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Williams D, Fernandez R, Stevenson D, Unruh M, Braun RT. Nursing home finances associated with real estate investment trust and private equity investments. Health Aff Sch 2024; 2:qxae037. [PMID: 38756179 PMCID: PMC11034530 DOI: 10.1093/haschl/qxae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/04/2024] [Accepted: 04/03/2024] [Indexed: 05/18/2024]
Abstract
In 2021, real estate investment trusts (REITs) and private equity (PE) held investments in 1915 (16%) and 1569 (13%) US nursing homes (NHs), respectively. We created a database of REIT and PE investments in NHs, merged it with Medicare Cost Report data (2011-2019), and used a difference-in-differences approach within an event-study framework to compare NH spending and financial performance before and after REIT or PE investment to NHs that did not receive REIT or PE investment. REIT investments were associated with higher total wages (3%), total nursing wages (3%; both logged, per resident day [PRD]), and current ratio (81%). PE investments were associated with lower net patient service revenue (7%), total expenses (7%), and total wages (8%; all logged, PRD). The impact of REIT and PE investments in NHs may vary in different market conditions, as may occur in the current environment of low, falling NH profits, potentially higher minimum staffing requirements, and rising interest rates. Therefore, it is important for stakeholders to understand the impact of these large, growing investments on the financial performance of NHs.
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Affiliation(s)
- Dunc Williams
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425-9620, United States
- Center for Telehealth—Telehealth Center of Excellence, Medical University of South Carolina, Charleston, SC 29425-9620, United States
| | - Rahul Fernandez
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
| | - David Stevenson
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN 37232, United States
- The Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN 37212-2637, United States
| | - Mark Unruh
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
| | - Robert Tyler Braun
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
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Sutton N, Ma N, Yang JS, Lin J. Quality effects of home acquisitions in residential aged care. Australas J Ageing 2024; 43:158-166. [PMID: 38317602 DOI: 10.1111/ajag.13268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVE The recent consolidation of the Australian residential aged care market has raised concerns about the potential adverse effects of acquisition activity on quality of care (QoC). We examined changes in QoC outcomes within acquired homes and the influence of the acquiring providers' characteristics on these post-acquisition outcomes. METHODS A retrospective observational study was conducted using de-identified data sets obtained under the legal authority of the Royal Commission into Aged Care Quality and Safety. Regression analysis was used to investigate post-acquisition changes in QoC outcomes for 225 Australian home acquisitions between 2015 and 2019. The outcomes were analysed for the first two full financial years before and after the acquisition. RESULTS After controlling for other factors, we find acquired homes were associated with significantly worse QoC outcomes in the 2 years after acquisition, with higher rates of hospitalisations and reported complaints to the regulator. However, these results were driven by homes acquired by providers that were smaller in scale, for-profit or had comparatively poorer average quality across the other homes they operated. CONCLUSIONS Our finding that homes' QoC on average declines in the first 2 years following acquisition, are consistent with studies in other countries and points to the potential risks that consolidation poses to the care delivered to older people in Australia during that period.
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Affiliation(s)
- Nicole Sutton
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Nelson Ma
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jin Sug Yang
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jiali Lin
- University of Technology Sydney, Sydney, New South Wales, Australia
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Hirooka K, Fukahori H, Ninomiya A, Fukui S, Takahashi K, Anzai T, Ishibashi T. Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities. Arch Gerontol Geriatr 2024; 117:105183. [PMID: 37690255 DOI: 10.1016/j.archger.2023.105183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia. METHOD Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan. RESULTS Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents. CONCLUSIONS Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.
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Affiliation(s)
- Kayo Hirooka
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan; The Dia Foundation for Research on Ageing Societies, Tokyo, Japan.
| | - Hiroki Fukahori
- Division of Gerontological Nursing, Faculty of Nursing and Medical Care, Keio University, Kanagawa, Japan
| | - Ayako Ninomiya
- The Dia Foundation for Research on Ageing Societies, Tokyo, Japan; Division of Fundamental Nursing, Josai International University, Chiba, Japan
| | - Sakiko Fukui
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan; The Dia Foundation for Research on Ageing Societies, Tokyo, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuhiko Anzai
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
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Tan AJ, Rusli KD, McKenna L, Tan LL, Liaw SY. Telemedicine experiences and perspectives of healthcare providers in long-term care: A scoping review. J Telemed Telecare 2024; 30:230-249. [PMID: 34666535 DOI: 10.1177/1357633x211049206] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To consolidate existing evidence on experiences and perspectives of healthcare providers involved in telemedicine services in long-term residential care. METHODS A scoping review was conducted. A systematic search for articles published in 2000-2021 was performed in CINAHL, Web of Science, PubMed, EMBASE and Scopus; further, relevant journals and grey literature websites were hand searched. Key search terms included 'telemedicine', 'telehealth' and 'nursing homes'. RESULTS Twenty-six articles were included. A narrative synthesis of evidence was conducted. The review identified four themes: (1) Presence of multidisciplinary care, (2) perceived usefulness of telemedicine, (3) perceived ease of use and (4) expanded role of nursing home staff. The presence of multidisciplinary care providers provided a wide range of telemedicine services to residents and promoted interprofessional collaboration between acute and long-term care. Telemedicine was perceived to increase timely onsite management by remote specialists, which enabled care quality improvement. However, technical problems associated with equipment usage reduced the ease of use of telemedicine. Concerns emerged from the expanded role of nursing home staff, which could negatively affect clinical decision-making and create medico-legal risks. CONCLUSION AND IMPLICATIONS Telemedicine is valuable in distance-based care, especially in the current 2019 coronavirus pandemic, for supporting continuity of care to nursing home residents. This review provided evidence from multiple healthcare providers' perspectives. Further research can elucidate their specific roles and responsibilities in telemedicine and challenges in work processes, which will facilitate developing evidence-based competencies and improving technical infrastructure, thus contributing to personal and organisational readiness for telemedicine integration.
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Affiliation(s)
- Apphia Jq Tan
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
| | - Khairul Db Rusli
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
| | - Lisa McKenna
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
| | - Laurence Lc Tan
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
- GeriCare@North, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
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Segelman M, Hariharan D, Fletcher D, Gasdaska A, Ingber MJ, Khatutsky G, Bercaw L, Feng Z. Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative. J Am Med Dir Assoc 2024; 25:12-16.e3. [PMID: 37301224 DOI: 10.1016/j.jamda.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DESIGN Cross-sectional retrospective study. SETTINGS AND PARTICIPANTS The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. METHODS We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. RESULTS Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). CONCLUSIONS AND IMPLICATIONS Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.
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Affiliation(s)
| | - Dhwani Hariharan
- Brandeis University, Waltham, MA, USA; RTI International, Waltham, MA, USA
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Luna G, Kim M, Miller R, Parekh P, Kim ES, Park SY, Abdulbaseer U, Gonzalez C, Stiehl E. Interprofessional relationships and their impact on resident hospitalizations in nursing homes: A qualitative study. Appl Nurs Res 2023; 74:151747. [PMID: 38007247 DOI: 10.1016/j.apnr.2023.151747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 08/09/2023] [Accepted: 10/24/2023] [Indexed: 11/27/2023]
Abstract
AIM The aim of this study is to explore experiences and perspectives of nurses and providers (e.g., physicians, medical directors, fellows, and nurse practitioners) on reducing preventable hospitalizations of nursing home (NH) residents in relation to interprofessional relationship and hospitalization decision-making process. BACKGROUND Preventable NH resident hospitalization continues to be a pressing public health issue. Studies show that improved interprofessional relationship may help reduce hospitalization, yet research on communication processes and interactions among different NH staff remains limited. METHODS This is a qualitative descriptive study. Two focus groups were held with fourteen nurses and thirteen in-depth, qualitative interviews were conducted with providers from two Chicagoland NHs. Focus group sessions and interviews were transcribed, coded, and analyzed for common themes based on qualitative description method. RESULTS All study participants agreed that providers have the ultimate responsibility for hospitalization decisions. However, nurses believed they could influence those decisions, depending on provider characteristics, trust, and resident conditions. Nurses and providers differed in the way they experienced and conveyed emotions, and differed in key elements affecting hospitalization decisions such as structural or environmental factors (e.g., lacking staff and equipment at the facility, poor communication between the NH and hospitals) and interpersonal factors (e.g., characteristics of effective nurses or providers and the effective interactions between them). CONCLUSIONS Interpersonal factors, including perceived competence, respect, and trust, may influence NH hospitalization decisions and be targeted for reducing preventable hospitalizations of residents.
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Affiliation(s)
- Geraldine Luna
- Chicago Department of Public Health, 333 S State St #200, Chicago, IL 60604, United States of America.
| | - Mhinjine Kim
- University of Illinois Chicago, 1603 W. Taylor St., Chicago, IL 60612, United States of America.
| | - Richard Miller
- University of Illinois Chicago, 2170 West Bowler Street, Chicago, IL 60612, United States of America.
| | - Pooja Parekh
- University of Illinois Chicago, 1355 S. Halsted St., Chicago, IL 60607, United States of America.
| | - Esther S Kim
- University of Illinois Chicago, 625 W Madison St., Chicago, IL 60661, United States of America.
| | - Sophia Yaejin Park
- University of Illinois Chicago, 1853 W Polk St, Chicago, IL 60612, United States of America.
| | - Ummesalmah Abdulbaseer
- University of Illinois Chicago, 1853 W Polk St, Chicago, IL 60612, United States of America.
| | - Cristina Gonzalez
- University of Illinois Chicago, 1853 W Polk St, Chicago, IL 60612, United States of America.
| | - Emily Stiehl
- University of Illinois Chicago, 1603 W. Taylor St., Chicago, IL 60612, United States of America.
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Brühmann BA, Kaier K, von der Warth R, Farin-Glattacker E. Cost-benefit analysis of the CoCare intervention to improve medical care in long-term care nursing homes: an analysis based on claims data. Eur J Health Econ 2023; 24:1343-1355. [PMID: 36481830 PMCID: PMC10533715 DOI: 10.1007/s10198-022-01546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/07/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Providing adequate medical care to nursing home residents is challenging. Transfers to emergency departments are frequent, although often avoidable. We conducted the complex CoCare intervention with the aim to optimize nursing staff-physician collaboration to reduce avoidable hospital admissions and ambulance transportations, thereby reducing costs. METHODS This prospective, non-randomized study, based on German insurance data, includes residents in nursing homes. Health care cost from a payer perspective and cost-savings of such a complex intervention were investigated. The utilisation of services after implementation of the intervention was compared with services in previous quarters as well as services in the control group. To compensate for remaining differences in resident characteristics between intervention and control group, a propensity score was determined and adjusted for in the regression analyses. RESULTS The study population included 1240 residents in the intervention and 7552 in the control group. Total costs of medical services utilisation were reduced by €468.56 (p < 0.001) per resident and quarter in the intervention group. Hospital stays were reduced by 0.08 (p = 0.001) and patient transports by 0.19 (p = 0.049). This led to 1.66 (p < 0.001) avoided hospital days or €621.37 (p < 0.001) in costs-savings of inpatient services. More services were billed by general practitioners in the intervention group, which led to additional costs of €97.89 (p < 0.001). CONCLUSION The benefits of our intervention clearly exceed its costs. In the intervention group, avoided hospital admissions led to additional outpatient billing. This indicates that such a multifactorial intervention program can be cost-saving and improve medical care in long-term care homes.
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Affiliation(s)
- Boris A Brühmann
- Institute of Medical Biometry and Statistics, Section of Health Care Research and Rehabilitation Research (SEVERA), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Division Methods in Clinical Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Rieka von der Warth
- Institute of Medical Biometry and Statistics, Section of Health Care Research and Rehabilitation Research (SEVERA), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Erik Farin-Glattacker
- Institute of Medical Biometry and Statistics, Section of Health Care Research and Rehabilitation Research (SEVERA), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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Cetin-Sahin D, Karanofsky M, Cummings GG, Vedel I, Wilchesky M. Measuring Potentially Avoidable Acute Care Transfers From Long-Term Care Homes in Quebec: a Cross Sectional Study. Can Geriatr J 2023; 26:339-349. [PMID: 37662066 PMCID: PMC10444526 DOI: 10.5770/cgj.26.620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Background Potentially avoidable emergency department transfers (PAEDTs) and hospitalizations (PAHs) from long-term care (LTC) homes are two key quality improvement metrics. We aimed to: 1) Measure proportions of PAEDTs and PAHs in a Quebec sample; and 2) Compare them with those reported for the rest of Canada. Methods We conducted a repeated cross-sectional study of residents who were received at one tertiary hospital between April 2017 and March 2019 from seven LTC homes in Quebec, Canada. The MedUrge emergency department database was used to extract transfers and resident characteristics. Using published definitions, PAEDTs and PAHs were identified from principal emergency department and hospitalization diagnoses, respectively. PAEDT and PAH proportions were compared to those reported by the Canadian Institute for Health Information. Results A total of 1,233 transfers by 692 residents were recorded, among which 36.3% were classified as being potentially avoidable: 22.8% 'PAEDT only', 11.6% 'both PAEDT & PAH', and 1.9% 'PAH only'. Shortness of breath was the most common reason for transfer. Pneumonia was the most common diagnosis from the 'both PAEDT & PAH' category. PAEDTs and PAHs accounted for 95% and 37% of potentially avoidable transfers, respectively. Among 533 hospitalizations, 31.3% were PAHs. These proportions were comparable to the rest of Canada, with some differences in proportions of transfers due to congestive heart failure, urinary tract infection, and implanted device management. Conclusions PAEDTs far outweigh PAHs in terms of frequency, and their monitoring is important for quality assurance as they may inform LTC-level interventions aimed at their reduction.
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Affiliation(s)
- Deniz Cetin-Sahin
- Department of Family Medicine, McGill University, Montreal, QC
- Donald Berman Maimonides Geriatric Centre for Research in Aging, Montreal, QC
| | - Mark Karanofsky
- Department of Family Medicine, McGill University, Montreal, QC
- Herzl Family Practice Centre, Jewish General Hospital CIUSSS Centre-Ouest-de-l’Île-de-Montréal, Montreal, QC
| | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, QC
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC
| | - Machelle Wilchesky
- Department of Family Medicine, McGill University, Montreal, QC
- Donald Berman Maimonides Geriatric Centre for Research in Aging, Montreal, QC
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC
- Division of Geriatric Medicine, McGill University, Montreal, QC, Canada
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Guerbaai RA, Dollinger C, Kressig RW, Zeller A, Wellens NIH, Popejoy LL, Serdaly C, Zúñiga F. Factors associated with avoidable hospital transfers among residents in Swiss nursing homes. Geriatr Nurs 2023; 53:12-18. [PMID: 37399613 DOI: 10.1016/j.gerinurse.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.
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Affiliation(s)
- Raphaëlle-Ashley Guerbaai
- Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland; Rehabilitation, Ageing and Independent Living (RAIL) research centre, School of Primary and Allied Health Care, Monash University, Frankston, Australia
| | - Claudia Dollinger
- Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland; Lindenhofgruppe AG, Lindenhof Spital, Bern, Switzerland
| | - Reto W Kressig
- University Department of Geriatric Medicine FELIX PLATTER & Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Nathalie I H Wellens
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Lori L Popejoy
- University of Missouri, Sinclair School of Nursing, Columbia, United States
| | | | - Franziska Zúñiga
- Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland.
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Xu H, Bowblis JR, Becerra AZ, Intrator O. Developing a Machine Learning Risk-adjustment Method for Hospitalizations and Emergency Department Visits of Nursing Home Residents With Dementia. Med Care 2023; 61:619-626. [PMID: 37440719 PMCID: PMC10526959 DOI: 10.1097/mlr.0000000000001882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Long-stay nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) are at high risk of hospital transfers. Machine learning might improve risk-adjustment methods for NHs. OBJECTIVES The objective of this study was to develop and compare NH risk-adjusted rates of hospitalizations and emergency department (ED) visits among long-stay residents with ADRD using Extreme Gradient Boosting (XGBoost) and logistic regression. RESEARCH DESIGN Secondary analysis of national Medicare claims and NH assessment data in 2012 Q3. Data were equally split into the training and test sets. Both XGBoost and logistic regression predicted any hospitalization and ED visit using 58 predictors. NH-level risk-adjusted rates from XGBoost and logistic regression were constructed and compared. Multivariate regressions examined NH and market factors associated with rates of hospitalization and ED visits. SUBJECTS Long-stay Medicare residents with ADRD (N=413,557) from 14,057 NHs. RESULTS A total of 8.1% and 8.9% residents experienced any hospitalization and ED visit in a quarter, respectively. XGBoost slightly outperformed logistic regression in area under the curve (0.88 vs. 0.86 for hospitalization; 0.85 vs. 0.83 for ED visit). NH-level risk-adjusted rates from XGBoost were slightly lower than logistic regression (hospitalization=8.3% and 8.4%; ED=8.9% and 9.0%, respectively), but were highly correlated. Facility and market factors associated with the XGBoost and logistic regression-adjusted hospitalization and ED rates were similar. NHs serving more residents with ADRD and having a higher registered nurse-to-total nursing staff ratio had lower rates. CONCLUSIONS XGBoost and logistic regression provide comparable estimates of risk-adjusted hospitalization and ED rates.
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Affiliation(s)
- Huiwen Xu
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - John R. Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH
- Scripps Gerontology Center, Miami University, Oxford, OH
| | - Adan Z. Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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Kristensen GS, Kjeldgaard AH, Søndergaard J, Andersen-Ranberg K, Pedersen AK, Mogensen CB. Associations between care home residents' characteristics and acute hospital admissions - a retrospective, register-based cross-sectional study. BMC Geriatr 2023; 23:234. [PMID: 37072701 PMCID: PMC10114422 DOI: 10.1186/s12877-023-03895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/15/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Care home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents' health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions. METHOD Data on all care home residents aged 65 + years living in Southern Jutland in 2018-2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression. RESULTS Most care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions. CONCLUSION This study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes. TRIAL REGISTRATION Not relevant.
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Affiliation(s)
- Gitte Schultz Kristensen
- Emergency Department, Aabenraa Hospital, Department of Regional Health Research, Faculty of Health Science, University Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark.
| | | | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karen Andersen-Ranberg
- Geriatric Research Unit, Department of Clinical Research, Department of Public Health, Department of Regional Health Research, Faculty of Health Science, Clinical research Department, Aabenraa Hospital, University of Southern Denmark University Hospital of Southern Denmark, Odense, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
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12
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Abstract
To improve the quality of nursing home care, reliable estimates of outcomes are essential. Obtaining such estimates requires optimal use of limited data, especially for small homes. We analyze the variation in mortality and hospital admissions across nursing homes in the Netherlands during the years 2010-2013. We use administrative data on all nursing home clients. We apply mixed-effects survival models, empirical Bayes estimation, and machine-learning techniques to optimally use the available longitudinal data. We find large differences in both outcomes across nursing homes, yet the estimates are surrounded by substantial uncertainty. We find no correlation between performance on mortality and avoidable hospital admissions, suggesting that these are related to different aspects of quality. Hence, caution is needed when evaluating the performance of individual nursing homes, especially when the number of outcome indicators is limited.
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Affiliation(s)
| | - Pieter Bakx
- Erasmus University Rotterdam, The Netherlands
| | - Albert Wong
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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13
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Fassmer AM, Allers K, Helbach J, Zuidema S, Freitag M, Zieschang T, Hoffmann F. Hospitalization of German and Dutch Nursing Home Residents Depend on Different Long-Term Care Structures: A Systematic Review on Periods of Increased Vulnerability. J Am Med Dir Assoc 2023; 24:609-618.e6. [PMID: 36898411 DOI: 10.1016/j.jamda.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE To investigate proportions of hospitalized nursing home residents during periods of increased vulnerability, ie, the first 6 months after institutionalization and the last 6 months before death, and comparing the figures between Germany and the Netherlands. DESIGN Systematic review, registered in PROSPERO (CRD42022312506). SETTING AND PARTICIPANTS Newly admitted or deceased residents. METHODS We searched MEDLINE via PubMed, EMBASE, and CINAHL from inception through May 3, 2022. We included all observational studies that reported the proportions of all-cause hospitalizations among German or Dutch nursing home residents during these defined vulnerable periods. Study quality was assessed using the Joanna Briggs Institute's tool. We assessed study and resident characteristics and outcome information and descriptively reported them separately for both countries. RESULTS We screened 1856 records for eligibility and included 9 studies published in 14 articles (Germany: 8; Netherlands: 6). One study for each country investigated the first 6 months after institutionalization. A total of 10.2% of the Dutch and 42.0% of the German nursing home residents were hospitalized during this time. Overall, 7 studies reported on in-hospital deaths, with proportions ranging from 28.9% to 29.5% for Germany and from 1.0% to 16.3% for the Netherlands. Proportions for hospitalization in the last 30 days of life ranged from 8.0% to 15.7% (Netherlands: n = 2) and from 48.6% to 58.0% (Germany: n = 3). Only German studies assessed the differences by age and sex. Although hospitalizations were less common at older ages, they were more frequent in male residents. CONCLUSIONS AND IMPLICATIONS During the observed periods, the proportion of nursing homes residents being hospitalized differed greatly between Germany and the Netherlands. The higher figures for Germany can probably be explained by differences in the long-term care systems. There is a lack of research, especially for the first months after institutionalization, and future studies should examine the care processes of nursing home residents following acute events in more detail.
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Affiliation(s)
- Alexander M Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany.
| | - Katharina Allers
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Jasmin Helbach
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Sytse Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael Freitag
- Division of General Practice, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Tania Zieschang
- Division of Geriatrics, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Lower Saxony, Germany
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14
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Ying M, Temkin-Greener H, Thirukumaran CP, Joynt Maddox KE, Holloway RG, Li Y. Skilled Nursing Facility Participation in Bundled Payments Was Related to Small Increases in Nurse Staffing Levels. J Appl Gerontol 2023; 42:456-463. [PMID: 36321398 DOI: 10.1177/07334648221137060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010-2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03 hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02 hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled payments for care improvement had no impact on CNA and all licensed nurse staffing levels. In conclusion, BPCI was associated with statistically significant but small increases in nurse staffing levels.
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Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Urology, Dow Division of Health Services Research, 12266University of Michigan Medical School, Ann Arbor, MI, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Caroline P Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Department of Orthopaedics, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, 12275Washington University School of Medicine, St Louis, MI, USA.,Center for Health Economics and Policy, 12275Institute for Public Health at Washington University in St Louis, St. Louis, Missouri, USA
| | - Robert G Holloway
- Department of Neurology, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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15
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Cetin-Sahin D, Cummings GG, Gore G, Vedel I, Karanofsky M, Voyer P, Gore B, Lungu O, Wilchesky M. Taxonomy of Interventions to Reduce Acute Care Transfers From Long-term Care Homes: A Systematic Scoping Review. J Am Med Dir Assoc 2023; 24:343-355. [PMID: 36758622 DOI: 10.1016/j.jamda.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/22/2022] [Accepted: 12/31/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To develop a taxonomy of interventions aimed at reducing emergency department (ED) transfers and/or hospitalizations from long-term care (LTC) homes. DESIGN A systematic scoping review. SETTING AND PARTICIPANTS Permanent LTC home residents. METHODS Experimental and comparative observational studies were searched in MEDLINE, CINAHL, Embase Classic + Embase, the Cochrane Library, PsycINFO, Social Work Abstracts, AMED, Global Health, Health and Psychosocial Instruments, Joanna Briggs Institute EBP Database, Ovid Healthstar, and Web of Science Core Collection from inception until March 2020. Forward/backward citation tracking and gray literature searches strengthened comprehensiveness. The Mixed Methods Appraisal Tool was used to assess study quality. Intervention categories and components were identified using an inductive-deductive thematic analysis. Categories were informed by 3 intervention dimensions: (1) "when/at what point(s)" on the continuum of care they occur, (2) "for whom" (ie, intervention target resident populations), and (3) "how" these interventions effect change. Components were informed by the logistical elements of the interventions having the potential to influence outcomes. All interventions were mapped to the developed taxonomy based on their categories, components, and outcomes. Distributions of components by category and study year were graphically presented. RESULTS Ninety studies (25 randomized, 23 high quality) were included. Six intervention categories were identified: advance care planning; palliative and end-of-life care; onsite care for acute, subacute, or uncontrolled chronic conditions; transitional care; enhanced usual care (most prevalent, 31% of 90 interventions); and comprehensive care. Four components were identified: increasing human resource capacity (most prevalent, 93%), training or reorganization of existing staff, technology, and standardized tools. The use of technology increased over time. Potentially avoidable ED transfers and/or hospitalizations were measured infrequently as primary outcomes. CONCLUSIONS AND IMPLICATIONS This proposed taxonomy can guide future intervention designs. It can also facilitate systematic reviews and precise effect size estimations for homogenous interventions when outcomes are comparable.
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Affiliation(s)
- Deniz Cetin-Sahin
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada; Donald Berman Maimonides Centre for Research in Aging, Montreal, Quebec, Canada
| | - Greta G Cummings
- College of Health Sciences, University of Alberta, Edmonton, Canada
| | - Genevieve Gore
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark Karanofsky
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada; Herzl Family Practice Centre, Jewish General Hospital CIUSSS Centre Ouest de l'ile de Montreal, Montreal, Quebec, Canada
| | - Phillippe Voyer
- Faculty of Nursing, Université Laval, Quebec City, Quebec, Canada
| | - Brian Gore
- Donald Berman Maimonides Centre for Research in Aging, Montreal, Quebec, Canada
| | - Ovidiu Lungu
- Department of Psychiatry, Université de Montréal, Montreal, Quebec, Canada
| | - Machelle Wilchesky
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada; Donald Berman Maimonides Centre for Research in Aging, Montreal, Quebec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada.
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16
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Braun RT, Williams D, Stevenson DG, Casalino LP, Jung HY, Fernandez R, Unruh MA. The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes. Health Aff (Millwood) 2023; 42:207-216. [PMID: 36696597 DOI: 10.1377/hlthaff.2022.00278] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25 percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.
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Affiliation(s)
| | - Dunc Williams
- Dunc Williams, Medical University of South Carolina, Charleston, South Carolina
| | - David G Stevenson
- David G. Stevenson, Vanderbilt University and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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Kiadaliri A, Lohmander LS, Dahlberg LE, Englund M. Incipient dementia and avoidable hospital admission in persons with osteoarthritis. Osteoarthr Cartil Open 2023; 5:100341. [PMID: 36798737 PMCID: PMC9926213 DOI: 10.1016/j.ocarto.2023.100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Objective To investigate the associations between incipient dementia (ID) and hospitalization for ambulatory care sensitive conditions (ACSCs) among people with osteoarthritis (OA) of the peripheral joints. Methods Among individuals aged 51-99 years residing in Skåne, Sweden, in 2009, we identified those with a doctor-diagnosed OA and no dementia during 1998-2009 (n = 57,733). Treating ID as a time-varying exposure, we followed people from January 1, 2010 or their 60th birthday (whichever occurred last) until hospitalization for ACSCs, death, 100th birthday, relocation outside Skåne, or December 31, 2019 (whichever occurred first). Using age as time scale, we applied flexible parametric survival models, adjusted for confounders, to assess the associations between ID and hospitalization for ACSCs. Results There were 58 and 33 hospitalizations for ACSCs per 1000 person-years among OA people with and without ID, respectively. The association between ID and hospitalization for any ACSCs was age-dependent with higher risk in ages<86 years and lower risks in older ages. Between ages 60 and 100 years, persons with ID had, on average, 5.8 (95% CI 0.9, 10.7), 1.6 (-2.6, 5.9) and 3.1 (2.3, 4.0) fewer hospital-free years for any, chronic and acute ACSCs, respectively, compared with persons without ID. Conclusions Among persons with OA, while ID was associated with increased risks of hospitalization for ACSCs in younger ages, it was associated with decreased risk in oldest ages. These results suggest the need for improvement in quality of ambulatory care including the continuity of care for people with OA having dementia.
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Affiliation(s)
- Ali Kiadaliri
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden,Centre for Economic Demography, Lund University, Lund, Sweden,Corresponding author. Skåne University Hospital, Clinical Epidemiology Unit, Remissgatan 4, SE-221 85 Lund, Sweden.
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Leif E. Dahlberg
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Kang Y, David SV, Bowblis JR, Intrator O, Downer B, Li CY, Goodwin JS, Xu H. Financial Performance is Associated With PPE Shortages in Chain-Affiliated Nursing Homes During the COVID-19 Pandemic: A Longitudinal Study. Inquiry 2023; 60:469580231219443. [PMID: 38102846 PMCID: PMC10725134 DOI: 10.1177/00469580231219443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/02/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Abstract
Many nursing homes operated at thin profit margins prior to the COVID-19 pandemic. This study examines the role of nursing homes' financial performance and chain affiliation in shortages of personal protection equipment (PPE) during the first year of the COVID-19 pandemic. We constructed a longitudinal file of 79 868 nursing home-week observations from 10 872 unique facilities. We found that a positive profit margin was associated with a 21.0% lower probability of reporting PPE shortages in chain-affiliated nursing homes, but not in non-chain nursing homes. Having adequate financial resources may help nursing homes address future emergencies, especially those affiliated with a multi-facility chain.
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Affiliation(s)
- Yejin Kang
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Orna Intrator
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Brian Downer
- University of Texas Medical Branch, Galveston, TX, USA
| | - Chih-Ying Li
- University of Texas Medical Branch, Galveston, TX, USA
| | | | - Huiwen Xu
- University of Texas Medical Branch, Galveston, TX, USA
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19
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Garrett MD. Critical Age Theory: Institutional Abuse of Older People in Health Care. EJMED 2022; 4:24-37. [DOI: 10.24018/ejmed.2022.4.6.1540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
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.
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Gayot C, Laubarie-Mouret C, Zarca K, Mimouni M, Cardinaud N, Luce S, Tovena I, Durand-Zaleski I, Laroche ML, Preux PM, Tchalla A. Effectiveness and cost-effectiveness of a telemedicine programme for preventing unplanned hospitalisations of older adults living in nursing homes: the GERONTACCESS cluster randomized clinical trial. BMC Geriatr 2022; 22:991. [PMID: 36550496 PMCID: PMC9773573 DOI: 10.1186/s12877-022-03575-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/01/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The GERONTACCESS trial evaluated the utility and cost-effectiveness of a gerontological telemedicine (TLM) programme for preventing unplanned hospitalisation of residents living in nursing homes (NHs) in regions lacking medical facilities and/or qualified medical providers ("medical deserts"). DESIGN GERONTACCESS was a 12-month, multicentre, prospective cluster-randomised trial conducted in NHs. The intervention group underwent TLM assessments every 3 months. The control group received the usual care. In both groups, comprehensive on-site assessments were conducted at baseline and the final visit. Care requirements were documented throughout the study. SETTING AND PARTICIPANTS NH residents aged ≥ 60 years with multiple chronic diseases. METHODS The study outcomes were the proportion of patients who experienced avoidable and unplanned hospitalisation, and the incremental cost savings per quality-adjusted life years from baseline to the 12-month follow-up. RESULTS Of the 426 randomised participants (mean ± standard deviation age, 87.2 ± 7.6 years; 311 [73.0%] women), 23.4% in the intervention group and 32.5% in the control group experienced unplanned hospitalisation (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.43 to 0.97; p = 0.034). Each avoided hospitalisation in the intervention group saved $US 3,846. CONCLUSIONS AND IMPLICATIONS The results of GERONTACCESS revealed that our gerontological, preventative TLM program significantly reduced unplanned hospitalisations. This innovative intervention limited disease progression and promoted a healthy lifestyle among NH residents. TRIAL REGISTRATION Clinicaltrials.gov, NCT02816177, registered June 28, 2016.
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Affiliation(s)
- Caroline Gayot
- grid.9966.00000 0001 2165 4861Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France ,grid.411178.a0000 0001 1486 4131CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042 France ,grid.411178.a0000 0001 1486 4131Unité de Recherche Clinique Et d’Innovation (URCI) en Gérontologie, CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France
| | - Cécile Laubarie-Mouret
- grid.9966.00000 0001 2165 4861Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France ,grid.411178.a0000 0001 1486 4131CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042 France
| | - Kevin Zarca
- grid.50550.350000 0001 2175 4109DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Maroua Mimouni
- grid.50550.350000 0001 2175 4109DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Noelle Cardinaud
- grid.9966.00000 0001 2165 4861Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France ,grid.411178.a0000 0001 1486 4131CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042 France
| | - Sandrine Luce
- grid.411178.a0000 0001 1486 4131Centre d’Épidémiologie, de Bio Statistique Et de Méthodologie de La Recherche (CEBIMER), CHU de Limoges, 2 Avenue Martin-Luther King, Limoges, F-87042 France
| | - Isabelle Tovena
- grid.9966.00000 0001 2165 4861Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
| | - Isabelle Durand-Zaleski
- grid.50550.350000 0001 2175 4109DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marie-Laure Laroche
- grid.9966.00000 0001 2165 4861Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
| | - Pierre-Marie Preux
- grid.411178.a0000 0001 1486 4131Centre d’Épidémiologie, de Bio Statistique Et de Méthodologie de La Recherche (CEBIMER), CHU de Limoges, 2 Avenue Martin-Luther King, Limoges, F-87042 France
| | - Achille Tchalla
- grid.9966.00000 0001 2165 4861Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France ,grid.411178.a0000 0001 1486 4131CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042 France ,grid.411178.a0000 0001 1486 4131Unité de Recherche Clinique Et d’Innovation (URCI) en Gérontologie, CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France ,Geriatric Medicine, University of Limoges, CHU Limoges, Laboratoire VieSanté - UR 24134, Limoges, France
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21
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Hickman SE, Mitchell SL, Hanson LC, Tu W, Stump TE, Unroe KT. The design and conduct of a pragmatic cluster randomized trial of an advance care planning program for nursing home residents with dementia. Clin Trials 2022; 19:623-635. [PMID: 35815777 PMCID: PMC9691516 DOI: 10.1177/17407745221108992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS A significant number of people with Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Advance care planning (ACP), the process of eliciting and documenting patient-centered preferences for care, is considered essential to providing high quality care for this population. Nursing homes are currently required by regulations to offer ACP to residents and families, but no training requirements exist for nursing home staff, and approaches to fulfilling this regulatory and ethical responsibility vary. As a result, residents may receive care inconsistent with their goals, such as unwanted hospitalizations. Pragmatic trials offer a way to develop and test ACP in real-world settings to increase the likelihood of adoption of sustainable best practices. METHODS The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support (APPROACHES)" project is designed to pragmatically test and evaluate a staff-led program in 137 nursing homes (68 = intervention, 69 = control) owned by two nursing home corporations. Existing nursing home staff receive standardized training and implement the ACP Specialist program under the supervision of a corporate lead. The primary trial outcome is the annual rate of hospital transfers (admissions and emergency department visits). Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical, or billing purposes. Configurational analysis will also be performed to identify conditions associated with implementation. RESULTS Partnerships with large corporate companies enable the APPROACHES trial to rely on corporate infrastructure to roll out the intervention, with support for a corporate implementation lead who is charged with the initial introduction and ongoing support for nursing home-based ACP Specialists. These internal champions connect the project with other company priorities and use strategies familiar to nursing home leaders for the initiation of other programs. Standardized data collection across nursing homes also supports the conduct of pragmatic trials in this setting. DISCUSSION Many interventions to improve care in nursing homes have failed to demonstrate an impact or, if successful, maintain an impact over time. Pragmatic trials, designed to test interventions in real-world contexts that are evaluated through existing data sources collected routinely as part of clinical care, are well suited for the nursing home environment. A robust program that increases access to ACP for nursing home residents has the potential to increase goal-concordant care and is expected to reduce hospital transfers. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve the quality of care for residents with dementia.
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Affiliation(s)
- Susan E Hickman
- School of Nursing, Indiana University, Indianapolis,
Indiana, U.S.,RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
| | - Susan L Mitchell
- Harvard Medical School, Boston, Massachusetts, U.S.,Beth Israel Deaconess Medical Center, Boston,
Massachusetts, U.S.,Marcus Institute for Aging Research, Boston, Massachusetts,
U.S
| | - Laura C Hanson
- School of Medicine, University of North Carolina, Chapel Hill,
North Carolina
| | - Wanzhu Tu
- IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S.,Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Timothy E Stump
- Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Kathleen T Unroe
- RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
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22
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TYLER DENISEA, FENG ZHANLIAN, GRABOWSKI DAVIDC, BERCAW LAWREN, SEGELMAN MICAH, KHATUTSKY GALINA, WANG JOYCE, GASDASKA ANGELA, INGBER MELVINJ. CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned. Milbank Q 2022; 100:1243-1278. [PMID: 36573335 PMCID: PMC9836234 DOI: 10.1111/1468-0009.12594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022] Open
Abstract
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.
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing 2022; 51:6834152. [PMID: 36413591 PMCID: PMC9681131 DOI: 10.1093/ageing/afac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.
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Affiliation(s)
- Carl Marincowitz
- Address correspondence to: Carl Marincowitz, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Louise Preston
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Anna Cantrell
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
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24
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Mukamel DB, Saliba D, Ladd H, Konetzka RT. Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes. J Am Med Dir Assoc 2022; 23:1793-1799.e3. [PMID: 35948066 DOI: 10.1016/j.jamda.2022.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/27/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Although many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits. DESIGN Retrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set. SETTING AND PARTICIPANTS A total of 15,718 nursing homes nationally reporting PBJ data during 2017-2019, their staff, and residents. METHODS We estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days. RESULTS The daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day = ∼2%; prior day = approximately -0.7% to -0.9%) than for CNAs (same day <1%; prior day < -0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings. CONCLUSIONS AND IMPLICATIONS Our findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.
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25
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Penneau A. Do mobile hospital teams in residential aged care facilities increase health care efficiency: an evaluation of French residential care policy. Eur J Health Econ 2022:1-15. [PMID: 36131213 PMCID: PMC9492467 DOI: 10.1007/s10198-022-01522-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
CONTEXT Patients in residential aged care facilities (RACF) are frequently admitted to hospital since the RACF often lack adequate medical resources. Different economic agents, whose missions and funding may conflict, provide care for RACF residents: residential facility, primary care physicians, and hospital. In this article, I estimate the economic impact of employing a mobile hospital team (MHT) in RACF, which modifies the relationship between these three agents by providing care directly in RACF. METHOD A national, patient level database on RACF from 2014 to 2017 is used to calculate RACF outcome indicators. I analyse the difference between RACFs, that use MHT for the first time during the period (treatment group), and those that did not use MHT at all in the same period using a difference in difference (DID) model. RESULTS The MHT had a significant impact on health care quality in treated RACFs and reduced the number of patients transferred to hospital and the number of emergency department visits, and increased palliative care utilisation at the end-of-life, without increasing total hospital expenditure. CONCLUSION MHT appear improve care quality in RACFs by filling the gap in care needs including better end of life care, without increasing health expenditure. Given the high number of hospital transfers especially towards the end of life, securing the right level and mix of social and medical resources in RACFs is essential. Transferring some competencies of MHT teams to residential facilities may improve the quality of life of residents while improving allocative efficiency of public resources.
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Affiliation(s)
- Anne Penneau
- Institute for Research and Information in Health Economics (IRDES), 117 bis rue Manin, 75019, Paris, France.
- Department of Economics (LEDa) Paris-Dauphine University PSL, Place du Maréchal de Lattre de Tassigny, 75016, Paris, France.
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26
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Bretschneider C, Poeck J, Freytag A, Günther A, Schneider N, Schwabe S, Bleidorn J. [Emergency situations and emergency department visits in nursing homes-a scoping review about circumstances and healthcare interventions]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022; 65:688-696. [PMID: 35581404 PMCID: PMC9113071 DOI: 10.1007/s00103-022-03543-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nursing home residents are more likely to be hospitalized as non-institutionalized peers. A large number of emergency medical services (EMS) and emergency department visits are classified as potentially avoidable. OBJECTIVES To identify circumstances that increase the number of emergency situations in nursing homes and approaches to reduce hospital admissions in order to illustrate the complexity and opportunities for action. MATERIALS AND METHODS Scoping review with analysis of current original and peer-reviewed papers (2015-2020) in PubMed, CINAHL, and hand-search databases. RESULTS From 2486 identified studies, 302 studies were included. Injuries, fractures, cardiovascular, respiratory, and infectious diseases are the most frequent diagnostic groups that have been retrospectively recorded. Different aspects could be identified as circumstances inducing emergency department visits: resident-related (e.g., multimorbidity, lack of volition, and advance directives), facility-related (e.g., staff turnover, uncertainties), physician-related (lack of accessibility, challenging access to specialists), and system-related circumstances (e.g., limited possibilities for diagnostics and treatment in facilities). Multiple approaches to reduce emergency department visits are being explored. CONCLUSIONS A variety of circumstances influence the course of action in emergency situations in nursing facilities. Therefore, interventions to reduce emergency department visits address, among other things, strengthening the competence of nursing staff, interprofessional communication, and systemic approaches. A comprehensive understanding of the complex processes of care is essential for developing and implementing effective interventions.
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Affiliation(s)
- Carsten Bretschneider
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
| | - Juliane Poeck
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland.
| | - Antje Freytag
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
| | | | - Nils Schneider
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Sven Schwabe
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Jutta Bleidorn
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Bachstr. 18, 07743, Jena, Deutschland
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27
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Tu W, Li R, Stump TE, Fowler NR, Carnahan JL, Blackburn J, Sachs GA, Hickman SE, Unroe KT. Age-specific rates of hospital transfers in long-stay nursing home residents. Age Ageing 2022; 51:6430100. [PMID: 34850811 DOI: 10.1093/ageing/afab232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION hospital transfers and admissions are critical events in the care of nursing home residents. We sought to determine hospital transfer rates at different ages. METHODS a cohort of 1,187 long-stay nursing home residents who had participated in a Centers for Medicare and Medicaid demonstration project. We analysed the number of hospital transfers of the study participants recorded by the Minimum Data Set. Using a modern regression technique, we depicted the annual rate of hospital transfers as a smooth function of age. RESULTS transfer rates declined with age in a nonlinear fashion. Rates were the highest among residents younger than 60 years of age (1.30-2.15 transfers per year), relatively stable between 60 and 80 (1.17-1.30 transfers per year) and lower in those older than 80 (0.77-1.17 transfers per year). Factors associated with increased risk of transfers included prior diagnoses of hip fracture (annual incidence rate ratio or IRR: 2.057, 95% confidence interval (CI): [1.240, 3.412]), dialysis (IRR: 1.717, 95% CI: [1.313, 2.246]), urinary tract infection (IRR: 1.755, 95% CI: [1.361, 2.264]), pneumonia (IRR: 1.501, 95% CI: [1.072, 2.104]), daily pain (IRR: 1.297, 95% CI: [1.055,1.594]), anaemia (IRR: 1.229, 95% CI [1.068, 1.414]) and chronic obstructive pulmonary disease (IRR: 1.168, 95% CI: [1.010,1.352]). Transfer rates were lower in residents who had orders reflecting preferences for comfort care (IRR: 0.79, 95% CI: [0.665, 0.936]). DISCUSSION younger nursing home residents may require specialised interventions to reduce hospital transfers; declining transfer rates with the oldest age groups may reflect preferences for comfort-focused care.
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Affiliation(s)
- Wanzhu Tu
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Ruohong Li
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Timothy E Stump
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Nicole R Fowler
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jennifer L Carnahan
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Justin Blackburn
- Department of Health Policy and Management, Indiana University Fairbanks School of Public Health, Indianapolis, IN 46202, USA
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN 46202, USA
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Webb HT, Lieb KM, Stump TE, Unroe KT, Carnahan JL. Describing Transfers Originating Out-of-Facility for Nursing Home Residents. J Am Med Dir Assoc 2022; 23:105-110. [PMID: 34181908 PMCID: PMC8709881 DOI: 10.1016/j.jamda.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/06/2021] [Accepted: 05/29/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers). DESIGN Secondary data analysis with multivariable model for community transfer risk factors. SETTING AND PARTICIPANTS Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016. METHODS Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis. RESULTS Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement. CONCLUSIONS AND IMPLICATIONS Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.
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Affiliation(s)
- Hanna T Webb
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristi M Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA
| | - Jennifer L Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA.
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29
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Xu H, Bowblis JR, Caprio TV, Li Y, Intrator O. Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes. J Am Med Dir Assoc 2021; 23:1297-1303. [PMID: 34919837 PMCID: PMC9200897 DOI: 10.1016/j.jamda.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Nursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents. DESIGN The 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.0 were analyzed. We implemented generalized estimating equation models to examine micropolitan-urban differences in ED rates and Blinder-Oaxaca decompositions to quantify the contributions of NH and market factors. SETTING AND PARTICIPANTS The study cohort included 12,883 unique privately owned, freestanding NHs from urban and micropolitan areas. MEASURES Quarterly risk-adjusted rates of any ED visits, outpatient ED visits, and PAED visits were calculated from Medicare claims and MDS. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and Area Health Resources File. RESULTS Over the study period, risk-adjusted rates averaged 10.2%, 3.4%, and 3.3% for any ED, outpatient ED, and PAED visits, respectively. Compared with urban NHs, micropolitan NHs reported similar rates of any ED, but significantly higher rates of outpatient ED and PAED (β = 0.20% and 0.27%; both P < .05). Observable differences in NH characteristics (eg, number of beds, percentage Medicare or Medicaid residents, and employment of nurse practitioners and physician assistants) explained more than 20% of the micropolitan-urban differences in rates of outpatient ED and PAED visits; market factors (mainly Medicare Advantage penetration) explained about 46% of the differences in rates of outpatient ED visits. CONCLUSIONS AND IMPLICATIONS Compared with urban NHs, micropolitan NHs tend to utilize more avoidable emergency care that can be partially explained by facility size, payer mix, use of nurse practitioners and physician assistants, and market structure.
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Affiliation(s)
- Huiwen Xu
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH, USA; Scripps Gerontology Center, Miami University, Oxford, OH, USA
| | - Thomas V Caprio
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Division of Geriatrics, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY, USA
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30
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Inacio MC, Jorissen RN, Wesselingh S, Sluggett JK, Whitehead C, Maddison J, Forward J, Bourke A, Harvey G, Crotty M. Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study. BMJ Open 2021; 11:e057247. [PMID: 34789497 PMCID: PMC8601069 DOI: 10.1136/bmjopen-2021-057247] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To: (1) examine the 90-day incidence of unplanned hospitalisation and emergency department (ED) presentations after residential aged care facility (RACF) entry, (2) examine individual-related, facility-related, medication-related, system-related and healthcare-related predictors of these outcomes and (3) create individual risk profiles. DESIGN Retrospective cohort study using the Registry of Senior Australians. Fine-Gray models estimated subdistribution HRs and 95% CIs. Harrell's C-index assessed risk models' predictive ability. SETTING AND PARTICIPANTS Individuals aged ≥65 years old entering a RACF as permanent residents in three Australian states between 1 January 2013 and 31 December 2016 (N=116 192 individuals in 1967 RACFs). PREDICTORS EXAMINED Individual-related, facility-related, medication-related, system and healthcare-related predictors ascertained at assessments or within 90 days, 6 months or 1 year prior to RACF entry. OUTCOME MEASURES 90-day unplanned hospitalisation and ED presentation post-RACF entry. RESULTS The cohort median age was 85 years old (IQR 80-89), 62% (N=71 861) were women, and 50.5% (N=58 714) had dementia. The 90-day incidence of unplanned hospitalisations was 18.0% (N=20 919) and 22.6% (N=26 242) had ED presentations. There were 34 predictors of unplanned hospitalisations and 34 predictors of ED presentations identified, 27 common to both outcomes and 7 were unique to each. The hospitalisation and ED presentation models out-of-sample Harrell's C-index was 0.664 (95% CI 0.657 to 0.672) and 0.655 (95% CI 0.648 to 0.662), respectively. Some common predictors of high risk of unplanned hospitalisation and ED presentations included: being a man, age, delirium history, higher activity of daily living, behavioural and complex care needs, as well as history, number and recency of healthcare use (including hospital, general practitioners attendances), experience of a high sedative load and several medications. CONCLUSIONS Within 90 days of RACF entry, 18.0% of individuals had unplanned hospitalisations and 22.6% had ED presentations. Several predictors, including modifiable factors, were identified at the time of care entry. This is an actionable period for targeting individuals at risk of hospitalisations.
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Affiliation(s)
- Maria C Inacio
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Robert N Jorissen
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Steve Wesselingh
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Janet K Sluggett
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Craig Whitehead
- Southern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John Maddison
- Northern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - John Forward
- Northern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - Alice Bourke
- Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - Gillian Harvey
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Maria Crotty
- Southern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Xu H, Intrator O, Culakova E, Bowblis JR. Changing landscape of nursing homes serving residents with dementia and mental illnesses. Health Serv Res 2021; 57:505-514. [PMID: 34747498 DOI: 10.1111/1475-6773.13908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/29/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster. DATA SOURCES 2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States. STUDY DESIGN Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster. DATA EXTRACTION METHODS We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data. PRINCIPAL FINDINGS Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE = 0.12), and -0.97 (SE = 0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively. CONCLUSIONS Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.
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Affiliation(s)
- Huiwen Xu
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, USA.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York, USA
| | - Eva Culakova
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, Ohio, USA.,Scripps Gerontology Center, Miami University, Oxford, Ohio, USA
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Honinx E, Piers RD, Onwuteaka-Philipsen BD, Payne S, Szczerbińska K, Gambassi G, Kylänen M, Deliens L, Van den Block L, Smets T. Hospitalisation in the last month of life and in-hospital death of nursing home residents: a cross-sectional analysis of six European countries. BMJ Open 2021; 11:e047086. [PMID: 34385245 PMCID: PMC8362714 DOI: 10.1136/bmjopen-2020-047086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To examine the rate and characteristics of hospitalisation in the last month of life and place of death among nursing home residents and to identify related care processes, facility factors and residents' characteristics. SETTING A cross-sectional study (2015) of deceased residents in 322 nursing homes in six European countries. PARTICIPANTS The nursing home manager (N=1634), physician (N=1132) and primary nurse (N=1384) completed questionnaires. OUTCOME MEASURES Hospitalisation and place of death were analysed using generalised linear and logistic mixed models. Multivariate analyses were conducted to determine associated factors. RESULTS Twelve to 26% of residents were hospitalised in the last month of life, up to 19% died in-hospital (p<0.001). Belgian residents were more likely to be hospitalised than those in Italy, the Netherlands and Poland. For those dying in-hospital, the main reason for admission was acute change in health status. Residents with a better functional status were more likely to be hospitalised or to die in-hospital. The likelihood of hospitalisation and in-hospital death increased if no conversation on preferred care with a relative was held. Not having an advance directive regarding hospitalisations increased the likelihood of hospitalisation. CONCLUSIONS Although participating countries vary in hospitalisation and in-hospital death rates, between 12% (Italy) and 26% (Belgium) of nursing home residents were hospitalised in the last month of life. Close monitoring of acute changes in health status and adequate equipment seem critical to avoiding unnecessary hospitalisations. Strategies to increase discussion of preferences need to be developed. Our findings can be used by policy-makers at governmental and nursing home level.
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Affiliation(s)
- Elisabeth Honinx
- Huisartsgeneeskunde, Vrije Universiteit Brussel, Jette, Brussels, Belgium
| | - Ruth D Piers
- Geriatrics, University Hospital Ghent, Gent, Oost-Vlaanderen, Belgium
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health/EMGO Institute for Health and Care Research/Expertise Center for Palliative Care, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Sheila Payne
- Institute for Health Research, Lancaster University Faculty of Health and Medicine, Lancaster, Lancashire, UK
| | - Katarzyna Szczerbińska
- Sociology of Medicine, Jagiellonian University Medical College Faculty of Medicine, Krakow, Poland
| | - Giovanni Gambassi
- Internal Medicine, Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Roma, Lazio, Italy
| | - Marika Kylänen
- Department of Health, National Institute for Health and Welfare, Helsinki, Uusimaa, Finland
| | - L Deliens
- Chronic Care, Universiteit Gent Faculteit Geneeskunde en Gezondheidswetenschappen, Gent, Belgium
| | - Lieve Van den Block
- Huisartsgeneeskunde, Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Brussel, Belgium
| | - Tinne Smets
- Huisartsgeneeskunde, Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Brussel, Belgium
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Pulst A, Fassmer AM, Schmiemann G. Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study. Aging Clin Exp Res 2021; 33:2231-41. [PMID: 33258074 DOI: 10.1007/s40520-020-01751-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/30/2020] [Indexed: 01/20/2023]
Abstract
Background Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce. Aims The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer. Methods We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively. Results Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3–83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%). Discussion Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences. Conclusion Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers. Electronic supplementary material The online version of this article (10.1007/s40520-020-01751-5) contains supplementary material, which is available to authorized users.
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Hatfield LA, Caudry D, Grabowski DC. Change in condition alerts for home care recipients: A stepped wedge cluster randomized trial. J Am Geriatr Soc 2021; 69:2548-2555. [PMID: 34138464 DOI: 10.1111/jgs.17324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Paid home care providers (caregivers) are in close, regular contact with people for whom they care (clients). This study evaluated whether caregivers, by noting changes in physical and mental health, could prevent hospitalizations. DESIGN Stepped wedge cluster randomized trial with 4 sequences, 244 clusters, an open cohort, and continuous outcome assessment. SETTING Franchises of a national home care company. PARTICIPANTS Eligible clusters were all franchises operating at the study start, excluding those in a previous pilot. The sample included all clients who received private-pay home care services from an eligible franchise, could be linked to Medicare enrollment records, and were enrolled in fee-for-service Medicare. INTERVENTION A telephone- and app-based questionnaire at the end of each caregiving shift asked caregivers whether they noted changes in mental or physical health of their client. This generated a change-in-condition report that staff at the franchise office addressed at their discretion (e.g., by contacting clients or primary care providers). The control condition was no questionnaire. The study was unblinded. Clusters were randomized to four treatment sequences in eight strata of franchise characteristics. MEASUREMENTS The primary outcome was hospitalization during months of home care enrollment. Secondary outcomes were emergency department (ED) visits and mortality. RESULTS Two hundred and forty-four franchises were randomized to the four sequences (n = 40, 66, 68, 70 franchises, respectively) and 40,137 people were observed during 276,938 person-months of home care enrollment. We found no evidence of impact on hospitalization (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.97, 1.10), ED visits (OR 1.03, 95% CI: 0.98, 1.08), or mortality (OR 1.07, 95% CI: 0.96, 1.19). CONCLUSION A technology-enabled intervention to identify health changes among home care recipients did not show evidence of impact on hospitalizations, ED visits, or mortality. Providing change-in-condition reports to home care staff, without a structured response to manage these changes, was not effective at improving care.
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Affiliation(s)
- Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Daryl Caudry
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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Ohta R, Ryu Y, Sano C. Effects of Implementation of Infection Control Measures against COVID-19 on the Condition of Japanese Rural Nursing Homes. Int J Environ Res Public Health 2021; 18:5805. [PMID: 34071413 DOI: 10.3390/ijerph18115805] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/30/2022]
Abstract
This study aimed to clarify the effect of coronavirus disease (hereafter, COVID-19) control on patients’ health conditions and staff’s working conditions in rural nursing homes. An interventional study including all staff and patients in a rural nursing home was performed from 1 April 2019 to 31 March 2021. Infection control measures against COVID-19 were initiated on 1 April 2020. The primary outcome was the frequency of patients’ medical care visits to the outpatient and emergency departments. The secondary outcome was the number of days-off taken by staff. Each group (pre- and post-COVID-19 control groups) had 48 participants. The number of visits to the outpatient department reduced from the pre-COVID-19 to post-COVID-19 control period the difference in number of visits to the emergency department was not significant, due to the low statistical power. The number of days-off taken by the staff was increased from the pre-COVID-19 to post-COVID-19 control period. This is the first study investigating COVID-19 control measures in a rural nursing home. It may help reduce the number of patient visits to medical facilities without increasing the risk of emergencies. A strict health check of the staff can allow staff to take more days off in rural contexts.
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Blackburn J, Balio CP, Carnahan JL, Fowler NR, Hickman SE, Sachs GA, Tu W, Unroe KT. Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project. BMC Health Serv Res 2021; 21:492. [PMID: 34030672 DOI: 10.1186/s12913-021-06419-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/19/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model. METHODS This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics. RESULTS The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1). CONCLUSIONS Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.
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Xu H, Bowblis JR, Caprio TV, Li Y, Intrator O. Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis. Med Care 2021; 59:38-45. [PMID: 33165147 DOI: 10.1097/mlr.0000000000001451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents. OBJECTIVES To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents. RESEARCH DESIGN We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors. SUBJECTS Privately owned, free-standing NHs in the United States (N=13,260). RESULTS Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED. CONCLUSIONS Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.
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Affiliation(s)
- Huiwen Xu
- Departments of Surgery, Cancer Control
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - John R Bowblis
- Department of Economics, Farmer School of Business
- Scripps Gerontology Center, Miami University, Oxford, OH
| | - Thomas V Caprio
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Medicine, Division of Geriatrics, University of Rochester School of Medicine and Dentistry, Rochester
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
| | - Yue Li
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Orna Intrator
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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Müller C, Hesjedal-Streller B, Fleischmann N, Tetzlaff B, Mallon T, Scherer M, Köpke S, Balzer K, Gärtner L, Maurer I, Friede T, König HH, Hummers E. Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial. Trials 2020; 21:913. [PMID: 33153484 PMCID: PMC7643262 DOI: 10.1186/s13063-020-04736-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention. METHODS This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed. DISCUSSION This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers. TRIAL REGISTRATION ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.
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Affiliation(s)
- Christiane Müller
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, D-37073, Göttingen, Germany.
| | - Berit Hesjedal-Streller
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, D-37073, Göttingen, Germany
| | - Nina Fleischmann
- Nursing Science, Fulda University of Applied Sciences, Building 31, Room 122, Leipziger Straße 123, D-36037, Fulda, Germany
| | - Britta Tetzlaff
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Tina Mallon
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Sascha Köpke
- Institute of Nursing Science, University Clinic Cologne, Gleueler Straße 176-178, D-50935, Köln, Germany
| | - Katrin Balzer
- Institute for Social Medicine and Epidemiology, Nursing Research Group, University of Lübeck, Ratzeburger Allee 160, Haus 50, D-23538, Lübeck, Germany
| | - Linda Gärtner
- Institute for Social Medicine and Epidemiology, Nursing Research Group, University of Lübeck, Ratzeburger Allee 160, Haus 50, D-23538, Lübeck, Germany
| | - Indre Maurer
- Chair of Organization and Corporate Development, Georg-August-University Göttingen, Platz der Göttinger Sieben 3, D-37073, Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, D-37073, Göttingen, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, D-37073, Göttingen, Germany
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Yang BK, Carter MW, Trinkoff AM, Nelson HW. Nurse Staffing and Skill Mix Patterns in Relation to Resident Care Outcomes in US Nursing Homes. J Am Med Dir Assoc 2020; 22:1081-1087.e1. [PMID: 33132015 DOI: 10.1016/j.jamda.2020.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/31/2020] [Accepted: 09/06/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates. DESIGN Retrospective secondary data analysis at the facility level, using administrative data. SETTING AND PARTICIPANTS Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325). METHODS Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant. RESULTS We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs. CONCLUSIONS AND IMPLICATIONS NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.
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Affiliation(s)
- Bo Kyum Yang
- Department of Health Sciences, Towson University, Towson, MD, USA.
| | - Mary W Carter
- Department of Health Sciences, Towson University, Towson, MD, USA
| | - Alison M Trinkoff
- Department of Family and Community Health, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Hubert W Nelson
- Department of Health Sciences, Towson University, Towson, MD, USA
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Hullick CJ, Hall AE, Conway JF, Hewitt JM, Darcy LF, Barker RT, Oldmeadow C, Attia JR. Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation. J Am Geriatr Soc 2020; 69:201-209. [PMID: 33124692 DOI: 10.1111/jgs.16890] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers. DESIGN A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016. SETTING A large regional and rural area of northern and western New South Wales, Australia. PARTICIPANTS Nine hospital EDs and 81 RACFs participated in the evaluation. INTERVENTION The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program. MEASUREMENTS ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up. RESULTS A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79; 95% confidence interval [CI] = .68-.92); P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80; 95% CI = .69-.92; P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven-day ED re-presentation fell from 5.7% to 4.9%, and 30-day hospital readmissions fell from 12% to 10%. CONCLUSION The stepped wedge design allowed rigorous evaluation of a real-world large-scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.
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Affiliation(s)
- Carolyn J Hullick
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Jane F Conway
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Jacqueline M Hewitt
- Hunter New England Central Coast Primary Health Network, Newcastle, New South Wales, Australia
| | - Leigh F Darcy
- Hunter Primary Care, Warabrook, New South Wales, Australia
| | - Roslyn T Barker
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - John R Attia
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
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Joseph JW, Kennedy M, Nathanson LA, Wardlow L, Crowley C, Stuck A. Reducing Emergency Department Transfers from Skilled Nursing Facilities Through an Emergency Physician Telemedicine Service. West J Emerg Med 2020; 21:205-209. [PMID: 33207167 PMCID: PMC7673904 DOI: 10.5811/westjem.2020.7.46295] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/11/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Transfers of skilled nursing facility (SNF) residents to emergency departments (ED) are linked to morbidity, mortality and significant cost, especially when transfers result in hospital admissions. This study investigated an alternative approach for emergency care delivery comprised of SNF-based telemedicine services provided by emergency physicians (EP). We compared this on-site emergency care option to traditional ED-based care, evaluating hospital admission rates following care by an EP. Methods We conducted a retrospective, observational study of SNF residents who underwent emergency evaluation between January 1, 2017–January 1, 2018. The intervention group was comprised of residents at six urban SNFs in the Northeastern United States, who received an on-demand telemedicine service provided by an EP. The comparison group consisted of residents of SNFs that did not offer on-demand services and were transferred via ambulance to the ED. Using electronic health record data from both the telemedicine and ambulance transfers, our primary outcome was the odds ratio (OR) of a hospital admission. We also conducted a subanalysis examining the same OR for the three most common chronic disease-related presentations found among the telemedicine study population. Results A total of 4,606 patients were evaluated in both the SNF-based intervention and ED-based comparison groups (n=2,311 for SNF based group and 2,295 controls). Patients who received the SNF-based acute care were less likely to be admitted to the hospital compared to patients who were transferred to the ED in our primary and subgroup analyses. Overall, only 27% of the intervention group was transported to the ED for additional care and presumed admission, whereas 71% of the comparison group was admitted (OR for admission = 0.15 [9% confidence interval, 0.13–0.17]). Conclusion The use of an EP-staffed telemedicine service provided to SNF residents was associated with a significantly lower rate of hospital admissions compared to the usual ED-based care for a similarly aged population of SNF residents. Providing SNF-based care by EPs could decrease costs associated with hospital-based care and risks associated with hospitalization, including cognitive and functional decline, nosocomial infections, and falls.
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Affiliation(s)
- Joshua W Joseph
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Maura Kennedy
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Larry A Nathanson
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | | | | | - Amy Stuck
- West Health Institute, La Jolla, California
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Sluggett JK, Lalic S, Hosking SM, Ilomӓki J, Shortt T, McLoughlin J, Yu S, Cooper T, Robson L, Van Dyk E, Visvanathan R, Bell JS. Root cause analysis of fall-related hospitalisations among residents of aged care services. Aging Clin Exp Res 2020; 32:1947-1957. [PMID: 31728845 DOI: 10.1007/s40520-019-01407-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/30/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. AIMS To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. METHODS An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. RESULTS Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. CONCLUSIONS This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.
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Affiliation(s)
- Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia.
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia.
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Sarah M Hosking
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- Centre of Research Excellence in Frailty and Healthy Ageing, National Health and Medical Research Council of Australia, Adelaide, SA, Australia
| | - Jenni Ilomӓki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | | | - Solomon Yu
- Centre of Research Excellence in Frailty and Healthy Ageing, National Health and Medical Research Council of Australia, Adelaide, SA, Australia
- Adelaide Geriatrics Training and Research with Aged Care (G-TRAC) Centre, School of Medicine, The University of Adelaide, Adelaide, SA, Australia
- Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Tina Cooper
- Resthaven Incorporated, Adelaide, SA, Australia
| | | | - Eleanor Van Dyk
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
| | - Renuka Visvanathan
- Centre of Research Excellence in Frailty and Healthy Ageing, National Health and Medical Research Council of Australia, Adelaide, SA, Australia
- Adelaide Geriatrics Training and Research with Aged Care (G-TRAC) Centre, School of Medicine, The University of Adelaide, Adelaide, SA, Australia
- Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia
- Centre of Research Excellence in Frailty and Healthy Ageing, National Health and Medical Research Council of Australia, Adelaide, SA, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Xu H, Bowblis JR, Li Y, Caprio TV, Intrator O. Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter? J Am Med Dir Assoc 2020; 21:1497-1503. [DOI: 10.1016/j.jamda.2020.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 03/30/2020] [Accepted: 04/26/2020] [Indexed: 11/16/2022]
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Xu H, Bowblis JR, Caprio TV, Li Y, Intrator O. Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban, Micropolitan, and Rural Nursing Homes. J Am Med Dir Assoc 2020; 22:1101-1106. [PMID: 33008755 DOI: 10.1016/j.jamda.2020.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Hospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3). DESIGN The longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs. SETTING AND PARTICIPANTS In total, 14,600 unique NHs. MEASURES Risk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File. RESULTS Over the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs. CONCLUSIONS/IMPLICATIONS Rurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.
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Affiliation(s)
- Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH; Scripps Gerontology Center, Miami University, Oxford, OH
| | - Thomas V Caprio
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Division of Geriatrics, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY; Geriatrics and Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Geriatrics and Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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Xu H, Intrator O, Bowblis JR. Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors? J Am Med Dir Assoc 2020; 21:1371-1377. [PMID: 32981663 PMCID: PMC7418696 DOI: 10.1016/j.jamda.2020.08.002] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/06/2020] [Indexed: 12/04/2022]
Abstract
Objectives During the Coronavirus Disease 2019 (COVID-19) pandemic, US nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during the COVID-19 pandemic. Design We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare and Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs. Setting and Participants 11,920 free-standing NHs. Measures The dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification and Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data. Results Of the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both >25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio [AOR] = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having 1-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages. Conclusions/Implications Abundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.
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Affiliation(s)
- Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Geriatrics and Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH; Scripps Gerontology Center, Miami University, Oxford, OH
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Smith TB, English TM, Naidoo J, Whitman MV. The Hospital Readmissions Reduction Program's Impact on Readmissions From Skilled Nursing Facilities. J Healthc Manag 2019; 64:186-96. [PMID: 31999269 DOI: 10.1097/JHM-D-18-00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
EXECUTIVE SUMMARY Hospital readmissions have long served as an indicator of patient recovery and the effectiveness of care. The present study examines the Hospital Readmissions Reduction Program's (HRRP's) impact on hospital readmissions from skilled nursing facilities (SNFs) and the characteristics of SNFs that were predictive of lower readmission rates. Adjusted 30-day readmission rates among 14,666 SNFs in the United States from 2011 through 2015 were examined using linear regression with generalized estimating equations to determine the relationship of the HRRP mandate to readmission rates from SNFs. Findings indicate a significant downward trend in adjusted 30-day readmission rates over time, decreasing 1.4% from 2011 to 2015. Furthermore, lower readmission rates were associated with SNF characteristics including location in a hospital facility, rural designation, higher registered nurse-to-nurse ratios, and not-for-profit status. We found a substantial decrease in SNF-related readmissions associated with HRRP, which may limit the impact of the Protecting Access to Medicare Act. Policy-makers may consider these systemic and structural differences before drafting future legislation targeting hospital readmission from SNFs. In addition, acute care facility operators who do not have an SNF may consider adding one to their facility and/or consider partnering with SNFs to ensure that high-quality programs in these SNFs are in place to reduce 30-day readmissions to the acute care facilities.
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Poss J, McGrail K, McGregor MJ, Ronald LA. Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study. J Am Med Dir Assoc 2020; 21:1490-1496. [PMID: 32646822 DOI: 10.1016/j.jamda.2020.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 02/26/2020] [Accepted: 04/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia). DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016. MEASURES Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors. RESULTS The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29-1.38) and nonprofit (adjHR 1.37; 95% CI 1.32-1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36-1.48) and nonprofit (adjHR 1.38, 95% CI 1.33-1.44). CONCLUSIONS AND IMPLICATIONS This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.
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Affiliation(s)
- Jeffrey Poss
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margaret J McGregor
- Community Geriatrics, Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa A Ronald
- Community Geriatrics, Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
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Harrington C, Ross L, Chapman S, Halifax E, Spurlock B, Bakerjian D. Nurse Staffing and Coronavirus Infections in California Nursing Homes. Policy Polit Nurs Pract 2020; 21:174-186. [PMID: 32635838 DOI: 10.1177/1527154420938707] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.
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Affiliation(s)
- Charlene Harrington
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Leslie Ross
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Susan Chapman
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Elizabeth Halifax
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Bruce Spurlock
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Debra Bakerjian
- Department of Social & Behavioral Sciences, University of California, San Francisco
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Fassmer AM, Hoffmann F. Acute health care services use among nursing home residents in Germany: a comparative analysis of out-of-hours medical care, emergency department visits and acute hospital admissions. Aging Clin Exp Res 2020; 32:1359-1368. [PMID: 31428997 DOI: 10.1007/s40520-019-01306-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/05/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Nursing home (NH) residents often utilise acute health care services. However, comparative data on those are lacking. AIMS Investigating German NH residents' use of out-of-hours medical care (OOHC), visits to emergency departments (EDs) and acute hospital admissions (AHAs). METHODS Using claims data of 1665 residents for 2014-2015, we conducted a retrospective cohort study, examining the incidence rates involving the different services. Multivariate Poisson regression analyses were performed to calculate relative risks (RRs). Differences in the utilisations over the days of the week and of the reasons for contacts were assessed. RESULTS In total, 3576 contacts occurred (mean age 80.5 years, women 66.3%), resulting in an overall incidence rate of 2.7 per person-year (95% confidence interval 2.6-2.8). Strongest predictors were polypharmacy (RR 1.79; 95% CI 1.50-2.12), followed by male sex and higher care dependency. Among the three services AHAs showed the highest rates. Injuries were the most common reasons for visiting EDs, whereas for OOHC use and AHAs, coded diagnoses covered a broader spectrum. Utilisation of the services on weekdays varied, particularly for OOHC. DISCUSSION Polypharmacy, a higher care dependency and male sex seem to play a role in predicting acute health care services. Considering the distribution of the diagnoses of all three types, certain patterns concerning the symptoms' acuity become apparent. CONCLUSIONS Our findings revealed high acute health care services use among NH residents in Germany and differences among the three available services. This information can be used to design studies for investigating the appropriateness of these contacts.
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Affiliation(s)
- Alexander Maximilian Fassmer
- Department of Health Services Research, VI. School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany.
| | - Falk Hoffmann
- Department of Health Services Research, VI. School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany
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Harrington C, Dellefield ME, Halifax E, Fleming ML, Bakerjian D. Appropriate Nurse Staffing Levels for U.S. Nursing Homes. Health Serv Insights 2020; 13:1178632920934785. [PMID: 32655278 PMCID: PMC7328494 DOI: 10.1177/1178632920934785] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/22/2020] [Indexed: 11/17/2022] Open
Abstract
US nursing homes are required to have sufficient nursing staff with the
appropriate competencies to assure resident safety and attain or maintain the
highest practicable level of physical, mental, and psychosocial well-being of
each resident. Minimum nurse staffing levels have been identified in research
studies and recommended by experts. Beyond the minimum levels, nursing homes
must take into account the resident acuity to assure they have adequate staffing
levels to meet the needs of residents. This paper presents a guide for
determining whether a nursing home has adequate and appropriate nurse staffing.
We propose five basic steps to: (1) determine the collective resident acuity and
care needs, (2) determine the actual nurse staffing levels, (3) identify
appropriate nurse staffing levels to meet residents care needs, (4) examine
evidence regarding the adequacy of staffing, and (5) identify gaps between the
actual staffing and the appropriate nursing staffing levels based on resident
acuity. Data sources and specific methodologies are analyzed, compared, and
recommended. The goal is to assist nursing home nurses and administrators to
ensure adequate nursing home staffing levels that protect resident health,
safety, and well-being.
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Affiliation(s)
- Charlene Harrington
- Department of Social & Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Mary Ellen Dellefield
- Department of Nursing & Patient Care Services, VA San Diego Healthcare System, San Diego, CA, USA
| | - Elizabeth Halifax
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Mary Louise Fleming
- Healthcare Administration and Interprofessional Leadership Program, School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Debra Bakerjian
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA
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