC facilities is occurring in all age groups and payors, though the predominant population is the very old Medicare patient, for whom successful rehabilitation may be most unsure. PAC facility care may be increasingly substituted for prolonged hospitalizations for patients with pneumonia, hip fracture, and sepsis.

Is personality associated with health care use by older adults?

CONTEXT

The patterns of health care utilization in the United States pose well-established challenges for public policy. Although economic and sociological research has resulted in considerable knowledge about what influences the use of health services, the psychological literature in this area is underdeveloped. Importantly, it is not known whether personality traits are associated with older adults' use of acute and long-term care services.

METHODS

Data were collected from 1,074 community-dwelling seniors participating in a Medicare demonstration. First they completed a self-report questionnaire measuring the "Big Five" personality traits: Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness. During the next two years, the participants maintained daily journals of their use of health care services. We used regression models based on the Andersen behavioral model of health care utilization to test for associations.

FINDINGS

Our hypothesis that higher Neuroticism would be associated with greater health care use was confirmed for three services-probability of any emergency department (ED) use, likelihood of any custodial nursing home use, and more skilled nursing facility (SNF) days for SNF users-but was disconfirmed for hospital days for those hospitalized. Higher Openness to Experience was associated with a greater likelihood of custodial home care use, and higher Agreeableness and lower Conscientiousness with a higher probability of custodial nursing home use. For users, lower Openness was associated with more ED visits and SNF days, and lower Conscientiousness with more ED visits. For many traits with significant associations, the predicted use was 16 to 30 percent greater for people high (low) versus low (high) in specific traits.

CONCLUSIONS

Personality traits are associated with Medicare beneficiaries' use of many expensive health care services, findings that have implications for health services research and policy. Accordingly, person-centered interventions, population-based translational effectiveness programs, and other personalized approaches that leverage the profound advances in personality psychology in recent decades should be considered.

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.

Effects of payment changes on trends in post-acute care

OBJECTIVE

To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.

DATA SOURCES

Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.

STUDY DESIGN

We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.

DATA EXTRACTION METHODS

A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.

PRINCIPAL FINDINGS

Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.

CONCLUSIONS

Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.

Bouncing-back: rehospitalization in patients with complicated transitions in the first thirty days after hospital discharge for acute stroke

BACKGROUND

"Bounce-backs" (movements from a less intensive to a more intensive care setting) soon after hospital discharge are common, but reasons for bouncing-back remain unknown.

OBJECTIVE

To examine how the primary diagnosis for first rehospitalization relates to thirty-day bounce-back number and initial discharge destination in acute stroke.

POPULATION

Administrative data from 5,250 Medicare beneficiaries > or = 65 years discharged with acute ischemic stroke in 1998-2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization.

ANALYSIS

Probability of thirty-day bounce-back was calculated using multivariate models.

RESULTS

Infections and aspiration pneumonitis were the most common reasons for rehospitalization, regardless of initial discharge site.

CONCLUSIONS

Efforts addressing aspirations and infections, the preventable complications of immobility, will be critical in decreasing acute stroke bounce-backs.

Perspectives on the state-of-the-science in rehabilitation medicine and its implications for Medicare postacute care policies

Better measurement of the case-mix complexity of patients receiving rehabilitation services is critical to understanding variations in the outcomes achieved by patients treated in different postacute care (PAC) settings. The Medicare program recognized this issue and is undertaking a major initiative to develop a new patient-assessment instrument that would standardize case-mix measurement in inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, and home health agencies. The new instrument, called the Continuity Assessment Record and Evaluation Tool, builds on the scientific advances in measurement to develop standard measures of medical acuity, functional status, cognitive impairment, and social support related to resource need, outcomes, and continuity of care for use in all PAC settings.