Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative

OBJECTIVES

The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital.

DESIGN

Cross-sectional retrospective study.

SETTINGS AND PARTICIPANTS

The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization.

METHODS

We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities.

RESULTS

Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001).

CONCLUSIONS AND IMPLICATIONS

Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.

What Drove Program Participants to Initially Attend Congregate Meals? Socialization, Health, and Other Reasons

The Congregate Nutrition Services support efforts to keep older Americans independent and engaged in their communities. We examined participants' self-reported reasons for initially attending the congregate meals program and whether reasons differed by participant characteristics. Descriptive statistics and tests of differences were used to compare participants (n = 1,072). Individuals attended congregate meals for several reasons, with the top two being socialization (36.3%) and age- or health-related reasons (18.7%). Those attending for socialization were less likely to be lower income, have food insecurity, or live with 3+ ADL limitations while participants who first attended due to age or health-related reasons were more likely to be low income, food insecure, and from historically marginalized populations. Health and social service professionals and community organizations could expand data collection on older adults in their communities and partner with congregate meal providers to encourage participation for individuals with unmet nutritional, health, and socialization needs.

Participation in a Medicare advanced primary care model and the delivery of high-value services

OBJECTIVE

To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services.

DATA SOURCES

Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare.

STUDY DESIGN

We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year.

DATA COLLECTION/EXTRACTION METHODS

Secondary data are linked at the provider level.

PRINCIPAL FINDINGS

We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening.

CONCLUSIONS

CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.

COVID-19 PANDEMIC INCREASED NURSING FACILITIES' RELIANCE ON CONTRACT STAFF TO ADDRESS STAFFING SHORTAGES

Nursing facilities (NFs) used a variety of strategies to mitigate worsening nursing staff shortages during the COVID-19 pandemic. We conducted analysis of payroll based journal PBJ data and interviewed 9 experts to understand COVID’s impact on NF staffing, especially changes in contract staffing. In 2020, NFs increased their use of contract staff hours per resident day (HPRD) by 24%. Use of contract staff during the first year of the pandemic (comparing 2020 to 2019) varied by some facility characteristics (e.g., profit status). NF providers, and industry and academic experts confirmed facilities used multiple strategies beyond using contract staffing, such as temporary nurse aides, hazard pay and flexible schedules to maintain staffing throughout the pandemic. Competition for nursing staff from other healthcare settings and non-healthcare industries has grown throughout the pandemic, continuing to threaten the stability of the NF workforce.

THE COVID-19 PANDEMIC MAY HAVE EXACERBATED NURSE STAFFING DISPARITIES IN NURSING FACILITIES

Nursing facilities (NFs) have historically struggled to maintain adequate nurse staffing. We used PBJ data linked with other publicly available sources and conducted stakeholder interviews to understand nurse staffing between 2019 and 2020. We found large declines in the population of NF residents and in staffing hours. Measured in hours per resident day (HPRD) to account for the size of the NF resident population, there were slight increases in staffing. Staffing was nonetheless a major challenge for NFs because they required increased staffing due to the impact of the pandemic. NFs in higher quartiles of percentage of minority residents lost nurse staffing HPRD relative to NFs in the lowest quartile of minority residents. Stakeholders explained that NFs with more minority residents were likely to employ staff who live in more vulnerable communities with a greater concentration of minorities, who were more impacted by COVID.

REASONS OLDER ADULTS START ATTENDING CONGREGATE MEAL PROGRAMS AND WHO ATTENDS FOR SOCIALIZATION

The Older Americans Act Nutrition Services Program’s congregate meals support food security and nutrition, promote socialization, and improve quality of life. Understanding what drives people to first attend a congregate meal program may support efforts to increase involvement. This study used the 2019 National Survey of Older Americans Act Participants to analyze the open-ended survey responses of congregate meal participants (N=1,072) on why they started attending the program. The top three reasons were that they sought socialization (36.3%), had a medical or age-related need (18.7%), or accompanied or were referred by a friend or relative (12.3%). We conducted descriptive analyses on differences in the demographic, socioeconomic, and health characteristics of those attending for socialization compared to others. Results indicated a relationship between attending congregate meals for socialization and several characteristics: these individuals are more often non-Hispanic white (p&lt; 0.05), widowed (p&lt; 0.05), aged 75 to 84 (p&lt; 0.05), and have at least a high school education (p&lt; 0.01). People who attend for socialization are also less likely to be lower income (p&lt; 0.01), living in cities (p&lt; 0.001), have food insecurity (p&lt; 0.01), and living with three or more ADLs (p&lt; 0.01). Findings suggest two subpopulations of congregate meal attendees: those who have the choice to attend and do so for socialization, and those who attend because of unmet needs (e.g., food insecurity or disability). Identification of different categories of participants and what drives them to attend congregate meal sites has implications for improvements to advertising congregate meal services, targeting of certain populations, and ultimately to increasing participation.

Implementation of a CMS Nursing Facility Initiative: Differences by Racial Minority Resident Population

Objectives: The CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Payment Reform (NFI 2) provided billing opportunities to incentivize participating facilities to keep long-stay residents onsite for acute care, rather than hospitalizing them. We examined cross-facility differences in NFI 2 implementation by racial composition of facility resident populations. Methods: We analyzed Medicare claims in conjunction with in-person and telephone interviews among facility staff to assess NFI 2 engagement in relation to racial minority resident population. Results: Participating facilities with larger racial minority resident populations faced additional barriers to NFI 2 implementation. These facilities submitted fewer NFI 2 claims, reported more challenges engaging resident families, and experienced greater facility staff and leadership instability, compared to facilities with predominantly white resident populations. Discussion: Addressing structural differences within facilities with larger populations of racial minority residents may encourage future development of targeted programs to support diverse nursing facilities.

National Family Caregiver Support Program Participants' Recommendations to Boost Caregiver Supports

For more than 20 years, family caregivers have been supported through the National Family Caregiver Support Program (NFCSP) of the Older Americans Act (Title IIIE). The NFCSP provides information to caregivers about available services; assistance in gaining access to services; counseling, support groups and caregiver training; respite care; and supplemental services. In the 2019 National Survey of Older Americans Act Participants, 1,909 NFCSP caregivers were asked “What recommendations do you have for improving the service?” The resulting 748 open-ended responses were thematically coded. The thematic analysis yielded six major themes: Additional Resources, Staffing, Communication, Care Coordination, Quality of Services, and Eligibility. Sub-themes were identified for Additional Resources and Staffing. The most common sub-themes for Additional Resources were requests for more help or services (e.g., grocery shopping), increased funding or financial assistance, and more service hours (e.g., overnight or holiday care). The most common sub-theme for Staffing was the need for consistent staffing due to high turnover of staff. Chi-Squared tests and Fisher’s Exact tests indicated that there were no significant associations between any of the recommendation themes and the gender of the caregiver, employment status of the caregiver, or whether the care recipient has Alzheimer’s or dementia. Many of the themes align with results from a recent RAISE Family Caregiving Advisory Council Report. Recommendations from both sets of findings indicate ways that programs, services, and policies can be enhanced to support the needs of care recipients and caregivers.

Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative

BACKGROUND/OBJECTIVES

Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated.

DESIGN

We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status.

SETTING

Participating NFs during fiscal years 2017 to 2018.

PARTICIPANTS

There were 47,202 long-stay NF residents from 260 facilities in seven states.

INTERVENTION

CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform.

MEASUREMENTS

Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions.

RESULTS

Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital.

CONCLUSION

Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Leveraging summary statistics to make inferences about complex phenotypes in large biobanks

As genetic sequencing becomes less expensive and data sets linking genetic data and medical records (e.g., Biobanks) become larger and more common, issues of data privacy and computational challenges become more necessary to address in order to realize the benefits of these datasets. One possibility for alleviating these issues is through the use of already-computed summary statistics (e.g., slopes and standard errors from a regression model of a phenotype on a genotype). If groups share summary statistics from their analyses of biobanks, many of the privacy issues and computational challenges concerning the access of these data could be bypassed. In this paper we explore the possibility of using summary statistics from simple linear models of phenotype on genotype in order to make inferences about more complex phenotypes (those that are derived from two or more simple phenotypes). We provide exact formulas for the slope, intercept, and standard error of the slope for linear regressions when combining phenotypes. Derived equations are validated via simulation and tested on a real data set exploring the genetics of fatty acids.