Inappropriate hospitalization of nursing facility residents: a symptom of a sick system of care for frail older people

Association between discontinuity in clinicians and outcomes of nursing home residents

Little is known about the impact of clinician discontinuity on quality of care for nursing home residents. We examined the association between clinician discontinuity and outcomes of residents with long-term care stays up to 3 years using claims for a national 20% sample of Medicare fee-for-service beneficiaries from 2014 through 2019. We used an event study analysis that accounted for staggered treatment timing. Estimates were adjusted for resident, clinician, and nursing home characteristics. Three sensitivity analyses were conducted. The first excluded small nursing homes, which were in the lowest quartile based on the number of beds. The second attributed residents to clinician practices rather than individual clinicians. The third removed the 3-year long-term care stay restriction. We found that, compared to residents who did not experience a clinician change, those with a clinician change had a 0.7 percentage point higher likelihood of an ambulatory care sensitive hospitalization in a given quarter (a 36.8% relative increase). Clinician discontinuity was not associated with ambulatory care sensitive emergency department visits. Results from our 3 sensitivity analyses were consistent with those from the primary analysis. Policymakers may consider using continuity in clinicians as a marker of nursing home quality.

Untangling the complex web of avoidable nursing home-to-hospital transfers of residents with dementia

INTRODUCTION

Nursing home (NH) residents with Alzheimer's disease or related dementias (ADRD) are at high risk for hospital transfer. We aimed to (1) describe characteristics and predictors of avoidable transfer of residents with ADRD and (2) explore how "what matters" influences the decision to transfer.

METHODS

We applied an exploratory, mixed methods design using data collected as part of a Centers for Medicare and Medicaid Services demonstration project. Advanced practice registered nurses documented retrospective details about nursing home (NH)-to-hospital transfers (n = 3687) from 16 NHs.

RESULTS

NH residents with ADRD had 1.22 times higher odds of having an avoidable NH-to-hospital transfer (odds ratio = 1.22; 95% confidence interval = 1.03, 1.45). Factors contributing to avoidable transfers were age, stage of ADRD, what matters to the resident and their family, changes in condition, and resources available in the NH.

DISCUSSION

These findings highlight the need for enhanced specificity in the discussion and documentation of resident and family preferences and continued investments in the NH workforce.

HIGHLIGHTS

This article reports on factors contributing to avoidable nursing home (NH)-to-hospital transfer of residents with Alzheimer's disease and related dementias (ADRD). The mixed methods design used in this study offers insight beyond what is possible using a single-method design. Using data collected from a Centers for Medicare and Medicaid Services demonstration project, advanced practice registered nurses documented retrospective details about NH-to-hospital transfers (n = 3687) of residents. NH residents with ADRD were more likely to have an avoidable NH-to-hospital transfer. Factors contributing to avoidable transfers were age, stage of ADRD, what matters to the resident and their family, changes in condition, and resources available in the NH. These findings highlight the need for enhanced specificity in discussion and documentation of resident and family preferences and continued investments in the NH workforce.

The rate, causes and predictors of ambulance call outs to residential aged care in the Australian Capital Territory: A retrospective observational cohort study

Older people in residential aged care are susceptible to acute illness or injury which may necessitate an ambulance call out, assessment/treatment by a paramedic and transfer to a hospital emergency department. Understanding the case mix of residential aged care ambulance attendances is important for prevention strategies and for planning services. A retrospective observational closed cohort study was designed to investigate the characteristics of emergency ambulance call outs to 15 residential aged care sites in the Australian Capital Territory over a 12-month period. Data were collected from the local ambulance service and the aged care sites. Case load data were analysed to determine rates, clinical characteristics, ambulance attendance outcomes and the temporal distribution of call outs. A Poisson regression model was developed to investigate demographic, morbidity and medication-related risk factors associated with the number of ambulance call outs per resident. Annual ambulance call out costs were estimated. There were 1,275 residents, with 396 (31.1%) requiring at least one ambulance call out over 12 months. Of 669 ambulance attendances, the majority (87.0%) were transported to emergency departments. Trauma (23.9%), pain (16.9%) and infections (9.4%) were the most common primary assessments by the ambulance attendees. Cases/day were similar throughout the year and on weekdays compared to weekends/public holidays. The main predictors of ambulance call out were multi-morbidity, taking regular anticholinergic medicines, being male and younger age. Estimated costs of ambulance call outs/year were $475/resident and $40,375/residential aged care site. The most frequent primary assessments (trauma, pain, infections) may constitute priorities for developing prevention strategies and for treatment initiatives within residential aged care. Strategies to reduce anticholinergic medication prescribing may also be a potential intervention to decrease ambulance call outs and hospital emergency department demand. The ambulance usage data from this study may be useful to compare with future datasets to measure the impact of the introduction of new services.

Emergency physicians' and nurses' perception on the adequacy of emergency calls for nursing home residents: a non-interventional prospective study

Introduction

A considerable percentage of daily emergency calls are for nursing home residents. With the ageing of the overall European population, an increase in emergency calls and interventions in nursing homes (NH) is to be expected. A proportion of these interventions and hospital transfers may be preventable and could be considered as inappropriate by prehospital emergency medical personnel. The study aimed to understand Belgian emergency physicians' and emergency nurses' perspectives on emergency calls and interventions in NHs and investigate factors contributing to their perception of inappropriateness.

Methods

An exploratory non-interventional prospective study was conducted in Belgium among emergency physicians and emergency nurses, currently working in prehospital emergency medicine. Electronic questionnaires were sent out in September, October and November 2023. Descriptive statistics were used to analyze the overall results, as well as to compare the answers between emergency physicians and emergency nurses about certain topics.

Results

A total of 114 emergency physicians and 78 nurses responded to the survey. The mean age was 38 years with a mean working experience of 10 years in prehospital healthcare. Nursing home staff were perceived as understaffed and lacking in competence, with an impact on patient care especially during nights and weekends. General practitioners were perceived as insufficiently involved in the patient's care, as well as often unavailable in times of need, leading to activation of Emergency Medical Services (EMS) and transfers of nursing home residents to the Emergency Department (ED). Advance directives were almost never available at EMS interventions and transfers were often not in accordance with the patient's wishes. Palliative care and pain treatment were perceived as insufficient. Emergency physicians and nurses felt mostly disappointed and frustrated. Additionally, differences in perception were noted between emergency physicians and nurses regarding certain topics. Emergency nurses were more convinced that the nursing home physician should be available 24/7 and that transfers could be avoided if nursing home staff had more authority regarding medical interventions. Emergency nurses were also more under the impression that pain management was inadequate, and emergency physicians were more afraid of the medical implications of doing too little during interventions than emergency nurses. Suggestions to reduce the number of EMS interventions were more general practitioner involvement (82%), better nursing home staff education/competences (77%), more nursing home staff (67%), mobile palliative care support teams (65%) and mobile geriatric nursing intervention teams (52%).

Discussion and conclusion

EMS interventions in nursing homes were almost never seen as necessary or indicated by emergency physicians and nurses, with the appropriate EMS level almost never being activated. The following key issues were found: shortages in numbers and competence of nursing home staff, insufficient primary care due to the unavailability of the general practitioner as well as a lack of involvement in patient care, and an absence of readily available advance directives. General practitioners should be more involved in the decision to call the Emergency Medical Services (EMS) and to transfer nursing home residents to the Emergency Department. Healthcare workers should strive for vigilance regarding the patients' wishes. The emotional burden of deciding on an avoidable hospital admission of nursing home residents, perhaps out of fear for medico-legal consequences if doing too little, leaves the emergency physicians and nurses frustrated and disappointed. Improvements in nursing home staffing, more acute and chronic general practitioner consultations, and mobile geriatric and palliative care support teams are potential solutions. Further research should focus on the structural improvement of the above-mentioned shortcomings.

Perceptions of Nurses Delivering Nursing Home Virtual Care Support: A Qualitative Pilot Study

Avoidable hospitalizations among nursing home residents result in poorer health outcomes and excess costs. Consequently, efforts to reduce avoidable hospitalizations have been a priority over the recent decade. However, many potential interventions are time-intensive and require dedicated clinical staff, although nursing homes are chronically understaffed. The OPTIMISTIC project was one of seven programs selected by CMS as "enhanced care & coordination providers" and was implemented from 2012 to 2020. This qualitative study explores the perceptions of the nurses that piloted a virtual care support project developed to expand the program's reach through telehealth, and specifically considered how nurses perceived the effectiveness of this program. Relationships, communication, and access to information were identified as common themes facilitating or impeding the perceived effectiveness of the implementation of virtual care support programs within nursing homes.

Critical Age Theory: Institutional Abuse of Older People in Health Care

Theories of elder abuse focus on the characteristics of the victim, the perpetrator, and the context of abuse. Although all three factors play a role, we are biased to notice individual misbehavior as the primary and sole cause of abuse. We see individuals as responsible for abuse. By examining abuses across a spectrum of healthcare services, abuse is more likely to be due to the institutional culture that includes the use of medications, Assisted Living, Skilled Nursing Facilities/nursing homes, hospices, hospitals, and Medicare Advantage programs. This study highlights multiple and consistent institutional abuses that result in harm and death of older adults on a consistent basis. The results show that when profit is increased, standards of care are diminished, and abuse ensues. Assigning responsibility to the management of healthcare becomes a priority in reducing this level of abuse. However, there are biases that stop us from assigning blame to institutions. Individual healthcare workers adhere to work protocol and rationalize the negative outcomes as inevitable or due to the vulnerability and frailness of older people. This culture is socialized for new employees that develop a culture of diminishing the needs of the individual patient in favor of the priorities dictated by the management protocol. In addition, the public is focused on assigning blame to individuals. Once an individual is assigned blame then they do not look beyond that to understand the context of abuse. A context that is generated by healthcare facilities maximizing profit and denigrating patient care. Regulatory agencies such as the U.S. DHHS, CDC, State Public Health Agencies, State/City Elder Abuse units, and Ombudsmen Programs all collude, for multiple reasons, in diminishing institutional responsibility.

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone.

CONTEXT

In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).

METHODS

Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.

FINDINGS

Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.

CONCLUSIONS

Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations

BACKGROUND

Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care.

METHODS

The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective.

RESULTS

Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate.

CONCLUSIONS

As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03590470 ).

Examining Social Networks in Text Messages About Nursing Home Resident Health Status

Social network analysis (SNA) uses quantitative methods to analyze relationships between people. In the current study, SNA was applied in two nursing homes (NHs) to describe how health care teams interact via text messages. Two data sources were used: (a) a Qualtrics^® survey completed by advanced practice RNs containing resident transfer data, and (b) text messages from a secure platform called Mediprocity™. SNA software was used to generate a visual representation of the social networks and calculate quantitative measures of network structure, including density, clustering coefficient, hierarchy, and centralization. Differences were found in the low and high transfer rate NHs for all SNA measures. Staff in the NH with low transfer rate had greater decision-making interactions, higher information exchange rates, and more individuals communicating with each other compared to the high transfer rate NH. SNA can be applied to examine communication patterns found in text messages occurring around the time of NH resident transfers. [Journal of Gerontological Nursing, 47(7), 16-22.].

Frailty and risk of mortality and hospitalization in nursing home residents affected by COVID-19

Coronavirus disease 2019 (COVID-19) is a widespread condition in nursing homes (NHs). However, no research was made regarding frailty in NH residents during COVID-19 pandemic. The aim of this study was to assess whether frailty, assessed by the multidimensional prognostic index (MPI), can predict mortality/hospitalization in COVID-19 NH residents. A Cox’s regression analysis was used, reporting the results as hazard ratios (HRs) with 95% confidence intervals (CIs). 1146 NH residents affected by COVID-19 were included (mean age: 86 years; 75.4% females). During the followup period, we observed 286 deaths and 239 hospitalizations. Taking those with MPI <0.41 as reference, an MPI ≥0.50 was associated with a higher risk of death (HR=1.41; 95%CI: 1.07-1.85). Similar results were obtained using the MPI score increase in 0.10 points (HR=1.12; 95%CI: 1.03-1.23). Using hospitalization as outcome, only MPI score as continuous variable was associated with this outcome (HR=1.08; 95%CI: 1.002-1.17). In conclusion, frailty, as assessed by the MPI, was associated with a significant higher risk of mortality and hospitalization in NH residents affected by COVID-19 further indicating the necessity of assessing frailty in NH.

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes

OBJECTIVES

Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ.

DESIGN

Data from a 2-year prospective study of residents who participated in a randomized controlled trial.

SETTING AND PARTICIPANTS

All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period.

METHODS

Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators.

RESULTS

A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days.

CONCLUSIONS/IMPLICATIONS

Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).

Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study

Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.

Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial

IMPORTANCE

Dementia is often underdiagnosed in nursing homes (NHs). This potentially results in inappropriate care, and high rates of emergency department (ED) transfers in particular.

OBJECTIVE

To assess whether systematic dementia screening of NH residents combined with multidisciplinary team meetings resulted in a lower rate of ED transfer at 12 months compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster randomized trial with NHs as the unit of randomization. The IDEM (Impact of Systematic Tracking of Dementia Cases on the Rate of Hospitalization in Emergency Care Units) trial took place at 64 public and private NHs in France. Recruitment started on May 1, 2010, and was completed on March 31, 2012. Residents who were aged 60 years or older, had no diagnosed or documented dementia, were not bedridden, had lived in the NH for at least 1 month at inclusion, and had a life expectancy greater than 12 months were included. The residents were followed up for 18 months. The main study analyses were completed on October 14, 2016.

INTERVENTION

Two parallel groups were compared: an intervention group consisting of NHs that set up 2 multidisciplinary team meetings to identify residents with dementia and to discuss an appropriate care plan, and a control group consisting of NHs that continued their usual practice. During the inclusion period of 23 months, all residents of participating NHs who met eligibility criteria were included in the study.

MAIN OUTCOMES AND MEASURES

The primary end point (ED transfer) was analyzed at 12 months, but the residents included were followed up for 18 months.

RESULTS

A total of 64 NHs participated in the study and enrolled 1428 residents (mean [SD] age, 84.7 [8.1] years; 1019 [71.3%] female): 599 in the intervention group (32 NHs) and 829 in the control group (32 NHs). The final study visit was completed by 1042 residents (73.0%). The main reason for early discontinuation was death (318 residents [22.7%]). The intervention did not reduce the risk of ED transfers during the 12-month follow-up: the proportion of residents transferred at least once to an ED during the 12-month follow-up was 16.2% in the intervention group vs 12.8% in the control group (odds ratio, 1.32; 95% CI, 0.83-2.09; P = .24).

CONCLUSIONS AND RELEVANCE

This study failed to demonstrate that systematic screening for dementia in NHs resulted in fewer ED transfers. The findings do not support implementation of multidisciplinary team meetings for systematic dementia screening of all NH residents, beyond the national recommendations for dementia diagnosis, to reduce ED transfers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01569997.

Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey

BACKGROUND

Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany.

METHODS

A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested.

RESULTS

486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement.

CONCLUSIONS

Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.

Nursing Facilities Can Reduce Avoidable Hospitalizations Without Increasing Mortality Risk For Residents

Implementation of the Centers for Medicare and Medicaid Services' Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents reflected recognition of the adverse impacts of excess hospitalizations on the cost of care and the well-being of long-stay residents. Prior studies of the initiative have found favorable effects on reducing hospitalizations and costs, but were these accompanied by unintended consequences for well-being? We tracked all-cause mortality rates in each year for the period 2014-16 among long-stay residents at nursing facilities in seven states that participated in the initiative, and we found no evidence of excess mortality. The initiative's effects on mortality rates were small-ranging from a reduction of 0.8 percentage points to an increase of 1.5 percentage points, relative to changes in mortality rates at comparison-group facilities-and none of the effects was significant. This suggests that efforts to reduce unnecessary hospitalizations among nursing facility residents can succeed without increasing mortality rates.

Association Between 5-Star Nursing Home Report Card Ratings and Potentially Preventable Hospitalizations

Nursing homes' publicly reported star ratings increased substantially since Centers for Medicare & Medicaid Services's Nursing Home Compare adopted a 5-star rating system. Our objective was to test whether the improvements in nursing home 5-star ratings were correlated with reductions in rates of hospitalization. We hypothesized that increased attention to 5-star star ratings motivated nursing homes to make changes that improved their star ratings but did not affect their hospitalization rate, resulting in a weakened association between ratings and hospitalizations. We used 2007-2010 Medicare hospital claims and nursing home clinical assessment data to compare the correlation between nursing home 5-star ratings and hospitalization rates before versus after 5-star ratings were publicly released. The correlation between the rate of hospitalization and a nursing home's 5-star rating weakened slightly after the ratings became publicly available. This decrease in correlation was concentrated among patients receiving post-acute care, who experienced relatively more hospitalizations from best-rated nursing homes. The improvements in nursing home star ratings after the release of Medicare's 5-star rating system were not accompanied by improvements in a broader measure of outcomes for post-acute care patients. Although this dissociation may be due to better matching of sicker patients to higher-quality nursing homes or superficial improvements by nursing homes to increase their ratings without substantial investments in quality improvement, the 5-star ratings nonetheless became less meaningful as an indicator of nursing home quality for post-acute care patients.

Nursing Home-Hospice Collaboration and End-of-Life Hospitalizations Among Dying Nursing Home Residents

OBJECTIVES

Nursing homes (NHs) collaboration with hospices appears to improve end-of-life (EOL) care among dying NH residents. However, the potential benefits of NH-hospice collaboration may vary with the patterns of this collaboration. This study examines the relationship between the attributes of NH-hospice collaboration, especially the exclusivity of NH-hospice collaboration (ie, the number of hospice providers in a NH), and EOL hospitalizations among dying NH residents.

DESIGN

This national retrospective cohort study linked 2000-2009 NH assessments (ie, the Minimum Data Set 2.0) and Medicare data. A linear probability model with facility fixed-effects was estimated to examine the relationship between EOL hospitalization and the attributes of NH-hospice collaborations, adjusting for individual and facility characteristics. We also performed a set of sensitivity analyses, including stratified analyses by volume of hospice services in a NH and stratified analyses by rural vs urban NH locations.

SETTINGS

All Medicare and/or Medicaid certified US NHs with at least 8 years of data and at least 30 beds.

PARTICIPANTS

NH decedents resided in Medicare and/or Medicaid certified NHs in the US between 2000 and 2009. We restricted the analyses to those continuously enrolled in Medicare fee-for-service in the last 6 months of life and those who were in NHs for the last 30 days of life. In total, we identified 2,954,276 NH decedents over the study period.

MEASUREMENTS

The outcome variable was measured as dichotomous, indicating whether a dying NH resident was hospitalized in the last 30 days of life. The attributes of NH-hospice collaboration were measured by the volume of hospice services (defined as the ratio of number of hospice days to the total NH days per NH per calendar year) and the number of hospice providers in a NH (defined as the number of unique hospice providers in a NH per year). We categorized NHs into groups based on the number of hospice providers (1, 2 or 3, and ≥4) in the NH, and conducted sensitivity analysis using a different categorization (1, 2, and 3+ hospice providers).

RESULTS

The pattern of NH-hospice collaboration changed significantly over years; the average number of hospices in a NH increased from 1.4 in 2000 to 3.2 in 2009. The volume of NH-hospice collaboration also increased substantially. The multivariate regression analyses indicated that having more hospice providers in the NH was not associated with lower risks of EOL hospitalizations. After accounting for individual and facility characteristics, increasing hospice providers from 1 to at least 4 was associated with an overall 1 percentage point increase in the likelihood of EOL hospitalizations among dying residents (P < .01), and such relationship remained in NHs with moderate or high volume NHs in the stratified analyses. Stratified analysis by rural vs urban NHs suggested that the relationship between the number of hospice providers and EOL hospitalizations was mainly in urban NHs.

CONCLUSIONS

More hospice providers in the NH was not associated with lower EOL hospitalizations, especially among NHs with relatively high volume of hospice services.

Falls, Depression, and Other Hospitalization Risk Factors for Adults in Residential Care Facilities

Prior research has shown a relationship between falls, hospitalizations, and depression among older adults in nursing home settings, but few studies have explored these relationships for younger and older adults in residential care facilities. This study examined risk factors for hospitalizations among assisted living residents. Using the 2010 National Survey of Residential Care Facilities, the study found that 24% of residents had a hospital stay in the past year. Residents with falls were more than twice as likely to have a hospitalization. For younger residents, depression was a key risk factor (OR = 1.74, p < .01). However, older residents with dementia had a lower risk of hospitalization (OR = 0.71, p < .01). More attention is needed to prevent falls and identify residents with depression and severe mental illness, who are at greater risk of hospitalization. Reducing avoidable hospitalizations can improve well-being for older and younger adults in residential care facilities.

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

IMPLICATIONS

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

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.

Reducing Inpatient Hospital and Emergency Room Utilization Among Nursing Home Residents

OBJECTIVE

To examine the association among nursing home residents between strength of relationship with a primary care provider (PCP) and inpatient hospital and emergency room (ER) utilization.

METHOD

Medicare administrative data for beneficiaries residing in a nursing home between July 2007 and June 2009 were used in multivariate analyses controlling for beneficiary, nursing home, and market characteristics to assess the association between two measures-percentage of months with a PCP visit and whether the patient maintained the same usual source of care after nursing home admission-and hospital admissions and ER visits for all causes and for ambulatory care sensitive conditions (ACSCs).

RESULTS

Both measures of strength of patient-provider relationships were associated with fewer inpatient admissions and ER visits, except regularity of PCP visits and ACSC ER visits.

DISCUSSION

Policy makers should consider increasing the strength of nursing home resident and PCP relationships as one strategy for reducing inpatient and ER utilization.

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.

The Role of Severe Dementia in Nursing Home Report Cards

Health care report cards are intended to improve quality, but there may be considerable heterogeneity in who benefits. In this article, we examine the intended and unintended effects of quality reporting for nursing home residents with severe dementia relative to other residents, using a difference-in-differences design to examine selected reported and unreported quality measures. Our results indicate that prior to public reporting, nursing home residents with severe dementia were at significantly higher risk of poor outcomes on most reported quality measures. After public reporting was initiated, outcomes for nursing home residents with severe dementia did not consistently improve or worsen. We see no evidence that individuals with severe dementia are being avoided by nursing homes, despite their potential negative impact on quality scores, but we do find an increase in coding of end-stage disease. Additional risk-adjustment, stratification, or additional quality measures may be warranted.

The effect of hospice on hospitalizations of nursing home residents

OBJECTIVES

Hospice enrollment is known to reduce risk of hospitalizations for nursing home residents who use it. We examined whether residing in facilities with a higher hospice penetration: (1) reduces hospitalization risk for nonhospice residents; and (2) decreases hospice-enrolled residents' hospitalization risk relative to hospice-enrolled residents in facilities with a lower hospice penetration.

METHODS

Medicare Beneficiary File, Inpatient and Hospice Claims, Minimum Data Set Version 2.0, Provider of Services File, and Area Resource File. Retrospective analysis of long-stay nursing home residents who died during 2005-2007. Overall, 505,851 nonhospice (67.66%) and 241,790 hospice-enrolled (32.34%) residents in 14,030 facilities nationwide were included. We fit models predicting the probability of hospitalization conditional on hospice penetration and resident and facility characteristics. We used instrumental variable method to address the potential endogeneity between hospice penetration and hospitalization. Distance between each nursing home and the closest hospice was the instrumental variable.

RESULTS

In the last 30 days of life, 37.63% of nonhospice and 23.18% of hospice residents were hospitalized. Every 10% increase in hospice penetration leads to a reduction in hospitalization risk of 5.1% for nonhospice residents and 4.8% for hospice-enrolled residents.

CONCLUSIONS

Higher facility-level hospice penetration reduces hospitalization risk for both nonhospice and hospice-enrolled residents. The findings shed light on nursing home end-of-life care delivery, collaboration among providers, and cost benefit analysis of hospice care.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations

BACKGROUND

Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services.

METHODS

We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation.

RESULTS

Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant.

CONCLUSIONS

Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study

Background

Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.

Methods

We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.

Results

Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.

Conclusions

ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.

The association between long-term care setting and potentially preventable hospitalizations among older dual eligibles

OBJECTIVE

To compare the probability of experiencing a potentially preventable hospitalization (PPH) between older dual eligible Medicaid home and community-based service (HCBS) users and nursing home residents.

DATA SOURCES

Three years of Medicaid and Medicare claims data (2003-2005) from seven states, linked to area characteristics from the Area Resource File.

STUDY DESIGN

A primary diagnosis of an ambulatory care sensitive condition on the inpatient hospital claim was used to identify PPHs. We used inverse probability of treatment weighting to mitigate the potential selection of HCBS versus nursing home use.

PRINCIPAL FINDINGS

The most frequent conditions accounting for PPHs were the same among the HCBS users and nursing home residents and included congestive heart failure, pneumonia, chronic obstructive pulmonary disease, urinary tract infection, and dehydration. Compared to nursing home residents, elderly HCBS users had an increased probability of experiencing both a PPH and a non-PPH.

CONCLUSIONS

HCBS users' increased probability for potentially and non-PPHs suggests a need for more proactive integration of medical and long-term care.

Effect of nursing home ownership on hospitalization of long-stay residents: an instrumental variables approach

Hospitalizations among nursing home residents are frequent, expensive, and often associated with further deterioration of resident condition. The literature indicates that a substantial fraction of admissions is potentially preventable and that nonprofit nursing homes are less likely to hospitalize their residents. However, the correlation between ownership and hospitalization might reflect unobserved resident differences rather than a causal relationship. Using national minimum data set assessments linked with Medicare claims, we use a national cohort of long-stay residents who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that IV estimates of the effect of nonprofit ownership on hospitalization are at least as large as the non-instrumented effects, indicating that selection bias does not explain the observed relationship. We also found evidence suggesting the lower rate of hospitalizations among nonprofits was due to a different threshold for transfer.

Hospitalizations of nursing home residents in the last year of life: nursing home characteristics and variation in potentially avoidable hospitalizations

OBJECTIVES

To examine the incidence of, variations in, and costs of potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents at the end of life and to identify the association between NH characteristics and a facility-level quality measure (QM) for PAH.

DESIGN

Retrospective.

SETTING

Hospitalizations originating from NHs.

PARTICIPANTS

Long-term care NH residents who died in 2007.

MEASUREMENTS

A risk-adjusted QM was constructed for PAH. A Poisson regression model was used to predict the count of PAH given residents' risk factors. For each facility, the QM was defined as the difference between the observed facility-specific rate (per 1,000 person-years) of PAH (O) and the expected risk-adjusted rate (E). A logistic regression model with state fixed-effects was then fit to examine the association between facility characteristics and the likelihood of having higher-than-expected rates of PAH (O-E > 0). QM values greater than 0 indicate worse-than-average quality.

RESULTS

Almost 50% of hospital admissions for NH residents in their last year of life were for potentially avoidable conditions, costing Medicare $1 billion. Five conditions were responsible for more than 80% of PAHs. PAH QM across facilities showed significant variation (mean 12.0 ± 142.3 per 1,000 person-years, range -399.48 to 398.09 per 1,000 person-years). Chain and hospital-based facilities were more likely to exhibit better performance (O-E < 0). Facilities with higher nursing staffing were more likely to have better performance, as were facilities with higher skilled staff ratio, those with nurse practitioners or physician assistants, and those with on-site X-ray services.

CONCLUSION

Variations in facility-level PAHs suggest that a potential for reducing hospital admissions for these conditions may exist. Presence of modifiable facility characteristics associated with PAH performance could help us formulate interventions and policies for reducing PAHs at the end of life.

Referrals from nursing home to hospital: reasons, appropriateness and costs

BACKGROUND

Nursing home residents represent a frail and multimorbid group of patients. The rationality of the hospitalisation of nursing home patients has therefore been questioned.

OBJECTIVE

To investigate hospital referrals of nursing home patients in the municipality of Stavanger, Norway and identify the number of inappropriate referrals and costs.

METHODS

The number of referrals was retrospectively identified by the emergency dispatch centre in the 18 municipalities of South Rogaland in 2011. For the municipality of Stavanger, referring instance, reason for referral, purpose of referral, the existence of an advance care plan, and appropriateness were assessed. Total costs and costs for inappropriate referrals were estimated.

RESULTS

In Stavanger there were 0.38 hospital referrals per nursing home bed per year as compared to 0.60 in the surrounding municipalities. Of 359 referrals, 78.6% resulted in an in-hospital stay, in-hospital mortality rate was 7.8%, and 7% were assessed as being inappropriate. The costs per referral were estimated to be €6198.

CONCLUSION

Stavanger had a lower referral rate than the surrounding municipalities. The results also show that the in-hospital mortality rate and the share of inappropriate referrals were low compared to other studies in the field. Further research is needed in order to evaluate which interventions are effective in improving medical care at nursing homes and thus reduce referral rates.

Medicaid bed-hold policies and hospitalization of long-stay nursing home residents

OBJECTIVE

To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents.

DATA SOURCES

A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005.

STUDY DESIGN

Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents.

PRINCIPAL FINDINGS

Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039-0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean.

CONCLUSIONS

Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program.

Predictors of early mortality among hospitalized nursing home residents

BACKGROUND

Emergency admissions from nursing homes (NHs) are associated with high mortality. Understanding the predictors of early mortality in these patients may guide clinicians in choosing appropriate site and level of care.

METHODS

We identified all consecutive admissions from NHs (all ages) to an Acute Medical Assessment Unit between January 2005 and December 2007. Analysis was performed at the level of the admission. The predictors of in-patient mortality at 7 days were examined using a generalized estimating equations analysis.

RESULTS

A total of 314 patients [32% male, mean age: 84.2 years (SD: 8.3 years)] were admitted during the study period constituting 410 emergency episodes. Twenty-three percent of admissions resulted in hospital mortality with 73% of deaths occurring within 1 week (50% within the first 3 days). For 7-day mortality outcome, patients with a modified early warning score (MEWS) of 4-5 on admission had 12 times the odds of death [95% confidence interval (CI) 1.40-103.56], whereas those with a score of ≥6 had 21 times the odds of death (95% CI 2.71-170.57) compared with those with a score of ≤1. An estimated glomerular filtration rate (eGFR) of 30-60 and <30 ml/min/m(2) was associated with nearly a 3-fold increase in the odds of death at 1 week (95% CI 1.10-7.97) and a 5-fold increase in the odds of death within 1 week (95% CI 1.75-14.96), respectively, compared with eGFR > 60 ml/min/m(2). C-reactive protein (CRP) >100 mg/l on admission was also associated with a 2.5 times higher odds of death (95% CI 1.23-4.95). Taking eight or more different medication items per day was associated with only a third of the odds of death (95% CI 0.09-0.98) compared with patients taking only three or fewer per day.

CONCLUSION

In acutely ill NH residents, MEWS is an important predictor of early hospital mortality and can be used in both the community and the hospital settings to identify patients whose death maybe predictable or unavoidable, thus allowing a more holistic approach to management with discussion with patient and relatives for planning of immediate care. In addition, CRP and eGFR levels on admission have also been shown to predict early hospital mortality in these patients and can be used in conjunction with MEWS in the same way to allow decision making on the appropriate level of care at the point of hospital admission.

Predictors of emergency commitment for nursing home residents: the role of resident and facility characteristics

OBJECTIVES

The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida.

DESIGN

This retrospective cohort study employed 2.5 years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database.

SETTING

Medicaid-certified NHs in Florida (N= 584).

PARTICIPANTS

Medicaid-enrolled NH residents (N= 32,604).

RESULTS

Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination.

CONCLUSION

Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events.

Hospitalization rates of nursing home residents and community-dwelling seniors in British Columbia

The overall use of acute care services by nursing home (NH) residents in Canada has not been well documented. Our objectives were to identify the major causes of hospitalization among NH facility residents and to compare rates to those of community-dwelling seniors. A retrospective cohort was defined using population-level health administrative data, including all individuals aged 65 years and older living in a British Columbia NH facility between April 1996 and March 1999. Hospitalization rates of NH residents were compared to estimated rates for community-dwelling seniors, using age- and sex-adjusted standardized incidence ratios (SIRs): SIR = 2.81 (95%CI: 2.71, 2.91) for femoral fractures, 1.96 (1.88, 2.04) for pneumonia, 0.73 (0.70, 0.76) for other heart disease, and 1.01 (0.99, 1.02) for all causes. NH residents have disproportionately higher rates of hospitalization for femoral fractures and pneumonia, with NH residents accounting for approximately one quarter of all femoral fracture hospitalizations of BC seniors.

Is higher volume of postacute care patients associated with a lower rehospitalization rate in skilled nursing facilities?

This study determined whether higher patient volume of skilled nursing facility (SNF) care was associated with a lower hospital transfer rate. Using the nursing home Minimum Data Set and the Online Survey, Certification, and Reporting file, we assembled a national cohort of Medicare SNF postacute care admissions between January and September of 2008. Multivariable analyses based on Cox proportional hazards models found that patients admitted to high-volume SNFs (annual number of admissions in the top tertile group) showed an approximately 15% reduced risk for 30-day rehospitalization and an approximately 25% reduced risk for 90-day rehospitalization, compared with patients admitted to low-volume SNFs (annual number of admissions in the bottom tertile group, or <45). Similar patterns of volume-outcome associations were found for hospital-based and freestanding facilities separately. The inverse volume-outcome association in postacute SNF care may reflect a "practice makes perfect" effect, a "selective referral" effect, or both.

Racial disparities in rehospitalization among Medicare patients in skilled nursing facilities

OBJECTIVES

We examined racial disparities in rehospitalization rates among a cohort of non-Hispanic White and Black Medicare beneficiaries admitted to skilled nursing facilities for postacute care.

METHODS

We analyzed the 2008 national Nursing Home Minimum Data Set, augmented with other databases. We used multivariable logistic regression to estimate overall racial disparities in rehospitalization rates within 30 days and 90 days of nursing facility admission and the extent to which the disparities were explained by patient, facility, market, and state factors. Stratified analyses identified persistent disparities within patient subgroups, facility types, and states.

RESULTS

The 30-day rehospitalization rates were 14.3% for White patients (n = 865 993) and 18.6% for Black patients (n = 94 651); the 90-day rehospitalization rates were 22.1% and 29.5%, respectively. Both patient and admitting facility characteristics accounted for a considerable portion of overall racial disparities, but disparities persisted after multivariable adjustments overall and in patient subgroups.

CONCLUSIONS

We found persistent racial disparities in rehospitalization among the nation's skilled nursing facility patients receiving postacute care. Targeted efforts are needed to remove these disparities.

Hospitalizations in nursing homes: does payer source matter? Evidence from New York State

The objective of this study was to examine the reasons for different hospitalization rates between Medicaid and private-pay nursing home residents-to disentangle within-facility differences from across-facility variations in hospitalizations between these two types of residents. Multiple data sources (2003) for New York State were linked. Hospitalization was the dependent variable. Individual payer status was the main independent variable. Facilities were stratified into four groups by ownership status and bed-hold payment eligibility. We found both within-facility (Medicaid residents were more likely to be hospitalized than private-pay residents within a facility) and across-facility differences (facilities with a higher concentration of Medicaid residents were more likely to hospitalize their residents) controlling for individual and facility characteristics. The magnitude of within-facility differences varied with facility ownership and bed-hold eligibility. To reduce hospitalizations of Medicaid residents and to improve both quality of care and costs, policymakers may need to align Medicaid's and Medicare's incentives.

Predictors of nursing home residents' time to hospitalization

Objectives

To model the predictors of the time to first acute hospitalization for nursing home residents, and accounting for previous hospitalizations, model the predictors of time between subsequent hospitalizations.

Data Sources

Merged file from New York State for the period 1998–2004 consisting of nursing home information from the minimum dataset and hospitalization information from the Statewide Planning and Research Cooperative System.

Study Design

Accelerated failure time models were used to estimate the model parameters and predict survival times. The models were fit to observations from 50 percent of the nursing homes and validated on the remaining observations.

Principal Findings

Pressure ulcers and facility-level deficiencies were associated with a decreased time to first hospitalization, while the presence of advance directives and facility staffing was associated with an increased time. These predictors of the time to first hospitalization model had effects of similar magnitude in predicting the time between subsequent hospitalizations.

Conclusions

This study provides novel evidence suggesting modifiable patient and nursing home characteristics are associated with the time to first hospitalization and time to subsequent hospitalizations for nursing home residents.