Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions.

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.

Optimize your documentation to improve Medicare reimbursement.

There's nothing more frustrating than not getting credit for work performed. Physicians often leave large amounts of compensation on the table, because even though services were provided, insurance payers do not recognize the work due to suboptimal documentation. This problem is especially apparent in preventive medicine and wellness visits with adult and geriatric patients, and results in physician services being undervalued. This article outlines specific documentation requirements for receiving full credit for the work already provided by most primary care physicians.

The HOME Study: Statistical and economic analysis plan for a randomised controlled trial comparing the addition of Proactive Psychological Medicine to usual care, with usual care alone, on the time spent in hospital by older acute hospital inpatients.

BACKGROUND: Prolonged acute hospital stays are a problem for older people and for health services. Failure to effectively manage the psychological and social aspects of illness is an important cause of prolonged hospital stay. Proactive Psychological Medicine (PPM) is a new way of providing psychiatry services to medical wards which is proactive, focussed, intensive and integrated with medical care. The primary aim of PPM is to reduce the time older people spend in hospital because of unmanaged psychological and social problems. The HOME Study will test the effectiveness and cost-effectiveness of PPM. METHODS/DESIGN: The study is a two-arm, parallel-group, randomised, controlled superiority trial with linked health economic analysis and an embedded process evaluation. The target population is people aged 65 years and older admitted to acute hospitals. Participants will be randomly allocated to either usual care plus PPM or usual care alone. The primary outcome is the number of days spent as an inpatient in a general hospital in the month following randomisation. Secondary outcomes include quality of life, cognitive function, independent functioning, symptoms of anxiety and depression, and experience of hospital stay. The cost-effectiveness of usual care plus PPM compared with usual care alone will be assessed using quality-adjusted life-years as an outcome as well as costs from the NHS perspective. DISCUSSION: This update to the published trial protocol gives a detailed plan of the statistical and economic analysis of The HOME Study. TRIAL REGISTRATION: ISRCTN registry, ISRCTN86120296. Registered on 3 January 2018.

Hospital Costs and Reimbursement Model for a Geriatric Emergency Department.

OBJECTIVES: The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED. METHODS: Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED. RESULTS: A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328. CONCLUSION: The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.

Reconciling economic concepts and person-centred care of the older person with cognitive impairment in the acute care setting.

Person-centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person-centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person-centred. In this article, we explore key concepts of neo-liberal thought which forms an important back-story to the articles. Economic concepts, "efficiency" and "freedom" are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo-liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power.

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures.

OBJECTIVES: Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN: A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING: Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS: Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS: Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS: Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00). CONCLUSION: Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

The associations of multimorbidity with the sum of annual medical and long-term care expenditures in Japan.

BACKGROUND: The occurrence of multimorbidity (i.e., the coexistence of multiple chronic diseases) increases with age in older adults and is a growing concern worldwide. Multimorbidity has been reported to be a driving factor in the increase of medical expenditures in OECD countries. However, to the best of our knowledge, there is no published research that has examined the associations between multimorbidity and either long-term care (LTC) expenditure or the sum of medical and LTC expenditures worldwide. We, therefore, aimed to examine the associations of multimorbidity with the sum of medical and LTC expenditures for older adults in Japan. METHODS: Medical insurance claims data for adults ≥75 years were merged with LTC insurance claims data from Kashiwa city, a suburb in the Tokyo metropolitan area, for the period between April 2012 and September 2013 to obtain an estimate of medical and LTC expenditures. We also calculated the 2011 updated and reweighted version of the Charlson Comorbidity Index (CCI) scores. Then, we performed multiple generalized linear regressions to examine the associations of CCI scores (0, 1, 2, 3, 4, or ≥ 5) with the sum of annual medical and LTC expenditures, adjusting for age, sex, and household income level. RESULTS: The mean sum of annual medical and LTC expenditures was ¥1,086,000 (US$12,340; n = 30,042). Medical and LTC expenditures accounted for 66 and 34% of the sum, respectively. Every increase in one unit of the CCI scores was associated with a ¥257,000 (US$2920); 95% Confidence Interval: ¥242,000, 271,000 (US$2750, 3080) increase in the sum of the expenditures (p < 0.001; n = 29,915). CONCLUSIONS: Using a merged medical and LTC claims dataset, we found that greater CCI scores were associated with a higher sum of annual medical and LTC expenditures for older adults. To the best of our knowledge, this is the first study to examine the associations of multimorbidity with LTC expenditures or the sum of medical and LTC expenditures worldwide. Our study indicated that the economic burden on society caused by multimorbidity could be better evaluated by the sum of medical and LTC expenditures, rather than medical expenditures alone.

Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans.

In July 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule rule for calendar year 2019 (MPFS2019). The proposal sets forth CMS-recommended updates to Medicare payment policies, payment rates, and quality provisions for services provided in the next calendar year. From year to year, the rule also can serve as a vehicle for soliciting input on new payment proposals and changes to existing policies. Among the payment and quality proposals in the MPFS2019 proposal, CMS proposed extensive changes to Current Procedural Terminology codes that are the framework for documentation and payment for office-based evaluation and management (E/M) services. The American Geriatrics Society (AGS) believes the proposed payment methodology changes for E/M services would have had a significant negative impact on care for older Americans. On September 10, 2018, the AGS submitted its comments on this proposal and other aspects of the rule, and the AGS also submitted a comment letter signed by 41 organizations from an AGS-led multispecialty coalition. The coalition also worked collaboratively on outreach to Congress, which included visits to Capitol Hill and a coalition letter stressing our collective support for reducing the burden of documentation for clinicians and our opposition to the proposed changes in payment methodology. In all letters, we noted that the AGS and members of our coalition hoped to work collaboratively with CMS and other stakeholders to develop a refined approach that would achieve the best possible outcomes for patients, particularly frail older Americans with multiple chronic conditions. In releasing their final MPFS2019, CMS postponed the E/M coding collapse for at least two years, a decision that speaks to the hard work of the AGS, its members, and the multi-specialty coalition, and which opens the door for further discussions about the future of payment for E/M services so critical to older people. J Am Geriatr Soc 67:145-150, 2019.

Efficacy and cost-effectiveness of a community-based model of care for older patients with complex needs: a study protocol for a multicentre randomised controlled trial using a stepped wedge cluster design.

BACKGROUND: Community-dwelling older persons with complex care needs may deteriorate rapidly and require hospitalisation if they receive inadequate support for their conditions in the community. INTERVENTION: A comprehensive, multidimensional geriatric assessment with care coordination was performed in a community setting-Older Persons ENablement And Rehabilitation for Complex Health conditions (OPEN ARCH). OBJECTIVES: This study will assess the acceptability and determine the impact of the OPEN ARCH intervention on the health and quality of life outcomes, health and social services utilisation of older people with multiple chronic conditions and emerging complex care needs. An economic evaluation will determine whether OPEN ARCH is cost-effective when compared to the standard care. METHODS/DESIGN: This multicentre randomised controlled trial uses a stepped wedge cluster design with repeated cross-sectional samples. General practitioners (GPs; n ≥ 10) will be randomised as 'clusters' at baseline using simple randomisation. Each GP cluster will recruit 10-12 participants. Data will be collected on each participant at 3-month intervals (- 3, 0, 3, 6 and 9 months). The primary outcome is health and social service utilisation as measured by Emergency Department presentations, hospital admissions, in-patient bed days, allied health and community support services. Secondary outcomes include functional status, quality of life and participants' satisfaction. Cost-effectiveness of the intervention will be assessed as the change to cost outcomes, including the cost of implementing the intervention and subsequent use of services, and the change to health benefits represented by quality adjusted life years. DISCUSSION: The results will have direct implications for the design and wider implementation of this new model of care for community-dwelling older persons with complex care needs. Additionally, it will contribute to the evidence base on acceptability, efficacy and cost-effectiveness of the intervention for this high-risk group of older people. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617000198325p . Registered on 6 February 2017.

[Comprehensive Care Home Unit: reduction of hospital resources during influenza outbreaks]. / Unidad domiciliaria de atención integral: Reducción de recursos hospitalarios durante brotes de gripe.

OBJECTIVE: The Comprehensive Care Home Unit of the General Hospital of Villarrobledo is a unit formed by a geriatrician who sees people in nursing homes to improve their quality of care. The activity of the Unit has been analyzed, mainly with the objective of avoiding referral to the emergency room, avoiding hospital admissions, avoiding hospital readmissions and reducing the number of hospital admission days. METHODS: We retrospectively described the clinical activity of the Unit during the influenza outbreak of 2017 and 2018. We selected sociodemographical variables, functional assessment scales (Katz index, Barthel index and the Functional Ambulation Classification), and the Global Deterioration Scale. We registered mortality, type of treatment, oncological patients and patients with supplementary tests. The population was divided into four subgroups: hospital admission avoided, hospital re-admission avoided, referral to the emergency department avoided and reduction of admission days. The demographic characteristics were described, including the mode or mean of the variables. An economic report was made, and an analysis of cost per process according to the subgroups, means of Related Groups for the Diagnosis and degree of dependency measured by the Barthel index. RESULTS: We selected 112 patients, they had a mean age of 82.2 years, Katz G (34.8%), IB 28.8 (DE 34.9), FAC 0 (63.4%) and GDS 7 (22.3%). The most frequent disease seen was respiratory infection (63.2%), 71.4% received active treatment, 10.7% complementary tests were performed, 17.9% oncological and 17% mortality. Cost analysis: hospital readmission avoided (€ 4,128 per patient) and patients with total disability (BI 0-20, € 3,623 per patient) presented more economic saving. The economic savings were more than € 230,000. CONCLUSIONS: The contribution of the Unit during periods of influenza outbreak is cost saving because of reduced numbers of admissions, numbers of readmissions, days of admission and emergency room visits.

OBJETIVO: La Unidad Domiciliaria de Atención Integral (UDAI) del Hospital General de Villarrobledo está formada por un geriatra que atiende a las personas institucionalizadas para mejorar su calidad asistencial. Se analizó la actividad de la UDAI, principalmente en el objetivo de evitar ingresos y reingresos hospitalarios, evitar visitas a urgencias y facilitar el alta hospitalaria prematura. METODOS: Describimos de forma retrospectiva la actividad de la UDAI durante los brotes de gripe del 2017 y 2018. Aportamos variables sociodemográficas, escalas de valoración funcional (índice de Katz, índice de Barthel y la Escala de Valoración Funcional de la Marcha), y la Escala de Deterioro Global. Registramos mortalidad, tipo de tratamiento, pacientes oncológicos y pruebas complementarias. Se dividió la población en cuatro subgrupos: ingreso hospitalario evitado, reingreso hospitalario evitado, derivación a urgencias evitada y reducción días de ingreso. Se describieron las características demográficas, incluido la moda o media de las variables. Se realizó una memoria económica, y un análisis de coste por proceso según los subgrupos, medias de Grupos Relacionados por el Diagnóstico y grado de dependencia medido por el Índice de Barthel. RESULTADOS: Se seleccionaron 112 pacientes, presentaban una edad media de 82,2 años, Katz G (34,8%), IB 28,8 (DE 34,9), FAC 0 (63,4%) y GDS 7 (22,3%). La enfermedad más frecuente fue la infección respiratoria (63,4%), recibieron tratamiento activo un 71,4%, se realizaron pruebas complementarias en un 10,7%, oncológico 17,9% y exitus 17%. Análisis de costes: el reingreso hospitalario evitado (4.128 € por paciente) y los pacientes con discapacidad total (IB 0 ­ 20, 3.623 € por paciente) presentaron un mayor ahorro de costes. El ahorro económico fue de más de 230.000€. CONCLUSIONES: La contribución de la UDAI durante los periodos de brote de gripe supone un ahorro de costes basado en disminuciones de hospitalizaciones, disminución de reingresos, acortamiento de estancias hospitalarias y reducción de derivaciones a urgencias.

Telemedicine in elderly patients with heart failure.

Here, we carry out a review of the literature focused on telemedicine projects developed in the field of heart failure. We will particularly detail the remote monitoring project called E-care, dedicated to automated, intelligent detection of situations at risk of heart failure. Prospects for the development of the E-care system in the field of geriatry will also be discussed. Results: Numerous telemedicine projects, based on connected objects or technology sciences of information and communication, have emerged in the last five years or are under development in the field of computer science'heart failure. This is the case of the E-care telemonitoring project, which fits perfectly within the framework of telemedicine 2.0 projects. Their potential contribution in terms of mortality or morbidity, in number of hospitalizations avoided is currently under study or documentation. Their impact in terms of health economics is also being validated, knowing that the oldest telemedicine projects had already validated the economic and social benefits brought by telemedicine solutions.

Estimating the future health and aged care expenditure in Australia with changes in morbidity.

AIMS: We estimate the pure effect of ageing on total health and aged care expenditure in Australia in the next 20 years. METHODS: We use a simple demographic projection model for the number of people in older age groups along with a needs based estimate of changes in the public and private cost of care per person in each group adjusted for expected changes in morbidity. RESULTS: A pure ageing model of expenditure growth predicts an increase in health expenditure per elderly person from $7439 in 2015 to $9594 in 2035 and an increase in total expenditure from $166 billion to $320 billion (an average annual growth of 3.33%). If people live longer without additional morbidity, then total health expenditure only grows at an average annual rate of 0.48%. If only some of those additional years are in good health, then the average year on year growth is 1.87%. CONCLUSION: Ageing will have a direct effect on the growth of health spending but is likely to be dwarfed by other demand and supply factors. A focus on greater efficiency in health production and finance is likely to be more effective in delivering high quality care than trying to restrain the demand for health and aged care among the elderly.

Experiences of older people following the introduction of consumer-directed care to home care packages: A qualitative descriptive study.

OBJECTIVE: To explore the experiences of older people receiving home care package (HCP) support following the introduction of consumer-directed care (CDC) by the Australian government on 1 July 2015. METHODS: Thirty-one older people with existing HCP support from two service providers in regional New South Wales, Australia, participated in a face-to-face interview and/or a qualitative survey. RESULTS: Analysis revealed the theme of Choices: Preferences, constraints, balancing and choosing. Participants described choosing to live at home with HCP support; however, they were constrained by poor communication and information about service changes and options, personal budgets and access to future care. HCP services remained largely unchanged during transition to CDC. CONCLUSION: Many aspects of the initial implementation of CDC were challenging for older people. Clear, relevant and timely communication and information about CDC and its consequences for consumers appear to be needed to enhance CDC.

Fall concern about older persons shifts to carers as changing health policy focuses on family, home-based care.

With the Singaporean population ageing at an exponential rate, home carers are increasingly becoming essential partners in fall prevention and care delivery for older persons living at home and in the community. Singapore, like other Asian countries, regards the family as the main support structure for the older person, and national policies have been implemented to support this cultural expectation. Family carers experience similar concerns as older persons with regard to fall risk, and identifying and addressing these concerns can potentially lower fall risk and improve fall prevention for older persons. It is timely to remind ourselves - as concern about falls in older persons begins to shift to carers - to incorporate the influence of Asian cultural values and unique family dynamics of outsourcing family caregiving, in the management of older persons' fall risk in the community.

Cost analysis of the very elderly admitted to intensive care units.

BACKGROUND: Very elderly patients are often admitted to intensive care units (ICUs) despite poor outcomes and frequent preference to avoid unnecessary prolongation of life. We sought to determine the cost of ICU admission for the very elderly and the factors influencing this cost. METHODS: This prospective, observational cohort study included patients ≥80 years old admitted to 22 Canadian ICUs from 2009 to 2013. A subset of consenting individuals comprised a longitudinal cohort followed over 12 months. Costs were calculated from ICU length of stay and unit costs for ICU admission from a Canadian academic hospital. A generalized linear model was employed to identify cost-predictive variables. RESULTS: In total, 1671 patients were included; 610 were enrolled in the longitudinal cohort. The average age was 85 years; median ICU length of stay was 4 days. Mortality was 35% (585/1671) in hospital and 41% (253/610) at 12 months. The average cost of ICU admission per patient was $31,679 ± 65,867. Estimated ICU costs were $48,744 per survivor to discharge and $61,783 per survivor at 1 year. For both decedents and survivors, preference for comfort measures over life support was an independent predictor for lower cost (P < 0.01). CONCLUSIONS: Considering the poor clinical outcomes, and that many ICU admissions may be undesired by very elderly patients, ICU costs in this population are substantial. Our finding that a preference for comfort care predicted a lower cost independent of mortality reinforces the importance of early goals of care discussions to avoid both undesired and potentially non-beneficial interventions, consequently reducing costs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01293708 . Registered on 10 February 2011.

Tales from the ACFI: Dementia in residential aged care.

OBJECTIVE: Provide an overview of how care needs in permanent residential aged care differ by dementia status. METHODS: On entry into permanent residential aged care, people's care needs are assessed on the Aged Care Funding Instrument (ACFI). ACFI also captures health conditions that are considered to affect the cost of people's care, such as dementia. Data were compared between 2009 and 2015. RESULTS: Assessed care needs have increased regardless of dementia status. However, compared with people without dementia, people with dementia were more likely to be rated 'high' in each of the three care need domains. In addition, people with dementia were more likely to require some assistance in specific areas that underlie these broad domains, such as nutrition, continence and cognition. CONCLUSION: Dementia is associated with increased complexity in assessed care needs in permanent residential aged care.