The Hospital Readmissions Reduction Program and Observation Hospitalizations.

The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS's 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.

A process-based approach to exploring the information behavior of informal caregivers of people living with dementia.

INTRODUCTION AND PURPOSE: Informal caregivers of persons living with dementia have significant unmet information needs that, if met, would better equip them to provide effective care. Despite the existence of health information technologies, websites, resources, and organizations dedicated to dementia caregiving, caregivers continue to report unmet information needs. Caregivers' continued unmet information needs suggest a misalignment between information products, and caregivers' information behavior-how caregivers generate, acquire, manage, use, communicate, and seek information. Researchers have developed conceptual models for understanding caregivers' information behavior, but these models are limited in that they are task-oriented, and they assume that caregivers' information needs will be met if they engage in information behavior. To address these limitations, the present study sought to explore caregivers' information behavior as a sociotechnical-systems-based process. METHODS: We conduced semi-structured interviews with 30 self-identified caregivers to explore their daily experience of caregiving activities, including their information behavior. We applied a process-based conceptual framework that takes into account inputs, processes, outputs, and feedback mechanisms within a sociotechnical system to guide analysis. The process of interest was caregivers' information behavior as modeled by the information-seeking and communication model (ISCM). We conducted a deductive content analysis guided by the components of the ISCM. We then used team-based affinity diagramming to collapse and categorize the ISCM components into inputs, processes, outputs, and feedback. RESULTS: We developed a conceptual model to depict caregivers' information behavior as a sociotechnical-systems-based process of inputs, processes, and outputs that feedback into the system. The conceptual model consisted of three inputs (i.e., information users, information providers, and information products), three information seeking and communication processes (i.e., information access, information interaction, and information assessment and processing), two outputs (i.e., utility and credibility), and feedback. DISCUSSION AND CONCLUSION: Building on and addressing the gaps in previous information behavior models, our conceptual framework advances the previous task-level understandings of caregivers' information behavior into a comprehensive feedback-driven, process-level perspective consisting of context-based inputs, information seeking and communication processes, outputs, and feedback. A sociotechnical-systems-based understanding of caregivers' information behavior allows for misalignments between information providers and products, and caregivers' information behavior not only to be illuminated, but systematically addressed.

Improving Healthcare Value: COVID-19 Emergency Regulatory Relief and Implications for Post-Acute Skilled Nursing Facility Care.

Rarely, if ever, does a national healthcare system experience such rapid and marked change as that seen with the COVID-19 pandemic. In March 2020, the president of the United States declared a national health emergency, enabling the Department of Health & Human Services authority to grant temporary regulatory waivers to facilitate efficient care delivery in a variety of healthcare settings. The statutory requirement that Medicare beneficiaries stay three consecutive inpatient midnights to qualify for post-acute skilled nursing facility coverage is one such waiver. This so-called Three Midnight Rule, dating back to the 1960s as part of the Social Security Act, is being scrutinized more than half a century later given the rise in observation hospital stays. Despite the tragic emergency circumstances prompting waivers, the Centers for Medicare & Medicaid Services and Congress now have a unique opportunity to evaluate potential improvements revealed by COVID-19 regulatory relief and should consider permanent reform of the Three Midnight Rule.

Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage.

OBJECTIVE: To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk. PARTICIPANTS AND METHODS: This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods. RESULTS: Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally. CONCLUSION: Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.