Primary care of long-stay nursing home residents: approaches of three health maintenance organizations

Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes

OBJECTIVES

To assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs.

METHOD

This multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC.

RESULTS

A total of 2444 ED admissions were analysed. The patients' mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million.

CONCLUSIONS

Emergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.

Physician Practice Characteristics Influencing Nurse Practitioner and Physician Assistant Care in Nursing Homes: A Scoping Review

OBJECTIVES

Physicians, nurse practitioners (NPs), and physician assistants (PAs) are key to the effective delivery of medical care in nursing homes (NHs). Although several studies have reported on the relationship between the care delivered by a given discipline and specific clinical outcomes, the mediating effect of physician practice characteristics is unknown. A scoping review was conducted to determine whether studies examining the impact of NP and PA care in NHs have accounted for both the collaborative relationship between themselves and physicians as well as physician practice size and type.

DESIGN

Scoping review.

SETTINGS AND PARTICIPANTS

NH and NH residents.

METHODS

Papers eligible for review included peer-reviewed studies written in English and that were quantitative in nature. Inclusion criteria required that more than 1 NH and more than a single NP or PA be included for the analysis. Further, the size of the NH studied must have equaled or exceeded 100 residents and more than 1 clinical outcome reported. Databases searched included Ovid MEDLINE, Cochrane Library, Web of Science; CINAHL, and AgeLine.

RESULTS

A total of 1878 studies underwent abstract review of which 1719 were excluded. A full-text review of the remaining articles was completed (n = 157, as 2 articles could not be retrieved), of which 16 met eligibility criteria. The study designs were generally retrospective and quasi-experimental in nature. No randomized controlled studies were identified. Physician practice variables such as number of physicians, total practice case load, case mix, and the nature of the collaborative practice between NP/PA and MD were infrequently specified. In no reports was the type of physician practice characterized and no physician practice variables were adjusted for with regard to outcomes.

CONCLUSIONS

None of the studies included in the review were found to have incorporated any physician variables into their outcome analyses. Before purporting equivalency between medical provider disciplines in NHs, future studies must, at the very least, consider the mediating effect of physician practice characteristics.

Acute outreach service to nursing homes: A systematic review with GRADE and triple aim approach

BACKGROUND

People living in nursing homes face the risk of visiting the emergency department (ED). Outreach services are developing to prevent unnecessary transfers to ED.

AIMS

We aim to assess the performance of acute care services provided to people living in nursing homes or long-term homecare, focusing on ED transfer prevention, safety, cost-effectiveness and experiences.

MATERIALS & METHODS

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were eligible for inclusion if they were peer-reviewed and examined acute outreach services dedicated to delivering care to people in nursing homes or long-term homecare. The service models could also have preventive components. The databases searched were Scopus and CINAHL. In addition, Robins-I and SIGN checklists were used. The primary outcomes of prevented ED transfers or hospitalisations and the composite outcome of adverse events (mortality/Emergency Medical Service or ED visit after outreach service contact related to the same clinical condition) were graded with GRADE.

RESULTS

Fifteen relevant original studies were found-all were observational and focused on nursing homes. The certainty of evidence for acute outreach services with preventive components to prevent ED transfers or hospitalisations was low. Stakeholders were satisfied with these services. The certainty of evidence for solely acute outreach services to prevent ED transfers or hospitalisations was very low and inconclusive. Reporting of adverse events was inconsistent, certainty of evidence for adverse events was low.

CONCLUSION

Published data might support adopting acute outreach services with preventive components for people living in nursing homes to reduce ED transfers, hospitalisations and possibly costs. If an outreach service is started, it is recommended that a cluster-randomised or quasi-experimental research design be incorporated to assess the effectiveness and safety of the service. More evidence is also needed on cost-effectiveness and stakeholders' satisfaction. Systematic review registration number: PROSPERO CRD42020211048, date of registration: 25.09.2020.

Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review

BACKGROUND

In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions.

METHODS

A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions.

CONCLUSION

There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff

BACKGROUND

Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives.

OBJECTIVES

To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives.

DESIGN

Prospective cohort study.

SETTING

One academic medical center and 23 SNFs.

PARTICIPANTS

We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days.

MEASUREMENTS

Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.

RESULTS

The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.

CONCLUSION

A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

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.

Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission

BACKGROUND

Close to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF.

OBJECTIVES

To describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs.

DESIGN

Trained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.

SETTING

SNFs from across the United States.

PARTICIPANTS

64 of 88 SNFs randomized to the intervention group submitted RCAs.

INTERVENTIONS

SNFs were implementing the INTERACT quality improvement program.

MEASURES

Data were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.

RESULTS

Among 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital.

CONCLUSION

RCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.

Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life

Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.

Factors associated with the use of advanced practice nurses/physician assistants in a fee-for-service nursing home practice: a comparison with primary care physicians

The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits.

Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs

OBJECTIVES

Beneficiaries dually eligible for Medicare and Medicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in this population.

DESIGN

Retrospective study of hospitalizations.

SETTING

Hospitalizations from nursing facilities (NF) including Medicare and Medicaid-covered stays, and Medicaid Home and Community-Based Services (HCBS) waiver programs.

PARTICIPANTS

Dually eligible individuals who received Medicare skilled nursing facility (SNF) or Medicaid NF services or HCBS waiver services in 2005.

INTERVENTIONS

None.

MEASUREMENTS

Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed without hospitalization.

RESULTS

More than one-third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH. PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH. The total Medicare costs for these hospitalizations were $3 billion, but only $463 million for Medicaid. A sensitivity analysis, assuming that 20%-60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population.

CONCLUSION

Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life.

Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital

OBJECTIVES

To determine the frequency and diagnoses associated with 7- and 30-day acute hospital readmissions of patients discharged to a skilled nursing facility (SNF) from an acute hospital.

DESIGN

A quality improvement project focusing on 30-day hospital readmissions, using retrospective data derived from the hospital's electronic data repository.

SETTING

A 350-bed nonteaching community hospital in southeast Florida.

MEASUREMENTS

Data were collected on all discharges of Medicare fee-for-service patients age 75 and older for a 17-month period in 2007 and 2008. The primary source of data was the hospital's electronic data repository. Seven and 30-day hospital readmission rates were calculated for all discharges to SNFs. Index hospital and readmission diagnoses were determined by hospital coders and categorized by the physician coauthors.

RESULTS

Among 10,777 discharges of patients age 75 and older, 3254 (30%) were discharged to an SNF, and of these, 584 (18%) were readmitted to the hospital within 30 days; 191 (33%) of these readmissions occurred within 7 days. The index diagnostic categories with the highest readmission rates were genitourinary disorders (30%) and cardiovascular disorders (25%). Specific diagnoses associated with the highest readmission rates included congestive heart failure (CHF) (31%), urinary tract infection (28%), renal failure (27%), and pneumonia and chronic obstructive pulmonary disease (23% each). Infections and cardiovascular disorders were the primary diagnoses for 63% of the hospital readmissions (36% and 27% respectively). The most frequent readmission primary diagnosis was the same as the index admission primary diagnosis in less than half the cases.

CONCLUSION

In this community hospital population, close to 1 in 5 discharges to an SNF resulted in a hospital readmission within 30 days. CHF, renal failure, UTI, pneumonia, and COPD were common index hospital and readmission diagnoses. Care paths and guidelines are available for these conditions that should be helpful to SNFs in initiatives designed to improve transitional care and reduce potentially avoidable hospital readmissions, as well as their associated morbidity and cost.

The interface between residential aged care and the emergency department: a systematic review

BACKGROUND

emergency care for older people living in residential aged care facilities (RACF) is a complex area of health policy. The epidemiology of patient transfer between RACF and hospital emergency departments (ED), clinical outcomes and costs associated with transfer and efficacy of programs aiming to reduce transfer are not well known.

DESIGN

systematic review based on a comprehensive literature search in three electronic databases and published article reference lists.

RESULTS

the incidence of transfer from RACF to ED is >30 transfers/100 RACF beds/year in most studies. The casemix from RACF is varied and reflects that of the broad elderly population, with some risk difference. At least 40% of transfers are not admitted to hospital. There is insufficient data to fully address our other questions; however, hospitalisations from RACF can be reduced through advanced care planning, use of management guidelines for acute illnesses and improved primary care.

CONCLUSIONS

residents of RACF have a high annual risk of transfer to ED. The clinical benefit and cost effectiveness of ED care, and alternate programs to reduce ED transfer, cannot be confidently compared from published work. Further research is required to accurately describe these and to determine their comparative worth.

Perspective: transforming chronic care for older persons

The size and impending morbidity of the aging baby boom generation could soon overwhelm the U.S. health care system. Transforming chronic care for older persons to avert this calamity will require rapid increases in the number of physicians who are skilled in providing chronic care and prompt adoption of new models for providing high-quality, cost-effective chronic care. The authors propose a new approach for attaining these objectives, recommending that today's leaders of academic medicine help transform geriatrics into a collaborative discipline of clinicians with advanced skills in leading educational, organizational, and research-related initiatives; that they support the collaboration of geriatrics with primary care and specialty disciplines in preparing physicians to practice effectively in new models of chronic care for older persons; and that they energetically promote rigorous training in chronic care at all levels of medical education. Implementing this strategy would require firm commitment by the Association of American Medical Colleges, specialty boards, accrediting organizations, academic institutions, the Centers for Medicare and Medicaid Services, legislators, and business leaders. Although garnering such support would be challenging and controversial, this approach could leverage the expertise of geriatric educator-leaders to help transform chronic care in the United States and to make high-quality, cost-effective chronic care accessible to most chronically ill Americans within 20 years.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Reducing Hospitalizations From Long-Term Care Settings

Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

A Pilot Study: Post-Acute Geriatric Rehabilitation Versus Usual Care in Skilled Nursing Facilities

OBJECTIVES

To compare discharge outcomes, postdischarge health care use, and death rates among patients treated in a postacute geriatric rehabilitation unit (GRU) housed within a skilled nursing facility (SNF) with those treated in a traditional SNF.

DESIGN

Retrospective observational pilot study.

SETTING

Two similar SNFs were compared.

PARTICIPANTS

All patients were admitted from the acute hospital to either the GRU (n = 95) or to the usual care (UC) SNF (n = 55).

INTERVENTION

The GRU intervention consisted of comprehensive geriatric assessment and weekly interdisciplinary team rounds with a geriatrician and a geriatric nurse practitioner (GNP). The geriatrician visited the GRU twice a week and the GNP was present 4 to 5 times per week. On discharge, GRU patients were followed up with telephonic case management for 1 year.

MEASUREMENTS

Demographic data collected included age, gender, and race. Information collected from each facility's patient records included admitting diagnosis, length of stay, discharge disposition, and functional outcomes. Emergency department (ED) visits and hospital readmissions for 1 year after discharge from the nursing facility were obtained from our institutional database. The Rehabilitation Outcome Measure (ROM) was used by each facility to measure functional status on admission and at the time of discharge.

RESULTS

Baseline patient characteristics were comparable between the 2 facilities. At discharge from the nursing facility, GRU patients showed greater improvement in ADLs and mobility, had a significantly shorter length of stay, and were discharged to home more often. At 1 year, GRU patients had significantly fewer hospital readmissions. GRU patients also had fewer ED visits and days in the hospital at 1 year, however these results were not significant.

CONCLUSION

These pilot results suggest that GRU may be an effective means to improve patient outcomes and reduce undesirable health care use after an acute illness. Further studies using a randomized design are needed.

Measuring practice patterns among acute care nurse practitioners

OBJECTIVE

This initiative was designed to develop a reliable instrument to measure the activities of acute care nurse practitioners (ACNPs). A sound, standardized method for measuring ACNP productivity will assist nursing leaders and administrators to demonstrate the effectiveness and productivity of ACNPs in and across institutions and systems.

BACKGROUND DATA

Current research on ACNPs uses many different methodologies and research designs, and fails to provide standard definitions to measure practice patterns, making it difficult to generalize across settings.

METHODS

Advisory groups from 2 New York academic health science centers developed a survey that covered the demographic, educational, and employment characteristics of ACNPs, and a 20-item classification of advanced practice nursing activities. Sixty-one ACNPs completed surveys, a 58% response rate.

RESULTS

The survey found strong similarities at both institutions. ACNPs spend most of their time in 5 activities involving direct care and 4 activities within indirect care. Strong Cronbach alphas confirmed that the instrument was reliable.

CONCLUSIONS/IMPLICATIONS

The availability of a reliable instrument for measuring ACNP practice patterns provides administrators with a powerful tool to demonstrate the contributions of their ACNPs. In addition, a standardized method for data collection can contribute to healthcare workforce policy discussions.

Strengthening research to improve the practice and management of long-term care

Past investments in long-term care (LTC) research have improved the quality of care and the quality of life for LTC recipients by conceptualizing the goals and measuring the outcomes of care, designing practical assessment tools, testing clinical interventions, and evaluating new service delivery programs and models. To build a balanced portfolio of LTC research that will yield and sustain increased dividends in quality and outcomes will require (1) increasing investment in both basic and applied LTC research to ensure that critical service delivery issues are addressed in a rigorous and timely fashion, (2) fostering better communication between researchers and users to ensure research salience and credibility, and (3) dedicating more resources to identifying and implementing successful methods for translating LTC research into practice.

Clinical challenges in the care of frail older persons

The clinical challenges of meeting the needs of frail older persons are essentially those encompassed by chronic disease multiplied by the special problems presented by aging, namely the presentation and management of disease and the special syndromes associated with geriatrics. The need to develop an approach to the care of frail older persons reflects a more general need to address system reform for chronic disease. The steps include new roles for patients and their families, the use of information technology to monitor changes in patients' status more continuously and to intervene in a more timely way, and a re-evaluation of the use of personnel at all levels. At present, we know more about how to deliver effective chronic care than we practice. The barriers to implementation include both a general reluctance to change and negative financial incentives to implement what has been shown to be effective.

Organizational interventions to improve health outcomes of older persons

BACKGROUND

With the reorganization of the financing of health care and creation of systems of care, it is possible to design and implement organizational interventions to improve the care of older persons beyond the services that can be provided by an individual provider.

OBJECTIVES

To review the effectiveness of organizational interventions for older persons, describe barriers to dissemination of success models into practice settings, and identify future directions for such interventions.

METHODS

Selective review of organizational interventions that have been aimed primarily at the geriatric population and have been formally evaluated using conventional research designs, usually randomized clinical trials.

RESULTS

Organizational interventions can be classified into two groups: component models and systems changes. The former can be superimposed upon an intact system but do not fundamentally change the system of care whereas the latter modify the basic structure of primary care. A variety of organizational interventions have been implemented in diverse settings, but the evidence supporting the effectiveness of these interventions is inconsistent. Even when such interventions have been effective in research settings, these interventions rarely reduce health care costs. Moreover, there have been formidable barriers to implementation of successful interventions into practice.

CONCLUSIONS

Organizational interventions are potentially powerful methods to influence health care and maintain health status of older persons. Nevertheless, gaps between knowledge and practice and unanswered questions about the effectiveness of organizational interventions currently limit the potential value of this approach to improving health care of older persons.

Nursing home residents covered by Medicare risk contracts: early findings from the EverCare evaluation project

OBJECTIVES

To compare the characteristics of a sample of EverCare nursing home residents with two control groups: one composed of other residents in the same homes and another made up of residents in matched nursing homes. To compare levels of unmet need, satisfaction with medical care, and the use of advance directives.

DESIGN

Quasi-experimental design using two control groups to minimize selection effects. Information collected by in-person surveys of nursing home residents and telephone surveys of proxies and family members.

SETTING

Nursing homes affiliated with EverCare and matched control homes.

PARTICIPANTS

Nursing home residents and their family members.

MEASUREMENTS

Questionnaire addressing function (activities of daily living (ADLs)), unmet care needs, pain, use of advance directives, satisfaction, and caregiver burden.

RESULTS

In general, the experimental and control groups were similar, but the EverCare sample had more dementia and less ADL disability. Family members in the EverCare sample expressed greater satisfaction with several aspects of the medical care they received than did controls. Satisfaction of residents in the EverCare sample was more comparable with that of controls. There was no difference in experience with advance directives between EverCare and control groups.

CONCLUSIONS

EverCare appears to be a model of managed care worth tracking. It is producing care that is at least comparable with what is available in the fee-for-service environment, with evidence that families seem to appreciate the added attention. There is some suggestion that it has enrolled a less disabled but more demented population. Pending results on the effects of this care on hospitalization and emergency care should shed useful light.

How EverCare nurse practitioners spend their time

OBJECTIVES

To describe how nurse practitioners (NPs) employed by EverCare, a Medicare HMO serving exclusively nursing home residents, spend their working days.

DESIGN

A descriptive study based on structured self-reports.

SETTING

Nursing homes.

PARTICIPANTS

Seventeen NPs employed by EverCare in five sites.

MEASUREMENTS

Self-reports of time spent over a 2-week period and specific reports of how time was spent on selected cases.

RESULTS

NPs spend about 35% of their working day on direct patient care and another 26% in indirect care activities. Of the latter, 46% of the time was spent interacting with nursing home staff, 26% with family, and 15% with the physicians. The mean time spent on a given patient per day was 42 minutes (median 30); of this time 20 minutes was direct care (median 15).

CONCLUSIONS

NPs' activities are varied. Much of their time is spent communicating with vital parties, an important function that supports the physicians' primary care role and should enhance families' satisfaction with care.

Dually incontinent nursing home residents: clinical characteristics and treatment differences

OBJECTIVE

Previous studies have described urinary and fecal incontinence in nursing homes and their separate effects on healthcare utilization. However, little is known about those who are incontinent of both.

DESIGN

Retrospective chart review.

SETTINGS

Twenty sites in three states

PARTICIPANTS

A total of 413 nursing home residents were categorized as having neither fecal nor urinary incontinence (C, n = 114), urinary incontinence only (UI, n = 53), fecal incontinence only (FI, n = 9), or were dually incontinent (DI, n = 237).

MEASUREMENTS

Charts were abstracted for sociodemographic information and health status information as well as utilization for the year before the date of abstraction. We then compared these characteristics across groups using ANOVA with pairwise comparisons and multiply adjusted regression.

RESULTS

Almost all patients with DI were cognitively and mobility impaired. However, there were no significant differences between the groups with respect to age and number of diagnoses. A diagnosis of stroke was also more common among those with DI compared with C. When examining healthcare utilization in multiply adjusted regression, dually incontinent residents received significantly fewer days of hospital care than those with UI.

CONCLUSIONS

Dual incontinence in NH residents is likely to have an important functional component. These residents seem to be treated less aggressively with respect to hospitalization compared with those with UI alone. The reasons for these differences need to be explored further.

Managed care and multilevel long-term care providers: reluctant partners

Managed care is reshaping our health care system, although long-term care is only beginning to feel its effects. We report on the managed care involvement of 492 multilevel, long-term care facilities (MLFs; including skilled nursing and assisted/independent living) nationally. Organizational structure and culture and especially environmental characteristics are associated with whether facilities have contracts with managed care organizations (MCOs), plan to have contracts, are only gathering information on MCOs, or intend to do nothing in the near future. Resource dependence theory best explains MCO contracting patterns with MLFs appearing to be responding more to survival than to growth.

Use of primary care teams by HMOS for care of long-stay nursing home residents

OBJECTIVE

To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long-stay residents of nursing homes.

DESIGN

Using mail survey techniques, 34 Medicare risk-contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long-stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs.

PARTICIPANTS

HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes.

MEASUREMENTS

Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs.

RESULTS

Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non-program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders.

CONCLUSIONS

Survey findings point to the potential importance of formal HMO primary care programs for long-term nursing home residents, which may expand with growth in the older population and Medicare-managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible.