Transition of care from post-acute services for the older adults in Quebec: a pilot impact evaluation

BACKGROUND

Early discharge of frail older adults from post-acute care service may result in individuals' reduced functional ability to carry out activities of daily living, and social, emotional, and psychological distress. To address these shortcomings, the Montreal West Island Integrated University Health and Social Services Centre in Quebec, Canada piloted a post-acute home physiotherapy program (PAHP) to facilitate the transition of older adults from the hospital to their home. This study aimed to evaluate: (1) the implementation fidelity of the PAHP program; (2) its impact on the functional independence, physical and mental health outcomes and quality of life of older adults who underwent this program (3) its potential adverse events, and (4) to identify the physical, psychological, and mental health care needs of older adults following their discharge at home.

METHODS

A quasi-experimental uncontrolled design with repeated measures was conducted between April 1st, 2021 and December 31st, 2021. Implementation fidelity was assessed using three process indicators: delay between referral to and receipt of the PAHP program, frequency of PAHP interventions per week and program duration in weeks. A battery of functional outcome measures, including the Functional Independence Measure (FIM) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 scale, as well as fall incidence, emergency visits, and hospitalizations were used to assess program impact and adverse events. The Patient's Global Impression of Change (PGICS) was used to determine changes in participants' perceptions of their level of improvement/deterioration. In addition, the Camberwell Assessment of Need for the Elderly (CANE) questionnaire was administered to determine the met and unmet needs of older adults.

RESULTS

Twenty-four individuals (aged 60.8 to 94 years) participated in the PAHP program. Implementation fidelity was low in regards with delay between referral and receipt of the program, intensity of interventions, and total program duration. Repeated measures ANOVA revealed significant improvement in FIM scores between admission and discharge from the PAHP program and between admission and the 3-month follow-up. Participants also reported meaningful improvements in PGICS scores. However, no significant differences were observed on the physical or mental health T-scores of the PROMIS Global-10 scale, in adverse events related to the PAHP program, or in the overall unmet needs.

CONCLUSION

Findings from an initial sample undergoing a PAHP program suggest that despite a low implementation fidelity of the program, functional independence outcomes and patients' global impression of change have improved. Results will help develop a stakeholder-driven action plan to improve this program. A future study with a larger sample size is currently being planned to evaluate the overall impact of this program.

CLINICAL TRIAL REGISTRATION

Retrospectively registered NCT05915156 (22/06/2023).

A Hybrid Type 1 trial of a multi-component mHealth intervention to improve post-hospital transitions of care for patients with serious mental illness: Study protocol

BACKGROUND

The transition from acute (e.g., psychiatric hospitalization) to outpatient care is associated with increased risk for rehospitalization, treatment disengagement, and suicide among people with serious mental illness (SMI). Mobile interventions (i.e., mHealth) have the potential to increase monitoring and improve coping post-acute care for this population. This protocol paper describes a Hybrid Type 1 effectiveness-implementation study, in which a randomized controlled trial will be conducted to determine the effectiveness of a multi-component mHealth intervention (tFOCUS) for improving outcomes for adults with SMI transitioning from acute to outpatient care.

METHODS

Adults meeting criteria for schizophrenia-spectrum or major mood disorders (n = 180) will be recruited from a psychiatric hospital and randomized to treatment-as-usual (TAU) plus standard discharge planning and aftercare (CHECK-IN) or TAU plus tFOCUS. tFOCUS is a 12-week intervention, consisting of: (a) a patient-facing mHealth smartphone app with daily self-assessment prompts and targeted coping strategies; (b) a clinician-facing web dashboard; and, (c) mHealth aftercare advisors, who will conduct brief post-hospital clinical calls with patients (e.g., safety concerns, treatment engagement) and encourage app use. Follow-ups will be conducted at 6-, 12-, and 24-weeks post-discharge to assess primary and secondary outcomes, as well as target mechanisms. We also will assess barriers and facilitators to future implementation of tFOCUS via qualitative interviews of stakeholders and input from a Community Advisory Board throughout the project.

CONCLUSIONS

Information gathered during this project, in combination with successful study outcomes, will inform a potential tFOCUS intervention scale-up across a range of psychiatric hospitals and healthcare systems.

CLINICALTRIALS

govregistration: NCT05703412.

Moderating effect of age on the relationship between physical health loss and emotional distress post-acute care in Japanese older hospitalized patients

BACKGROUND

At present, there are no consistent findings regarding the association between physical health loss and mental health in older adults. Some studies have shown that physical health loss is a risk factor for worsening of mental health. Other studies revealed that declining physical health does not worsen mental health. This study aimed to clarify whether the relationship between physical health loss and emotional distress varies with age in older inpatients post receiving acute care.

METHODS

Data for this study were collected from 590 hospitalized patients aged ≥ 65 years immediately after their transfer from an acute care ward to a community-based integrated care ward. Emotional distress, post-acute care physical function, and cognitive function were assessed using established questionnaires and observations, whereas preadmission physical function was assessed by the family members of the patients. After conducting a one-way analysis of variance (ANOVA) and correlation analysis by age group for the main variables, a hierarchical multiple regression analysis was conducted with emotional distress as the dependent variable, physical function as the independent variable, age as the moderator variable, and cognitive and preadmission physical function as control variables.

RESULTS

The mean GDS-15 score was found to be 6.7 ± 3.8. Emotional distress showed a significant negative correlation with physical function in younger age groups (65-79 and 80-84 years); however, no such association was found in older age groups (85-89, and ≥ 90 years). Age moderated the association between physical function and emotional distress. Poor physical function was associated with higher emotional distress in the younger patients; however, no such association was observed in the older patients.

CONCLUSIONS

Age has a moderating effect on the relationship between physical health loss and increased emotional distress in older inpatients after acute care. It was suggested that even with the same degree of physical health loss, mental damage differed depending on age, with older patients experiencing less damage.

Post-Acute Care in China: Development, Challenges, and Path Forward

OBJECTIVES

To evaluate the evolution and challenges of China's post-acute care (PAC) system over the past 20 years and suggest actionable policy recommendations for its improvement.

DESIGN

A retrospective review of policies and initiatives aimed at PAC system development, analyzed alongside unsolved challenges in light of global PAC practices, informed by literature reviews and collaborative discussion.

SETTING AND PARTICIPANTS

PAC in China involves diverse settings such as general hospitals, inpatient rehabilitation centers, skilled nursing facilities, community health centers, and homes. The patients are mainly those discharged from acute hospitals with functional impairment and in need of continuous care.

METHOD

An extensive search of government policy documents, statistical sources, peer-reviewed studies, and the gray literature. The research team conducted literature reviews and discussions regularly to shape the findings.

RESULTS

China has strengthened its PAC system through improved rehabilitation and nursing infrastructure, establishment of tiered rehabilitation networks, and adoption of innovative payment methods. However, challenges persist, including a lack of clinical consensus, resource constraints in PAC facilities and among professionals, the need for integrated care coordination, and the unification of PAC assessment tools and payment mechanisms.

CONCLUSIONS AND IMPLICATIONS

Although China has made substantial progress in its PAC system over 2 decades, continued efforts are needed to address its lingering challenges. Elevating awareness of PAC's significance and instituting policy adjustments targeting these challenges are essential for the system's optimization.

Comparative Analysis of Palliative Care Needs Identified in Inpatient Rehabilitation and Skilled Nursing Facilities by Multidisciplinary Team Members

OBJECTIVE

Assess access to, need for, and beliefs surrounding specialized palliative care (PC).

DESIGN

Observational, comparative analysis needs assessment survey.

SETTING

Four inpatient rehabilitation facilities (IRFs) or skilled nursing facilities with long-term care (SNFs/LTC) that provide subacute rehabilitation within 1 tertiary care system.

PARTICIPANTS

Allied health professionals, physicians, nursing, case managers, social workers, spiritual care (n=198).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of patient needs, attitudes about current systems, individual beliefs, and barriers to PC. Confidence in management, communicating, and navigating primary PC competencies among clinical pathway employees.

RESULTS

Of 198 respondents, 37% said PC was available at their facility. Those in IRF reported higher frequencies of grief/unmet spiritual needs of patients compared with SNF/LTC (P≤.001). Conversely, SNF/LTC reported higher frequencies of agitation, poor appetite, and end-of-life care (P≤.003). Respondents in SNF/LTC felt more confident managing end-of-life care, explaining what hospice and PC are and appropriateness for referral to each, discussing advance directives, determining appropriate decision-makers, and navigating ethical decisions than in IRFs (P≤.007). SNF/LTC participants reported higher effectiveness of their current system involving PC and ease of hospice transition compared with IRFs (P≤.008). A majority agreed that PC does not take away patient hope, could prevent recurrent hospitalizations, improve symptom management, communication, and patient and family satisfaction. The most common reported barriers to PC consultation were (1) attitudes and beliefs of staff or patients and families, (2) system issues with access, cost, or prognosis communication, and (3) lack of understanding of PC role.

CONCLUSIONS

A gap exists in PC access in IRF and SNF/LTC despite patient needs and staff beliefs. Future studies should focus on identifying which patients should be referred to PC in the post-acute setting and what outcomes can be used as a guide to meet the needs of this growing area of practice.

The health effects of nursing home specialization in post-acute care

Nursing homes serve both long-term care and post-acute care (PAC) patients, two groups with distinct financing mechanisms and requirements for care. We examine empirically the effect of nursing home specialization in PAC using 2011-2018 data for Medicare patients admitted to nursing homes following a hospital stay. To address patient selection into specialized nursing homes, we use an instrumental variables approach that exploits variation over time in the distance from the patient's residential ZIP code to the closest nursing home with different levels of PAC specialization. We find that patients admitted to nursing homes more specialized in PAC have lower hospital readmissions and mortality, longer nursing home stays, and higher Medicare spending for the episode of care, suggesting that specialization improves patient outcomes but at higher costs.

Resource Utilization Groups in transitional home care: validating the RUG-III/HC case-mix system in hospital-to-home care programs

BACKGROUND

Transitional hospital-to-home care programs support safe and timely transition from acute care settings back into the community. Case-mix systems that classify transitional care clients into groups based on their resource utilization can assist with care planning, calculating reimbursement rates in bundled care funding models, and predicting health human resource needs. This study evaluated the fit and relevance of the Resource Utilization Groups version III for Home Care (RUG-III/HC) case-mix classification system in transitional care programs in Ontario, Canada.

METHODS

We conducted a retrospective analysis of clinical assessment data and administrative billing records from a cohort of clients (n = 1,680 care episodes) in transitional home care programs in Ontario. We classified care episodes into established RUG-III/HC groups based on clients' clinical and functional characteristics and calculated four case-mix indices to describe care relative resource utilization in the study sample. Using these indices in linear regression models, we evaluated the degree to which the RUG-III/HC system can be used to predict care resource utilization.

RESULTS

A majority of transitional home care clients are classified as being Clinically complex (41.6%) and having Reduced physical functions (37.8%). The RUG-III/HC groups that account for the largest share of clients are those with the lowest hierarchical ranking, indicating low Activities of Daily Living limitations but a range of Instrumental Activities of Daily Living limitations. There is notable heterogeneity in the distribution of clients in RUG-III/HC groups across transitional care programs. The case-mix indices reflect decreasing hierarchical resource use within but not across RUG-III/HC categories. The RUG-III/HC predicts 23.34% of the variance in resource utilization of combined paid and unpaid care time.

CONCLUSIONS

The distribution of clients across RUG-III/HC groups in transitional home care programs is remarkably different from clients in long-stay home care settings. Transitional care programs have a higher proportion of Clinically complex clients and a lower proportion of clients with Reduced physical function. This study contributes to the development of a case-mix system for clients in transitional home care programs which can be used by care managers to inform planning, costing, and resource allocation in these programs.

Hospital Discharge Planners Need More Information When Referring Patients to Home Health Care: Insights From the Coronavirus Disease 2019 Pandemic

Hospital discharge planners play an important role in helping patients choose appropriate home health care. However, during the COVID-19 pandemic, they may not have had enough information to make the best decisions for their patients. A study of 58 discharge planners from Michigan hospitals found that 90% of them wanted information about the quality of home health agencies and whether they were prepared for COVID-19. However, only about 20% had this information readily available. The study also found that discharge planners varied in how they incorporated quality information. Some did not incorporate any quality information at all, while others provided it to patients without explaining its significance. Only about 25% of discharge planners helped patients interpret different sources of information. These findings suggest that hospital discharge planners had an unmet need for quality information, and they also provided limited assistance to patients. This may have led to some patients receiving suboptimal care. Thus, we proposed that hospital discharge planners need more information about the quality of home health agencies. Discharge planners should be more transparent about the quality of information they have, and they should help patients interpret it.

Breaking the Cycle: Using Serious Illness Communication to Optimize Care Transition Planning in Serious Illness

It is widely recognized that many older adults in their last year of life will cycle between hospitals and skilled nursing facilities-a phenomenon described as "rehabbing to death." Several strategies to address this complex problem have been proposed, including developing and testing serious illness communication models to provide goal-concordant care by aligning what matters most to patients with how they spend their time in the last months of life. Serious illness communication (SIC) includes structured skills clinicians can use with patients and caregivers to assess illness understanding, goals and values, share information, and make recommendations. Despite the potential of SIC models, there is a lack of literature focused on developing and testing SIC strategies in the context of care transition planning for older adults with serious illness. Our interprofessional team developed "Rehabbing to Death: Practical Strategies to Optimize Care Transitions for Patients with Serious Illness," an evidence-based, interprofessional SIC training curriculum for hospital-based rehabilitation clinicians. This 3-session curriculum was designed to enable rehabilitation clinicians to acquire knowledge of trajectories and outcomes for patients living with serious illness and communication skills to use with patients, families, and interprofessional colleagues. Nine rehabilitation clinicians (n = 3 equally from Physical Therapy, Occupational Therapy, and Speech-Language Pathology) participated in our pilot. Sessions were highly attended [100% (n = 9) sessions 1 and 2, 89% (n = 8) session 3]. Participants who completed the curriculum reported increased self-rated confidence in knowledge of serious illness and ability to communicate prognostic information and recommendations for care transitions with patients, families, and colleagues. In addition, 78% of participants would recommend the curriculum to a colleague and strongly agreed that curricular content and skills were relevant to their clinical practice. Pilot results suggest that implementing an SIC curriculum for hospital-based rehabilitation clinicians is feasible, given high rates of completion and satisfaction.

Clinical characteristics, hospital course, and disposition of patients with nontraumatic spinal cord injury in a large private health care system in the United States

OBJECTIVES

To evaluate the clinical characteristics, hospital courses, outcomes after hospitalization, and factors associated with outcomes in patients with nontraumatic spinal cord injuries (NTSCI).

DESIGN

Retrospective analysis.

SETTING

A large for-profit United States health care system.

PARTICIPANTS

2807 inpatients with NTSCI between 2014 and 2020 were identified using International Classification of Disease codes.

MAIN OUTCOME MEASURE

Demographic, clinical characteristics, hospital course, and disposition data collected from electronic health record.

RESULTS

The mean age was 57.91 ± 16.41 years with 69.83% being male. Incomplete cervical level injury was the most common injury type, spinal stenosis was the most common diagnostic etiology and central cord syndrome was the most common clinical syndrome. The average length of stay was 9.52 ± 15.8 days, with the subgroup of 1308 (46.6%) patients who were discharged home demonstrating a shorter length of stay (6.42 ± 10.24 days). Falls were the most common hospital-acquired complication (n = 424, 15.11%) and 83 patients deceased. There were increased odds of non-home discharge among patients with the following characteristics: older age, Medicare insurance, non-black racial minority, increased Charlson Comorbidity Index (CCI), intensive care unit (ICU) stay, use of steroid or anticoagulant medications, and hospital-acquired pulmonary complications. Increased in-hospital mortality was observed in those with Medicaid insurance, ICU stay, increased CCI, diagnosis of degenerative spine disease, other unspecified level of injury, and hospital-acquired pulmonary complications.

CONCLUSIONS

NTSCI in this sample were predominantly incomplete cervical central SCIs. Increased CCI, ICU stay, and hospital-acquired pulmonary complications were associated with poorer outcomes after acute care hospitalization among patients with NTSCI.

Home-based rehabilitation versus hospital-based rehabilitation for stroke patients in post-acute care stage: Comparison on the quality of life

BACKGROUND

This study focused on the integrated post-acute care (PAC) stage of stroke patients, and employed a retrospective study to examine the satisfaction with life quality in two groups, one that received home-based rehabilitation and one that received hospital-based rehabilitation. A secondary purpose was to analyze the correlations among the index and components concerning their quality of life (QOL) and compare the advantages and disadvantages of these two approaches to PAC.

METHODS

This research was a retrospective study of 112 post-acute stroke patients. The home-based group received rehabilitation for one to two weeks, and two to four sessions per week. The hospital-based group received the rehabilitation for three to six weeks, and 15 sessions per week. The home-based group mainly received the training and guidance of daily activities at the patients' residence. The hospital-based group mainly received physical facilitation and functional training in the hospital setting.

RESULTS

The mean scores of QOL assessment for both groups were found to be significantly improved after intervention. Between-group comparisons showed that the hospital-based group had better improvement than the home-based group in mobility, self-care, pain/discomfort and depression/anxiety. In the home-based group, the MRS score and the participant's age can explain 39.4% of the variance of QOL scores.

CONCLUSION

The home-based rehabilitation was of lower intensity and duration than the hospital-based one, but it still achieved a significant improvement in QOL for the PAC stroke patients. The hospital-based rehabilitation offered more time and treatment sessions. Therefore hospital-based patients responded with better QOL outcomes than the home-based patients.

Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home

OBJECTIVES

To adapt a successful acute care transitional model to meet the needs of veterans transitioning from post-acute care to home.

DESIGN

Quality improvement intervention.

SETTING AND PARTICIPANTS

Veterans discharged from a subacute care unit in the VA Boston Healthcare System's skilled nursing facility.

METHODS

We used the Replicating Effective Programs framework and Plan-Do-Study-Act cycles to adapt the Coordinated-Transitional Care (C-TraC) program to the context of transitions from a VA subacute care unit to home. The major adaptation of this registered nurse-driven, telephone-based intervention was combining the roles of discharge coordinator and transitional care case manager. We report the details of the implementation, its feasibility, and results of process measures, and describe its preliminary impact.

RESULTS

Between October 2021 and April 2022, all 35 veterans who met eligibility criteria in the VA Boston Community Living Center (CLC) participated; none were lost to follow-up. The nurse case manager delivered core components of the calls with high fidelity-review of red flags, detailed medication reconciliation, follow-up with primary care physician, and discharge services were discussed and documented in 97.9%, 95.9%, 86.8%, and 95.9%, respectively. CLC C-TraC interventions included care coordination, patient and caregiver education, connecting patients to resources, and addressing medication discrepancies. Nine medication discrepancies were discovered in 8 patients (22.9%; average of 1.1 discrepancies per patient). Compared with a historical cohort of 84 veterans, more CLC C-TraC patients received a post-discharge call within 7 days (82.9% vs 61.9%; P = .03). There was no difference between rates of attendance to appointments and acute care admissions post-discharge.

CONCLUSIONS AND IMPLICATIONS

We successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.

Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury

BACKGROUND

Hospital length of stay (HLOS) after traumatic brain injury (TBI) is a metric of injury severity, resource utilization, and access to services. This study aimed to evaluate socioeconomic and clinical factors associated with prolonged HLOS after TBI.

METHODS

Retrospective data from adult hospitalized patients diagnosed with acute TBI at a US Level 1 trauma center between August 1, 2019 - April 1, 2022 were extracted from the electronic health record. HLOS was stratified by Tier (1: 1-74th percentile; 2: 75-84th; 3: 85-94th; 4: 95-99th). Demographic, socioeconomic, injury severity, and level-of-care factors were compared by HLOS. Multivariable logistic regressions evaluated associations between socioeconomic and clinical variables and prolonged HLOS, using multivariable odds ratios (mOR) and [95% confidence intervals]. Estimated daily charges were calculated for a subset of medically-stable inpatients awaiting placement. Statistical significance was assessed at p < 0.05.

RESULTS

In 1443 patients, median HLOS was 4 days (interquartile range 2-8; range 0-145). HLOS Tiers were 0-7, 8-13, 14-27, and ≥28 days (Tiers 1-4, respectively). Patients with Tier 4 HLOS differed significantly from others, with increased Medicaid insurance (53.4% vs. 30.3-33.1%, p = 0.003), severe TBI (Glasgow Coma Scale 3-8: 38.4% vs. 8.7-18.2%, p < 0.001), younger age (mean 52.3-years vs. 61.1-63.7-years, p = 0.003), low socioeconomic status (53.4% vs. 32.0-33.9%, p = 0.003), and need for post-acute care (60.3% vs. 11.2-39.7%, p < 0.001). Independent factors associated with prolonged (Tier 4) HLOS were Medicaid (mOR = 1.99 [1.08-3.68], vs. Medicare/commercial), moderate and severe TBI (mOR = 3.48 [1.61-7.56]; mOR = 4.43 [2.18-8.99], respectively, vs. mild TBI), and need for post-acute placement (mOR = 10.68 [5.74-19.89], while age was protective (per-year mOR = 0.98 [0.97-0.99]). Estimated daily charges for a medically-stable inpatient was $17126.

CONCLUSIONS

Medicaid insurance, moderate/severe TBI, and need for post-acute care were independently associated with prolonged HLOS ≥28 days. Medically-stable inpatients awaiting placement accrue immense daily healthcare costs. At-risk patients should be identified early, receive care transitions resources, and be prioritized for discharge coordination pathways.

Perception of transitional care quality associated with functional outcomes among patients with fractures and stroke in Taiwan

This study aimed to examine the relationship between self-perceived quality of transitional care and functional outcome among patients with stroke and fractures. The Care Transition Measure (CTM-15) was used to survey patient's self-perceived transitional care quality before discharge. General estimating equations were used to investigate the influences of transitional care quality on patient's functional outcomes at before, 1 week after, and 1 or 3 months after discharge. Among stroke patients, higher CTM-15 scores were positively associated with greater outcome in Instrumental Activities of Daily Living (IADL) following discharge. Higher scores for "reader-friendly written care plan," "consideration of patient's preferences," and "understanding of health management" had significantly positive effects on functional recovery in IADL among both patient groups following discharge. These findings suggest that heterogeneity in transitional care needs between medical and surgical patients shall not be overlooked. A one-size-fits-all strategy may be insufficient for ensuring patient care continuity following discharge.

Post-stroke delirium and challenges for the rehabilitation setting: A narrative review

INTRODUCTION

Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.

METHODS

Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.

RESULTS

PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.

CONCLUSIONS

PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.

Using phenotypic data from the Electronic Health Record (EHR) to predict discharge

BACKGROUND

Timely discharge to post-acute care (PAC) settings, such as skilled nursing facilities, requires early identification of eligible patients. We sought to develop and internally validate a model which predicts a patient's likelihood of requiring PAC based on information obtained in the first 24 h of hospitalization.

METHODS

This was a retrospective observational cohort study. We collected clinical data and commonly used nursing assessments from the electronic health record (EHR) for all adult inpatient admissions at our academic tertiary care center from September 1, 2017 to August 1, 2018. We performed a multivariable logistic regression to develop the model from the derivation cohort of the available records. We then evaluated the capability of the model to predict discharge destination on an internal validation cohort.

RESULTS

Age (adjusted odds ratio [AOR], 1.04 [per year]; 95% Confidence Interval [CI], 1.03 to 1.04), admission to the intensive care unit (AOR, 1.51; 95% CI, 1.27 to 1.79), admission from the emergency department (AOR, 1.53; 95% CI, 1.31 to 1.78), more home medication prescriptions (AOR, 1.06 [per medication count increase]; 95% CI 1.05 to 1.07), and higher Morse fall risk scores at admission (AOR, 1.03 [per unit increase]; 95% CI 1.02 to 1.03) were independently associated with higher likelihood of being discharged to PAC facility. The c-statistic of the model derived from the primary analysis was 0.875, and the model predicted the correct discharge destination in 81.2% of the validation cases.

CONCLUSIONS

A model that utilizes baseline clinical factors and risk assessments has excellent model performance in predicting discharge to a PAC facility.

Epidemiology of demographic, clinical characteristics and hospital course of patients with spinal cord injury associated with vertebral fracture in a large private health care system in the United States

OBJECTIVES

To evaluate the demographics, clinical characteristics, hospital course, and factors associated with outcomes in patients with spinal cord injury associated with vertebral fracture (SCI-VF).

DESIGN

Retrospective analysis of data collected from electronic health record.

SETTING

A large for-profit United States health care system.

PARTICIPANTS

2219 inpatients with SCI-VF between 2014 and 2020 identified using International Classification of Disease codes.

MAIN OUTCOME MEASURE

: In-hospital mortality, and disposition (home vs. no-home discharge) after hospitalization.

RESULTS

The mean age of patients admitted with a diagnosis of SCI-VF was 54.80 ± 20.85 years with 68.27% identified as male. The cervical spine was the most prevalent site of fracture, displaced vertebral fracture was the most common radiographic diagnosis, and the majority of injuries were classified as incomplete. 836 (37.67% of all 2219) patients were discharged home and had a shorter length of stay (7.56 ± 13.58 days) when compared to the average of the total study population (11.56 ± 19.2 days). The most common hospital-acquired complication (HAC) was falls (n = 259, 11.67%). Characteristics associated with in-hospital mortality in the 96 patients (6.94% of 1,383 patients with no-home discharge) included initial respiratory failure, ICU stay, increased medical comorbidity index value, insulin use, and presence of cardiovascular, pulmonary, and gastrointestinal HACs.

CONCLUSIONS

A large observational study of patients with SCI-VF can add to the knowledge of SCI characteristics in the U.S. population. Recognizing the common hospital-acquired conditions and clinical characteristics associated with increased in-hospital mortality can be helpful to improve the care of patients with SCI-VF.

Post-Acute Care in Inpatient Rehabilitation Facilities Between Traditional Medicare and Medicare Advantage Plans Before and During the COVID-19 Pandemic

OBJECTIVES

Compare post-acute care (PAC) utilization and outcomes in inpatient rehabilitation facilities (IRF) between beneficiaries covered by Traditional Medicare (TM) and Medicare Advantage (MA) plans during the COVID-19 pandemic relative to the previous year.

DESIGN

This multiyear cross-sectional study used Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) data to assess PAC delivery from January 2019 to December 2020.

SETTING AND PARTICIPANTS

Inpatient rehabilitation for stroke, hip fracture, joint replacement, and cardiac and pulmonary conditions among Medicare beneficiaries 65 years or older.

METHODS

Patient-level multivariate regression models with difference-in-differences approach were used to compare TM and MA plans in length of stay (LOS), payment per episode, functional improvements, and discharge locations.

RESULTS

A total of 271,188 patients were analyzed [women (57.1%), mean (SD) age 77.8 (0.06) years], among whom 138,277 were admitted for stroke, 68,488 hip fracture, 19,020 joint replacement, and 35,334 cardiac and 10,069 pulmonary conditions. Before the pandemic, MA beneficiaries had longer LOS (+0.22 days; 95% CI: 0.15-0.29), lower payment per episode (-$361.05; 95% CI: -573.38 to -148.72), more discharges to home with a home health agency (HHA) (48.9% vs 46.6%), and less to a skilled nursing facility (SNF) (15.7% vs 20.2%) than TM beneficiaries. During the pandemic, both plan types had shorter LOS (-0.68 day; 95% CI: 0.54-0.84), higher payment (+$798; 95% CI: 558-1036), increased discharges to home with an HHA (52.8% vs 46.6%), and decreased discharges to an SNF (14.5% vs 20.2%) than before. Differences between TM and MA beneficiaries in these outcomes became smaller and less significant. All results were adjusted for beneficiary and facility characteristics.

CONCLUSIONS AND IMPLICATIONS

Although the COVID-19 pandemic affected PAC delivery in IRF in the same directions for both TM and MA plans, the timing, time duration, and magnitude of the impacts were different across measures and admission conditions. Differences between the 2 plan types shrank and performance across all dimensions became more comparable over time.

Post-discharge light physical activity indicates recovery in acutely hospitalized older adults - the Hospital-ADL study

BACKGROUND

Physical activity (PA) levels might be a simple overall physical function indicator of recovery in acutely hospitalized older adults; however it is unknown which amount and level of PA is associated with recovery. Our objective was to evaluate the amount and level of post discharge PA and its optimum cut-off values associated with recovery among acutely hospitalized older adults and stratified for frailty.

METHODS

We performed a prospective observational cohort study including acutely hospitalized older adults (≥ 70 years). Frailty was assessed using Fried's criteria. PA was assessed using Fitbit up to one week post discharge and quantified in steps and minutes light, moderate or higher intensity. The primary outcome was recovery at 3-months post discharge. ROC-curve analyses were used to determine cut-off values and area under the curve (AUC), and logistic regression analyses to calculate odds ratios (ORs).

RESULTS

The analytic sample included 174 participants with a mean (standard deviation) age of 79.2 (6.7) years of whom 84/174 (48%) were frail. At 3-months, 109/174 participants (63%) had recovered of whom 48 were frail. In all participants, determined cut-off values were 1369 steps/day (OR: 2.7, 95% confidence interval [CI]: 1.3-5.9, AUC 0.7) and 76 min/day of light intensity PA (OR: 3.9, 95% CI: 1.8-8.5, AUC 0.73). In frail participants, cut-off values were 1043 steps/day (OR: 5.0, 95% CI: 1.7-14.8, AUC 0.72) and 72 min/day of light intensity PA (OR: 7.2, 95% CI: 2.2-23.1, AUC 0,74). Determined cut-off values were not significantly associated with recovery in non-frail participants.

CONCLUSIONS

Post-discharge PA cut-offs indicate the odds of recovery in older adults, especially in frail individuals, however are not equipped for use as a diagnostic test in daily practice. This is a first step in providing a direction for setting rehabilitation goals in older adults after hospitalization.

Trauma patients with limited English proficiency: Outcomes from two level one trauma centers

BACKGROUND

Outcomes for surgical patients with limited English proficiency (LEP) may be worse compared to patients with English proficiency. We sought to evaluate the association of LEP with outcomes for trauma patients.

METHODS

Admitted adult patients on trauma service at two Level One trauma centers from 2015 to 2019 were identified.

RESULTS

12,562 patients were included in total; 7.3% had LEP. On multivariable analyses, patients with LEP had lower odds of discharge to post-acute care versus home compared to patients with English proficiency (OR 0.69; 95% CI 0.58-0.83; p < 0.001) but had similar length of stay (Beta coefficient 1.16; 95% CI 0.00-2.32; p = 0.05), and 30-day readmission (OR 1.08; 95% CI 0.87-1.35; p = 0.46).

CONCLUSIONS

Trauma patients with LEP had comparable short-term outcomes to English proficient patients but were less likely to be discharged to post-acute care facilities. The role of structural barriers, family preferences, and other factors merit future investigation.

Development and Evaluation of Rehabilitation Service Areas for the United States

BACKGROUND

Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries.

METHODS

A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries.

RESULTS

The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care.

CONCLUSIONS

Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.

The Effects of Post-Acute Care in Patients with Heart Failure in Taiwan: A Single Center Experience

Background

The National Health Insurance Administration in Taiwan has promoted the heart failure post-acute care (HF-PAC) program as a means to provide proactive integrated care within the optimal treatment timeframe to enhance functional recovery after acute decompensated heart failure (HF).

Objectives

The aim of this program was to reduce HF readmission rates, improved medication prescription rates, and improve the quality of life in HF patients.

Methods

Patients who had a reduced left ventricular ejection fraction (LVEF) of ≤ 40% were included and followed up for 6 months after discharge. They underwent cardiac rehabilitation and physiological, and nutritional status evaluations. The main clinical outcomes of the HF-PAC program were guideline-directed medical therapy prescription rate and 6-month readmission rate.

Results

A total of 122 patients were recruited from June 2018 to December 2020 at a medical center in southern Taiwan. The patients' activities of daily living, nutritional status, quality of life and LVEF were significantly improved during the HF-PAC program. More than 95% of the patients received guideline-directed medical prescriptions at the end of the HF-PAC program. The cardiovascular-related 6-month re-admission rate after the HF-PAC program ended was 27.7%, and it could be predicted by the New York Health Association functional class [hazard ratio (HR) 95% confidence interval (95% CI) = 4.12 (1.36-12.46)], value of the Mini Nutritional Assessment - Short Form [HR (95% CI) = 0.46 (0.31-0.68)] and LVEF [HR (95% CI) = 0.95 (0.91-0.99)].

Conclusions

By incorporating multidisciplinary healthcare teams, the HF-PAC program improves the guideline- directed medical therapy prescription rate, thus improving patients' cardiac function, physical activity recovery, the quality of life, and also reduces their readmission rate.

The Increased Clinical and Economic Burden of Hyperkalemia in Medicare Patients Admitted to Long-Term Care Settings

INTRODUCTION

Older patients are at increased risk for hyperkalemia (HK). This study describes the prevalence, recurrence, and clinical and economic burden of HK in Medicare patients admitted to a long-term care (LTC) setting.

METHODS

Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) claims identified patients aged ≥ 65 years with index admission between 2017 and 2019 to a LTC setting (skilled nursing, home health, inpatient rehabilitation, or long-term acute care). Beneficiaries were required to have 12 months continuous medical and pharmacy coverage prior to index LTC admission and ≥ 30 days after LTC discharge (follow-up). Patient characteristics, healthcare resource utilization, and costs were assessed. HK was defined as ICD-10 diagnosis code E87.5 in any claim position or Medicare Part D fill for oral potassium binder.

RESULTS

Of 4,562,231 patients with a LTC stay, the prevalence of HK was 14.7% over the full study period (pre-index, index stay, and follow-up). Excluding those with HK only during the follow-up period resulted in 4,081,103 patients. Of these, 290,567 (7.1%) had HK and 3,790,536 (92.9%) did not have HK during or within 14 days prior to index LTC stay. The HK recurrence rate during index stay and follow-up was 48.3%. Unmatched HK versus non-HK patients were more often male (43.0% vs. 35.4%), Black (13.5% vs. 8.0%), dual eligible for Medicaid (34.2% vs. 25.0%), with higher mean Charlson Comorbidity Index scores (6.2 vs. 3.9) (all p < 0.0001). After propensity matching, HK patients were 2.2 times more likely to be hospitalized, with higher mortality (30.8% vs. 21.5%) and higher total healthcare costs during both index stay (US$26,520 vs. $18,021; p < 0.0011) and follow-up ($57,948 vs. $41,744 (p < 0.0011) versus matched non-HK patients.

CONCLUSION

Prevalence and recurrence of HK was high among LTC patients, and HK was associated with significantly greater clinical and economic burden during and post-LTC.

The Influence of Prior Functional Status on Self-Care Improvement During a Skilled Nursing Facility Stay

OBJECTIVES

Older adults' prior health status can influence their recovery after a major illness. We investigated the association between older adults' independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change in self-care function during an SNF stay.

DESIGN

Retrospective study of 100% national CMS data files from October 1, 2018, to December 31, 2019.

SETTINGS AND PARTICIPANTS

The sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from an SNF between October 1, 2018, and December 31, 2019.

METHODS

The admission Minimum Data Set (MDS) was used to determine residents' prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7-42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge.

RESULTS

Most residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared with approximately 70% of residents without these conditions. Compared with residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 vs 4.21 points, respectively) and discharge (6.44 vs 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 vs 1.62 points, respectively).

CONCLUSIONS AND IMPLICATIONS

Our findings are evidence that the new MDS item for a resident's independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.

Medication regimen complexity index and rehabilitation outcomes in post-acute hip fracture patients study: a retrospective study

BACKGROUND

Polypharmacy is a common problem amongst the elderly population. The complexity of the drug regimen refers not only to a simple medication count, but also to the number of daily doses, frequency, and special instructions given for their use. Medication regimen complexity may affect health outcomes, including an increase in hospitalization rates, drug non-adherence, and mortality rates.

AIM

To assess whether the admission medication regimen complexity index score is associated with rehabilitation outcomes in hip fracture patients; secondary- to assess whether changes in the medication regimen complexity index scores during rehabilitation are associated with rehabilitation outcomes.

METHOD

A retrospective study of 336 hip fracture patients admitted to a post-acute rehabilitation hospital. Primary rehabilitation outcome was assessed via the discharge functional independence measure score. Secondary outcomes included functional independence measure score changes, length of stay and discharge destination.

RESULTS

Patients with low admission medication regimen complexity index scores attained significantly higher admission and discharge motor functional independence measure scores (40.1 vs. 37.1, p = 0.044; 57.1 vs. 52.9, p = 0.014, respectively), a higher motor functional independence measure score effectiveness (36.1 vs. 31.3, p = 0.030) and a higher rate of favorable motor functional independence measure effectiveness score (58.1% vs. 42.0%, p = 0.004). A multiple linear regression analysis revealed that the admission medication regimen complexity index score was not associated with the discharge functional independence measure score (standardized coefficient = - 0.058; p = 0.079).

CONCLUSION

A high medication regimen complexity which usually implies severe comorbidity should not be considered a barrier for the rehabilitation of older patients.

Coordinating illness and insurance trajectories: Evidence from a post-acute care unit

This article examines how healthcare practitioners incorporate patients' insurance coverage and financial situation into their professional judgment. It does so by introducing the concept of an "insurance trajectory" that healthcare workers must coordinate with their medical management of illness and recovery. Drawing on 15 months of ethnography and 16 in-depth interviews at a post-acute care unit in New York City, this article argues that providers engage in anticipation work to align the tempo of recovery with the timeline of insurance coverage, in order to maximize revenue for the organization and minimize costs for patients. It identifies three modalities of anticipation work from intake to discharge: the creation of roadmaps on which illness and insurance trajectories intersect to predict an ideal discharge date, the synchronization of trajectories to avoid denials of coverage during rehabilitation, and the projection of futures to prevent illness and insurance trajectories from decoupling once patients are discharged. These findings expand our understanding of the effects of managed care on healthcare workers' practices and decision-making.

Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia

OBJECTIVES

To examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time.

DESIGN

Retrospective cohort study based on secondary data analyses.

SETTING

New York State Medicare beneficiaries who were admitted to an SNF in 2014.

PARTICIPANTS

Total of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home.

MEASUREMENTS

We used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics.

RESULTS

Among SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD.

CONCLUSION

Newly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.

National survey of health services provided by pediatric post-acute care facilities in the US

PURPOSE

The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff.

METHODS

An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery.

RESULTS

Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%).

CONCLUSION

PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

Discharge locations after hospitalizations involving opioid use disorder among medicare beneficiaries

BACKGROUND

Hospitalizations involving opioid use disorder (OUD) have been increasing among Medicare beneficiaries of all ages. With rising OUD-related acute care use comes the need to understand where post-acute care is provided and the capacities for OUD treatment in those settings. Our objective was to describe hospitalized Medicare beneficiaries with OUD, their post-acute care locations, and all-cause mortality and readmissions stratified by post-acute care location.

METHODS

We conducted a retrospective cohort study of acute hospitalizations using 2016-2018 Medicare Provider Analysis and Review (MedPAR) files linked to Medicare enrollment data and the Residential History File (RHF) for 100% of Medicare fee-for-service beneficiaries. The RHF which provides a person-level chronological history of health service utilization and locations of care was used to identify hospital discharge locations. We used ICD-10 codes for opioid dependence or "abuse" to identify OUD diagnoses from the MedPAR file. We conducted logistic regression to identify factors associated with discharge to an institutional setting versus home adjusting for demographics, comorbidities, and hospital stay characteristics.

RESULTS

Our analysis included 459,763 hospitalized patients with OUD. Of these, patients aged < 65 years and those dually enrolled in Medicaid comprised the majority (59.1%). OUD and opioid overdose were primary diagnoses in 14.3% and 6.2% of analyzed hospitalizations, respectively. We found that 70.3% of hospitalized patients with OUD were discharged home, 15.8% to a skilled nursing facility (SNF), 9.6% to a non-SNF institutional facility, 2.5% home with home health services, and 1.8% died in-hospital. Within 30 days of hospital discharge, rates of readmissions and mortality were 29.7% and 3.9%; respectively, with wide variation across post-acute locations. Factors associated with greater odds of discharge to institutional settings were older age, female sex, non-Hispanic White race and ethnicity, dual enrollment, longer hospital stay, more comorbidities, intensive care use, surgery, and primary diagnoses including opioid or other drug overdoses, fractures, and septicemia.

CONCLUSIONS

More than one-quarter (25.8%) of hospitalized Medicare beneficiaries with OUD received post-acute care in a setting other than home. High rates and wide variation in all-cause readmissions and mortality within 30 days post-discharge emphasize the need for improved post-acute care for people with OUD.

Trends in Post-Acute Care Utilization During the COVID-19 Pandemic

OBJECTIVE

To examine the effect of the COVID-19 pandemic on post-acute care utilization and spending.

DESIGN

We used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending.

SETTING AND PARTICIPANTS

We identified and included 975,179 hospital discharges who were aged ≥65 years.

METHODS

We summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings.

RESULTS

The percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased.

CONCLUSIONS AND IMPLICATIONS

Changes in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care.

Management of post-acute COVID-19 patients in geriatric rehabilitation: EuGMS guidance

Aim

To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation.

Findings

This guidance addresses general requirements for post-acute COVID-19 geriatric rehabilitation and critical aspects for quality assurance during the COVID-19 pandemic. Furthermore, the guidance describes relevant care processes and procedures divided in five topics: patient selection; admission; treatment; discharge; and follow-up and monitoring.

Message

This guidance is designed to provide support to care professionals involved in the geriatric rehabilitation treatment of post-acute COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00575-4.

Purpose

To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation.

Methods

The guidance is based on guidelines for post-acute COVID-19 geriatric rehabilitation developed in the Netherlands, updated with recent insights from literature, related guidance from other countries and disciplines, and combined with experiences from experts in countries participating in the Geriatric Rehabilitation Special Interest Group of the European Geriatric Medicine Society.

Results

This guidance for post-acute COVID-19 rehabilitation is divided into a section addressing general recommendations for geriatric rehabilitation and a section addressing specific processes and procedures. The Sect. “General recommendations for geriatric rehabilitation” addresses: (1) general requirements for post-acute COVID-19 rehabilitation and (2) critical aspects for quality assurance during COVID-19 pandemic. The Sect. “Specific processes and procedures”, addresses the following topics: (1) patient selection; (2) admission; (3) treatment; (4) discharge; and (5) follow-up and monitoring.

Conclusion

Providing tailored geriatric rehabilitation treatment to post-acute COVID-19 patients is a challenge for which the guidance is designed to provide support. There is a strong need for additional evidence on COVID-19 geriatric rehabilitation including developing an understanding of risk profiles of older patients living with frailty to develop individualised treatment regimes. The present guidance will be regularly updated based on additional evidence from practice and research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00575-4.

Inpatient Hospital Costs for COVID-19 Patients in the United States

Introduction

Reliable cost and resource use data for COVID-19 hospitalizations are crucial to better inform local healthcare resource decisions; however, available data are limited and vary significantly.

Methods

COVID-19 hospital admissions data from the Premier Healthcare Database were evaluated to estimate hospital costs, length of stay (LOS), and discharge status. Adult COVID-19 patients (ICD-10-CM: U07.1) hospitalized in the US from April 1 to December 31, 2020, were identified. Analyses were stratified by patient and hospital characteristics, levels of care during hospitalization, and discharge status. Factors associated with changes in costs, LOS, and discharge status were estimated using regression analyses. Monthly trends in costs, LOS, and discharge status were examined.

Results

Of the 247,590 hospitalized COVID-19 patients, 49% were women, 76% were aged ≥ 50, and 36% were admitted to intensive care units (ICU). Overall median hospital LOS, cost, and cost/day were 6 days, US$11,267, and $1772, respectively; overall median ICU LOS, cost, and cost/day were 5 days, $13,443, and $2902, respectively. Patients requiring mechanical ventilation had the highest hospital and ICU median costs ($47,454 and $41,510) and LOS (16 and 11 days), respectively. Overall, 14% of patients died in hospital and 52% were discharged home. Older age, Black and Caucasian race, hypertension and obesity, treatment with extracorporeal membrane oxygenation, and discharge to long-term care facilities were major drivers of costs, LOS, and risk of death. Admissions in December had significantly lower median hospital and ICU costs and LOS compared to April.

Conclusion

The burden from COVID-19 in terms of hospital and ICU costs and LOS has been substantial, though significant decreases in cost and LOS and increases in the share of hospital discharges to home were observed from April to December 2020. These estimates will be useful for inputs to economic models, disease burden forecasts, and local healthcare resource planning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01887-4.

Psychometrics of the observational scales of the Utrecht Scale for Evaluation of Rehabilitation (USER): Content and structural validity, internal consistency and reliability

INTRODUCTION

Establish content and structural validity, internal consistency, inter-rater reliability, and measurement error of the physical and cognitive scales of the Utrecht Scale for Evaluation clinical Rehabilitation (USER) in geriatric rehabilitation.

MATERIAL AND METHODS

First, an expert consensus-meeting (N=7) was organised for content validity wherein scale content validity index (CVI) was measured. Second, in a sample of geriatric rehabilitation patient structural validity (N=616) was assessed by confirmatory factor analyses for exploring unidimensionality. Cut-off criteria were: Root Mean Square Error of Approximation (RMSEA) ≤0.08; Comparative Fit Index (CFI) and Tucker Lewis Index (TLI) ≥0.95. Local independence (residual correlation<0.20) and monotonicity (H_i-coefficient ≥0.30 and H_s-coefficient ≥0.50) were also calculated. Cronbach alphas were calculated for internal consistency. Alpha's > 0.7 was considered adequate. Third, two nurses independently administered the USER to 37 patients. Intraclass-correlation coefficients (ICC) were calculated for inter-rater reliability (IRR), standard error of measurement (SEM) and Smallest Detectable Change (SDC).

RESULTS

The CVI for physical functioning was moderate (0.73) and excellent for cognitive functioning (0.97). Structural validity physical scale was acceptable (CFI;0.95, TLI;0.93, RMSEA;0.07, ECV;0.78, OmegaH;0.87; Monotonicity;(H_i;0.52-0.75 and H_s;0.63)). Cognitive scale was good (CFI;0.98, TLI;0.96, RMSEA;0.05, ECV;0.66 and OmegaH;0.90. Monotonicity;(H_i;0.30 -0.70 and H_s;0.61)). Cronbach's alpha were high: physical scale;0.92 and cognitive scale;0.94. Reliability physical scale ICC;0.94, SEM;5 and SDC;14 and cognitive scale ICC;0.88, SEM;5 and SDC;13.

CONCLUSION

The observational scales of the USER have shown sufficient content and structural validity, internal consistency, and interrater reliability for measuring physical and cognitive function in geriatric rehabilitation.

TRIAL REGISTRATION

N/A.

Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial

INTRODUCTION

Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care.

INTERVENTION

The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC.

OBJECTIVES

The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care.

METHODS

Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days.

CONCLUSION

This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.

Improved outcomes with delayed admission to post-acute care: results of a natural experiment

PURPOSE

To determine the effectiveness of a post-acute care scheme by exploiting a natural experiment.

METHODS

We used a reduction in funding for an Irish PAC scheme based in private nursing homes as a natural experiment to explore the effectiveness of this scheme in a single large general hospital.

RESULTS

Compared with an equivalent 3-month period in 2017 (pre-change, N = 169), those admitted to PAC in 2019 (post-change, N = 179), spent a median 6 days longer in acute care, although total duration spent in healthcare settings was the same. Compared with 2017, readmissions to hospital within 90 days of discharge (43/179 (24.0% v 58/169 (34.3%), p = 0.03) and discharge to long-term care from the PAC facility (3 (1.7%) v 14 (8.3%), p = 0.004) were significantly lower in 2019.

CONCLUSION

Our results suggest that the longer stay in acute care and shorter stay in PAC was beneficial for patients and led to improved outcomes.

Cognitive status as a robust predictor of repeat falls in older Veterans in post-acute care

BACKGROUND

While repeat falls are common in post-acute care (PAC), risk factors have not been fully elucidated.

AIMS

The objective of thids study is to evaluate the contribution of cognitive function to repeat falls in older PAC Veterans.

METHODS

Data were collected from medical records for 91 single and 30 repeat fallers over 5 consecutive years (2011-2016).

RESULTS

After controlling for demographic and medical factors, lower Mini-Mental State Exam (MMSE) score was associated with increased odds of repeat falls. MMSE scores below 20 (with age held constant at the mean) were associated with a greater than 50% chance of a repeat fall (compared to 24.7% base rate). Admission for a neurologic reason further increased risk.

DISCUSSION

PAC Veterans who experience a fall have an increased risk of repeat falls with concomitant cognitive dysfunction and/or admission for neurologic reasons.

CONCLUSIONS

Results support tailoring multi-component interventions for those with cognitive dysfunction utilizing standardized mental status screening upon admission.

Community Discharge Among Post-Acute Nursing Home Residents: An Association With Patient Safety Culture?

OBJECTIVES

We examined whether better patient safety culture (PSC) in skilled nursing facilities was associated with higher likelihood of successful community discharge for post-acute care residents.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Medicare beneficiaries who were newly admitted for post-acute care (N = 53,929) to skilled nursing facilities participating in PSC survey (N = 818).

METHODS

Facility-level PSC scores were obtained from a national, random survey conducted in 2017. Survey data was linked to Minimum Dataset 3.0, Medicare Provider Analysis and Review, Master Beneficiary Summary File, Nursing Home Compare File, Payroll-Based Journal, and Areal Health Resources File. Successful discharge to community was the outcome of interest. Facility-level PSC scores were the key covariate. We controlled for individual-level, facility-level, and area-level characteristics. Separate logistic regression models for each of the 12 PSC domains and for the overall score were fit.

RESULTS

Post-acute care residents who were successfully discharged to community were more likely to be female (63.7%), white (87.1%), Medicare-only (88.1%), cognitively intact (87.8%), and admitted following a surgery (40.9%) The multivariable analyses showed that teamwork (odds ratio 1.09, P = .02) and supervisor expectations and actions promoting resident safety (odds ratio 1.11, P = .01) were significantly associated with the increased likelihood of successful community discharge.

CONCLUSIONS AND IMPLICATIONS

This is the first study to analyze the relationship between patient safety culture and successful discharge among post-acute care residents. Our results suggest that nursing home leaders may want to focus their quality and safety improvement efforts on specific PSC domains (eg, teamwork) as means for improving community discharge for post-acute care residents.

Home Health And Postacute Care Use In Medicare Advantage And Traditional Medicare

This article compares patterns of postacute care-including care provided by skilled nursing facilities, inpatient rehabilitation facilities, and home health agencies-under Medicare Advantage and traditional Medicare. Overall, Medicare Advantage enrollees received less postacute care, both institutional and home health, than traditional Medicare enrollees did for three common conditions.

Variation in 30-Day Readmission Rates from Inpatient Rehabilitation Facilities to Acute Care Hospitals

OBJECTIVES

To quantify the rate of readmission from inpatient rehabilitation facilities (IRFs) to acute care hospitals (ACHs) during the first 30 days of rehabilitation stay. To measure variation in 30-day readmission rate across IRFs, and the extent that patient and facility characteristics contribute to this variation.

DESIGN

Retrospective analysis of an administrative database.

SETTING AND PARTICIPANTS

Adult IRF discharges from 944 US IRFs captured in the Uniform Data System for Medical Rehabilitation database between October 1, 2015 and December 31, 2017.

METHODS

Multilevel logistic regression was used to calculate adjusted rates of readmission within 30 days of IRF admission and examine variation in IRF readmission rates, using patient and facility-level variables as predictors.

RESULTS

There were a total of 104,303 ACH readmissions out of a total of 1,102,785 IRFs discharges. The range of 30-day readmission rates to ACHs was 0.0%‒28.9% (mean = 8.7%, standard deviation = 4.4%). The adjusted readmission rate variation narrowed to 2.8%‒17.5% (mean = 8.7%, standard deviation = 1.8%). Twelve patient-level and 3 facility-level factors were significantly associated with 30-day readmission from IRF to ACH. A total of 82.4% of the variance in 30-day readmission rate was attributable to the model predictors.

CONCLUSIONS AND IMPLICATIONS

Fifteen patient and facility factors were significantly associated with 30-day readmission from IRF to ACH and explained the majority of readmission variance. Most of these factors are nonmodifiable from the IRF perspective. These findings highlight that adjusting for these factors is important when comparing readmission rates between IRFs.

Association between level of care and colonization with resistant gram-negative bacteria among nursing-home residents

In this cross-sectional study, we examined the relationship between resident level of care in the nursing home and colonization with resistant gram-negative bacteria. Residential-care residents were more likely to be colonized with resistant gram-negative bacteria than were postacute care residents (odds ratio, 2.3; 95% confidence interval, 1.40-3.80; P < .001).

Inpatient rehabilitation service utilization and outcomes under US ACA Medicaid expansion

Background

To investigate the impact of the US Medicaid expansion on care utilization and health outcomes of patients treated in the inpatient rehabilitation facilities (IRF).

Methods

A retrospective observational study with a difference-in-difference design. The data was obtained from Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI). Sample included all Medicaid beneficiaries (aged 18–64 years) who received initial inpatient rehabilitation for stroke, hip fracture (acute conditions), or joint replacement (elective condition) (N = 14,917) before (2013) and after (2016) the expansion. The study estimated the differences in length of stay, functional improvement, and possibility of returning to community before and after ACA Medicaid expansion in the expansion regions relative to the non-expansion regions. The analysis was fully adjusted for patient demographics, health conditions, facility characteristics and time trends.

Results

Compared with non-expansion states, service volume in the expansion regions increased more for the two acute conditions (49 and 27% vs. 1% and − 4%) and decreased less for the selective condition (− 12% vs. -34%) after ACA Medicaid expansion. Medicaid expansion was associated with significant decreases in patient functional improvements (− 1.63 points for stroke, − 3.61 points for fracture and − 2.73 points for joint; P < 0.05). Length of stay and the possibility of returning to community after discharge were not significantly different.

Conclusions

Medicaid expansion was associated with increases in the utilization of inpatient rehabilitation services and decreases in the patient functional improvements. Cautions should be taken with the decreases in functional improvements among some subpopulation in the short-term; longer follow up periods are needed to account for gradual changes in patient needs.

A Cross-Sectional Survey of Internal Medicine Residents' Knowledge, Attitudes, and Current Practices Regarding Patient Transitions to Post-Acute Care

OBJECTIVES

Prior studies have found suboptimal knowledge about post-acute care (PAC) among inpatient providers and poor communication at discharge that can lead to unsafe discharge transitions, but little is known about residents and the PAC transition. The aim of this study is to assess internal medicine residents' knowledge, attitudes, and current practice regarding patient transitions to PAC.

DESIGN

A multisite, cross-sectional 36-question survey.

SETTING AND PARTICIPANTS

Internal Medicine and Medicine-Pediatrics residents at 3 university-based Internal Medicine training programs in the United States.

METHODS

Survey delivered electronically to residents in 2018 and 2019. Survey responses were described by collapsing 4-point Likert responses into dichotomous variables, and thematic content analysis was used to evaluate free text responses.

RESULTS

Of 482 residents surveyed, 236 responded (49%). Despite high reported confidence in their ability to transition patients to PAC, only 31% of residents knew how often patients received skilled therapies at skilled nursing facilities (SNFs) and 23% knew how frequently nursing services are provided. The majority of residents (79%) identified the discharge summary as the main way they communicated care instructions to the SNF, but only 55% reported always completing it prior to discharge. Upper-level residents were more likely to know how much therapy patients received at a SNF, but resident knowledge about PAC did not vary by residency year in other domains. Residents who experienced a clinical rotation at a SNF had higher levels of knowledge compared to residents who did not.

CONCLUSIONS

This national survey of internal medicine residents identified common knowledge gaps regarding PAC. These knowledge gaps did not improve throughout residency without deliberate exposure to PAC environments. This suggests a need for dedicated curriculum development as discharges to PAC continue to rise exponentially.

Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study

BACKGROUND

Despite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use.

METHODS

We extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients' ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a "traveler". We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived.

RESULTS

Although 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding "travelers," for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities.

CONCLUSIONS

Geographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries-the "traveler effect".

Older patients with active cancer have favorable inpatient rehabilitation outcomes

OBJECTIVES

To investigate the characteristics and rehabilitation outcomes of older patients with active cancer (OPAC) undergoing post-acute inpatient rehabilitation (IR), and to evaluate which clinical factors are associated with poor rehabilitation outcomes.

MATERIALS AND METHODS

This is a retrospective study of patients aged ≥65 with active cancer undergoing IR following acute hospitalization at our tertiary hospital centre (N = 330). We collected data on patient, malignancy, and hospitalization characteristics, and IR outcomes including function, mobility, discharge destination, and mortality. Multivariate stepwise logistic regression was used to identify independent associations with the composite outcome of death within three months or discharge to long-term care (LTC).

RESULTS

Patient mean age was 80.1 ± 7.2 years. The most common malignancies were colon (30.9%) and hematologic (16.1%). Most patients were hospitalized urgently (64.8%) and underwent surgery (72.4%). From IR admission to discharge, patients ambulating independently increased from 14.0% to 52.0%. Discharge destination was to the community (80.4%), to LTC (7.6%), and transfer to an acute ward (7.2%), while 4.8% died during IR. One-year survival was 62.1%. The composite outcome was met by 24.8% of patients with multivariate logistic regression revealing independent associations (p < 0.05) with high baseline dependency, metastatic disease, low mobility score on IR admission, complications during acute care, and ≥ 75th percentile values for lactate dehydrogenase and alkaline phosphatase.

CONCLUSION

OPAC have favorable IR outcomes including high rate of community discharge, function and mobility gains, and lower mortality rates when compared with previously studied cancer rehabilitation populations. We identified several clinical markers associated with the composite outcome, which can guide post-acute discharge planning in patients with an unclear prognosis.

Trends in inpatient discharges with drug or alcohol admission diagnoses to a skilled nursing facility among older adults, New York City 2008-2014

Background

Recent research shows an increase in drug and alcohol-related hospitalizations in the USA, especially among older adults. However, no study examines trends in discharges to a skilled nursing facility (SNF) after a drug or alcohol-related hospitalization. Older adults are more likely to need post-hospital care in a SNF after a hospitalization due to an increased presence of chronic diseases and functional limitations. Therefore, the objective of this study was to estimate trends in drug or alcohol-related hospitalizations with discharge to a SNF among adults age 55 and older.

Methods

We analyzed data from New York State’s Statewide Planning and Research Cooperative System to calculate the number of cannabis, cocaine, opioid, and alcohol-related hospitalizations in New York City that resulted in discharge to a SNF from 2008 to 2014 among adults age 55 and older. Using New York City population estimates modified from US Census Bureau, we calculated age-specific rates per 100,000 adults. Trend tests were estimated using joinpoint regressions to calculate annual percentage change (APC) with 95% confidence intervals (CI) and stratified by adults age 55–64 and adults age 65 and older.

Results

During the study period, among adults age 55–64, there were significant increases in cocaine, cannabis, and opioid-related hospitalizations that resulted in discharge to a SNF. For adults ≥ 65 years, there were sharp increases across all substances with larger increases in opioids (APC of 10.66%) compared to adults 55–64 (APC of 6.49%). For both age groups and among the four substances, alcohol-related hospitalizations were the leading cause of discharge to a SNF.

Conclusions

We found an increase in hospital discharges to SNFs for patients age 55 and older admitted with alcohol or drug-related diagnoses. Post-acute and long-term care settings should prepare to care for an increase in older patients with substance use disorders by integrating a range of harm reduction interventions into their care settings.

Use of a Computerized Algorithm to Evaluate the Proportion and Causes of Potentially Preventable Readmissions Among Patients Discharged to Skilled Nursing Facilities

OBJECTIVES

Older patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for hospital readmission. Yet, as in the community setting, some readmissions may be preventable with optimal transitional care. This study examined the proportion of 30-day hospital readmissions from SNFs that could be considered potentially preventable readmissions (PPRs) and evaluated the reasons for these readmissions.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Post-acute practice of an integrated health care delivery system serving 11 SNFs in the US Midwest. Patients discharged from the hospital to an SNF and subsequently readmitted to the hospital within 30 days from January 1, 2009, through November 31, 2016.

METHODS

A computerized algorithm evaluated the relationship between initial and repeat hospitalizations to determine whether the repeat hospitalization was a PPR. We assessed for changes in PPR rates across the system over the study period and evaluated the readmission categories to identify the most prevalent PPR categories.

RESULTS

Of 11,976 discharges to SNFs for post-acute care among 8041 patients over the study period, 16.6% resulted in rehospitalization within 30 days, and 64.8% of these rehospitalizations were considered PPRs. Annual proportion of PPRs ranged from 58.2% to 66.4% [mean (standard deviation) 0.65 (0.03); 95% confidence interval CI 0.63-0.67; P = .36], with no discernable trend. Nearly one-half (46.2%) of all 30-day readmissions were classified as potentially preventable medical readmissions related to recurrence or continuation of the reason for initial admission or to complications from the initial hospitalization.

CONCLUSIONS AND IMPLICATIONS

For this cohort of patients discharged to SNFs, a computerized algorithm categorized a large proportion of 30-day hospital readmissions as potentially preventable, with nearly one-half of those linked to the reason for the initial hospitalization. These findings indicate the importance of improvement in postdischarge transitional care for patients discharged to SNFs.

Comparative effectiveness of long-term acute care hospital versus skilled nursing facility transfer

Background

Long-term acute care hospital (LTACH) use varies considerably across the U.S., which may reflect uncertainty about the effectiveness of LTACHs vs. skilled nursing facilities (SNF), the principal post-acute care alternative. Given that LTACHs provide more intensive care and thus receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer.

Methods

Using Medicare claims linked to electronic health record (EHR) data from six Texas Hospitals between 2009 and 2010, we conducted a retrospective cohort study of patients hospitalized on a medicine service in a high-LTACH use region and discharged to either an LTACH or SNF and followed for one year. The primary outcomes included mortality, 60-day recovery without inpatient care, days at home, and healthcare spending

Results

Of 3503 patients, 18% were transferred to an LTACH. Patients transferred to LTACHs were younger (median 71 vs. 82 years), less likely to be female (50.5 vs 66.6%) and white (69.0 vs. 84.1%), but were sicker (24.3 vs. 14.2% for prolonged intensive care unit stay; median diagnosis resource intensity weight of 2.03 vs. 1.38). In unadjusted analyses, patients transferred to an LTACH vs. SNF were less likely to survive (59.1 vs. 65.0%) or recover (62.5 vs 66.0%), and spent fewer days at home (186 vs. 200). Adjusting for demographic and clinical confounders available in Medicare claims and EHR data, LTACH transfer was not significantly associated with differences in mortality (HR, 1.12, 95% CI, 0.94–1.33), recovery (SHR, 1.07, 0.93–1.23), and days spent at home (IRR, 0.96, 0.83–1.10), but was associated with greater Medicare spending ($16,689 for one year, 95% CI, $12,216–$21,162).

Conclusion

LTACH transfer for Medicare beneficiaries is associated with similar clinical outcomes but with higher healthcare spending compared to SNF transfer. LTACH use should be reserved for patients who require complex inpatient care and cannot be cared for in SNFs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05847-6.

Expectations and experiences with physician care among patients receiving post-acute care in US skilled nursing facilities

BACKGROUND

In the US, post-acute care in skilled nursing facilities (SNFs) is common and outcomes vary greatly across facilities. Little is known about the expectations of patients and their caregivers about physician care during the hospital to SNF transition. Our objectives were to (1) describe the experiences and expectations of patients and their caregivers with SNF physicians in SNFs, and (2) identify patterns that differed between patients with vs. without cognitive impairment.

METHODS

This qualitative study used grounded theory approach to analyze data collected from semi-structured interviews at five SNFs in January-August 2018. Patients admitted for short-term SNF care 5-10 days prior were eligible to participate. Thematic analysis was performed to detect recurrent themes with a focus on modifiable aspects of physician care. Analysis was stratified by patient cognitive impairment (measured by the Montreal Cognitive Assessment at the time of the interview).

RESULTS

Fifty patients and six caregivers were interviewed. Major themes were: (1) patients had poor awareness of the physician in charge of their care; (2) they were dissatisfied with the frequency of interaction with the physician; and (3) participants valued the perception of receiving individualized care from the physician. Less cognitively impaired patients were more concerned about limited interactions with the physicians and were more likely to report attempts to seek out the physician.

CONCLUSION

Patient and caregiver expectations of SNF physicians were not well aligned with their experiences. SNFs aiming to improve satisfaction with care may focus efforts in this area, such as facilitating frequent communication between physicians, patients and caregivers.

Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care

OBJECTIVES

Our study examined the proportion of skilled nursing facility (SNF) post-acute care residents who did not receive timely primary care provider (PCP) services following discharge, factors associated with lack of timely PCP services, and factors associated with perfect 30-day home time among those who did not receive timely PCP services.

DESIGN

Longitudinal cohort study; data sources included Medicare claims and other administrative databases.

SETTING AND PARTICIPANTS

25,357 fee-for-service New York State Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care in 2014 and then discharged to the community.

METHODS

Our outcomes were a timely PCP visit (within 7 days of SNF discharge) and perfect 30-day home time, and we examined their association with patient, SNF, and county factors.

RESULTS

Among SNF discharges, 60.6% had a timely PCP visit. In multivariate regression analyses, female sex, nonwhite race, Medicare only status, less functional impairment and medical comorbidity, a surgical hospitalization, fewer hospital days, more SNF days, absence of home health services, for-profit SNF status, higher SNF star rating, lower ratio of registered nurse/total nursing hours, and rural counties were associated with lower odds of a timely PCP visit following SNF discharge. Among those without a timely PCP visit, female sex, less cognitive and functional impairment, less medical comorbidity, a surgical hospitalization, fewer hospital days, receipt of home health services, and higher SNF star rating were associated with increased odds of perfect 30-day home time following SNF discharge.

CONCLUSIONS AND IMPLICATIONS

That 4 in 10 post-acute care SNF patients did not have a timely PCP visit post-SNF discharge, with racial minority and rural county status associated with decreased odds of a timely PCP visit, is concerning. Examination of whether the timing and type of outpatient visit may have varying effects on different post-acute care subpopulations would build on this work.