Mental Health Treatment Among Nursing Home Residents With Alzheimer's Disease and Related Dementias.

OBJECTIVES: To examine the prevalence of mental health treatment among nursing home (NH) long-stay residents with Alzheimer's disease and related dementias (ADRD) and explore factors associated with utilization. DESIGN: Retrospective cohort study. Minimum Data Set data (April 2017-September 2018), Medicare Master Beneficiary Summary File, Part B Carrier file and Part D prescription file were used to identify mental illness and ADRD diagnoses, patient characteristics, and mental health treatment. SETTING AND PARTICIPANTS: All US Medicare- or Medicaid-certified NHs. Fee-for-service Medicare beneficiaries aged 65 and older who had a quarterly or annual Minimum Data Set assessment with ADRD and were enrolled in Medicare Parts B and D. Two cohorts: residents with both ADRD and psychiatric disorders; residents with ADRD only. METHODS: Primary outcomes: receipt of (1) any mental health treatment (medication or psychotherapy); (2) any psychotherapy in a calendar quarter. SECONDARY OUTCOMES: antipsychotics, antidepressants, hypnotics, antiepileptics, short-session ( ≤ 30 minutes), long-session ( ≥ 45 minutes), and family/group psychotherapy. Covariates included predisposing, enabling characteristics, and needs factors. Generalized Estimating Equation models of quarterly data, nested within patients, were estimated for each outcome among each cohort. RESULTS: Analyses included 1,913,945 resident-quarter observations from 503,077 unique NH long-stay residents. Overall, 68.5% of NH long-stay residents with ADRD have psychiatric disorders; of these, 85% received mental health treatment. African American or Hispanic residents were less likely to use antidepressants. African American residents or residents living in rural locations were less likely to receive long-session psychotherapy. Hispanic residents were more likely to receive long-session psychotherapy. Residents in minority groups were more likely to receive group/family psychotherapy. CONCLUSIONS AND IMPLICATIONS: Most of NH long-stay residents with ADRD had psychiatric disorders and most of them received treatment. Antidepressants or long-session psychotherapy were less likely to be provided to African American residents. Factors that determine the efficacy of mental health treatment and reasons for the racial disparities require further exploration.

Outcomes After Community Discharge From Skilled Nursing Facilities: The Role of Medicaid Home and Community-Based Services.

This study investigated the association between Medicaid Home and Community-Based Services (HCBS) generosity and post-discharge outcomes among dual-eligible beneficiaries discharged from skilled nursing facilities (SNFs). We linked multiple national datasets for duals discharged from SNFs between 2010 and 2013. Accounting for SNF fixed effects, we estimated the effect of HCBS generosity, measured by its breadth and intensity, on the likelihood of remaining in the community, risks of death, nursing home (NH) admission, and hospitalizations within 30 and 180 days after SNF discharge. We found that higher HCBS generosity was associated with an increased likelihood of remaining in the community. HCBS breadth and intensity were both significantly associated with reduced risks of NH admission, while higher HCBS intensity was related to a reduced risk of acute hospitalizations within 30 days after discharge. Our findings suggest that more generous HCBS programs may facilitate smoother transitions and sustainable community living following SNF discharge.

Driving Cessation and Late-Life Depressive and Anxiety Symptoms: Findings from the National Health and Aging Trends Study.

OBJECTIVES: To describe the association between driving cessation and depressive and anxiety symptoms over time by assessing depression and anxiety at 1- and 4-years follow-up. METHODS: The study examined community-dwelling adults aged 65 years and older from the National Health and Aging Trends Study who were driving at the 2015 interview and completed 1-year (N = 4,182) and 4-year (N = 3,102) follow-up interviews. Outcomes were positive screens for depressive and anxiety symptoms in 2016 or 2019, and the primary independent variable was driving cessation within one year of the baseline interview. RESULTS: Adjusting for socio-demographic and clinical characteristics, driving cessation was associated with depressive symptoms at 1 year (OR = 2.25, 95% CI: 1.33-3.82) and 4-year follow-up (OR = 3.55, 95% CI: 1.72-7.29). Driving cessation was also associated with anxiety symptoms at 1 year (OR = 1.71, 95% CI: 1.05-2.79) and 4 year follow up (OR = 3.22, 95% CI: 1.04-9.99). CONCLUSIONS: Driving cessation was associated with an increased risk of developing depressive and anxiety symptoms in later life. However, reasons for this association remain unclear. CLINICAL IMPLICATIONS: Although the mechanism linking driving cessation with worse mental health symptoms is uncertain, driving facilitates many important activities. Clinicians should monitor the well-being of patients who stop or intend to stop driving.

Older Adults Receiving Rehabilitation Services Are More Likely to Get Bathing and Toileting Equipment Installed.

IMPORTANCE: Adaptive equipment, such as shower grab bars and modified toilet seating, is effective but underused in the United States. To change this, a better understanding of how equipment ends up being installed is needed. We hypothesized that rehabilitation services were a major mechanism. OBJECTIVE: To examine the association between receipt of rehabilitation services and installation of adaptive equipment. DESIGN: Observational cohort of the National Health and Aging Trends Study in 2015 and 2016. SETTING: Community. PARTICIPANTS: A total of 416 community-dwelling adults age 65 yr or older who needed bathing equipment and 454 who needed toileting equipment. OUTCOMES AND MEASURES: Study outcomes were the installation of bathing or toileting equipment. The primary independent variable was the receipt of rehabilitation services between 2015 and 2016. RESULTS: Among older adults who needed equipment in 2015, 34.3% had bathing equipment and 19.2% had toileting equipment installed by 2016. In multivariate logistic regression analyses, rehabilitation services were associated with installation of bathing (odds ratio [OR] = 5.07, 95% confidence interval [CI] [2.60, 9.89]) and toileting equipment (OR = 2.67, 95% CI [1.48, 4.84]). CONCLUSIONS AND RELEVANCE: A minority of those in need have adaptive equipment installed within a year. In the current health care system, rehabilitation providers play a major role in equipment installation. What This Article Adds: Rehabilitation providers are involved in the installation of adaptive bathroom equipment among older persons who need it. Still, most in need of equipment do not have it after a year, suggesting that further work is needed to increase access to rehabilitation providers and develop other avenues for obtaining equipment.

Hospitalization's association with depression in adults over 50 years old: does living arrangement matter? Findings from the Health and Retirement Study.

OBJECTIVES: To examine how living arrangements are associated with depressive symptoms in late middle-life and older adults following hospitalization within the last two years. DESIGN: We used the 2016 wave of the Health and Retirement Study (HRS), a nationally representative survey of adults over 50 years old living in the United States. METHODS: The dependent variable was whether HRS participants screened positive for having depressive symptoms. The primary independent variable was self-reported hospitalization in the prior two years. We stratified bivariate analyses and multivariate logistic regressions by living arrangement to examine hospitalizations' association with depressive symptoms. RESULTS: Depressive symptoms were less prevalent among participants who were married or partnered and living with a partner (14.0%) compared to those who were not married or partnered and were living with others (31.7%) and were not married or partnered and were living alone (27.8%). In multivariate analyses stratified by living arrangement, however, hospitalization was associated with depressive symptoms for those married or partnered and living with a partner (OR = 1.39, 95% CI: 1.14-1.69) but not for those who were not married and living with other(s) (OR = 0.88, 95% CI: 0.65-1.18) and not married or partnered and living alone (OR = 1.06, 95% CI: 0.82-1.36). CONCLUSIONS: Late middle-life and older adults residing with spouses or cohabitating appear at risk for having depressive symptoms following a hospitalization. A better understanding of how relationships and living arrangements may affect depression risk in the context of an acute medical illness is needed to identify points of intervention.

Lonely older adults are more likely to delay or avoid medical care during the coronavirus disease 2019 pandemic.

OBJECTIVES: To examine the relationship between loneliness and self-reported delay or avoidance of medical care among community-dwelling older adults during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Analyses of data from a nationally representative survey administered in June of 2020, in COVID-19 module of the Health and Retirement Study. Bivariate and multivariable analyses determined associations of loneliness with the likelihood of, reasons for, and types of care delay or avoidance. RESULTS: The rate of care delay or avoidance since March of 2020 was 29.1% among all respondents (n = 1997), and 10.1% higher for lonely (n = 1,150%, 57.6%) versus non-lonely respondents (33.5% vs. 23.4%; odds ratio = 1.59, p = 0.003 after covariate adjustment). The differences were considerably larger among several subgroups such as those with emotional/psychiatric problems. Lonely older adults were more likely to cite "Decided it could wait," "Was afraid to go," and "Couldn't afford it" as reasons for delayed or avoided care. Both groups reported dental care and doctor's visit as the two most common care delayed or avoided. CONCLUSIONS: Loneliness is associated with a higher likelihood of delaying or avoiding medical care among older adults during the pandemic.

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.

Medicaid home- and community-based services and discharge from skilled nursing facilities.

OBJECTIVE: To examine the association between the generosity of Medicaid home- and community-based services (HCBS) and the likelihood of community discharge among Medicare-Medicaid dually enrolled older adults who were newly admitted to skilled nursing facilities (SNFs). DATA SOURCES: National datasets, including Medicare Master Beneficiary Summary File (MBSF), Medicare Provider and Analysis Review (MedPAR), Medicaid Analytic eXtract (MAX), minimum data set (MDS), and publicly available data at the SNF or county level, were linked. STUDY DESIGN: We measured Medicaid HCBS generosity by its breadth and intensity and described their variation at the county level. A set of linear probability models with SNF fixed effects were estimated to characterize the association between HCBS generosity and likelihood of community discharge from SNFs. We further stratified the analyses by the type of index hospitalizations (medical vs surgical events), age group, and the Medicaid cost-sharing policy for SNF services. DATA EXTRACTION METHODS: The final analytical sample included 224 229 community-dwelling dually enrolled older duals who were newly admitted to SNFs after an acute inpatient event between October 1, 2010, and September 30, 2013. PRINCIPAL FINDINGS: We observed substantial cross-sectional and over-time variations in HCBS breadth and intensity. Regression results indicate that on average, a 10 percentage-point increase in HCBS breadth was associated with a 0.7 percentage-point increase (P < 0.01) in the likelihood of community discharge. Such relationship could be modified by individual factors and state policies: significant effects of HCBS breadth were detected among medical patients (0.7 percentage-point, P < 0.05), individuals aged older than 85 (1.5 percentage-point, P < 0.01), and states with and without lesser-of policies (0.5 and 2.3 percentage-point, respectively, P < 0.05). No significant relationship between HCBS intensity and community discharge was detected. CONCLUSIONS: Higher Medicaid HCBS breadth but not intensity was associated with a greater likelihood of community discharge, and such relationship could be modified by individual factors and state policies.

Near Vision but not Hearing Loss is Associated with Lacking a Usual Source of Health Care.

Objectives: Sensory loss may be a barrier to accessing healthcare services, and this study seeks to examine the association of sensory loss with whether older adults report having a usual source of health care. Methods: Our study included 7548 older adults who participated in the National Health and Aging Trends Study in 2015. Having a self-reported usual source of health care was our outcome, and hearing and vision loss were our primary independent variables. Results: In multivariate analysis accounting for demographics, socioeconomic, health status, and environmental covariates, near vision loss but not distance vision or hearing loss was associated with decreased odds of having a usual source of health care. Discussion: That older adults with near vision loss were less likely to report having a usual source of health care is concerning. Examining barriers to care is needed to identify sensory loss-relevant processes to optimize and intervene upon.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care.

BACKGROUND/OBJECTIVES: Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services. DESIGN: Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File. SETTING: AL facilities and Medicare HH agencies in the United States. PARTICIPANTS: 741,926 Medicare HH admissions of AL residents in 2017. MEASUREMENTS: Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission. RESULTS: Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)). CONCLUSION: For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Is well-being prior to receiving rehabilitation services associated with postrehabilitation mental health and functioning?

OBJECTIVES: Millions of older adults receive rehabilitation services every year, which aim to restore, maintain, or limit decline in functioning. We examine whether lower reported well-being prior to receiving rehabilitation services is associated with increased odds of worsening anxiety symptoms, depressive symptoms, and impairment in self-care and household activities following rehabilitation. METHODS: Data come from the National Health and Aging Trends Study (NHATS), an annual survey of a nationally representative sample of Medicare beneficiaries aged 65 years and older. Our sample consists of 811 NHATS participants who, in the 2015 interview, had information on well-being and, in the 2016 interview, reported receiving rehabilitation services in the prior year. RESULTS: In multivariable logistic regression analyses, compared to the highest quartile, those in the lowest quartile of well-being at baseline have increased odds of having worsening depressive symptoms (OR = 9.25, 95% CI: 3.78-22.63) and worsening impairments in self-care activities (OR = 2.39, 95% CI: 1.12-5.11). CONCLUSION: Our findings suggest that older adults with the lowest levels of baseline well-being may be susceptible to having worsening depressive symptoms and impairment in self-care activities following rehabilitation services. Examination on whether consideration of well-being during the rehabilitation process could lead to better mental health and functional outcomes following rehabilitation is needed.

Patients discharged from higher-quality skilled nursing facilities spend more days at home.

OBJECTIVE: To evaluate the association of skilled nursing facility (SNF) quality with days spent alive in nonmedical settings ("home time") after SNF discharge to the community. DATA SOURCES: Secondary data are from Medicare claims for New York State (NYS) Medicare beneficiaries, the Area Health Resources File, and Nursing Home Compare. STUDY DESIGN: We estimate home time in the 30- and 90-day periods following SNF discharge. Two-part zero-inflated negative binomial regression models characterize the association of SNF quality with home time. DATA EXTRACTION METHODS: We use Medicare claims data to identify 25 357 NYS fee-for-service Medicare beneficiaries aged 65 years and older with an SNF admission for postacute care who were subsequently discharged to home in 2014. PRINCIPAL FINDINGS: Following 30 and 90 days after SNF discharge, the average home time is 28.0 (SD = 6.1) and 81.6 (SD = 20.2) days, respectively. A number of patient- and SNF-level factors are associated with home time. In particular, within 30 and 90 days of discharge, respectively, patients discharged from 2- to 5-star SNFs spend 1.2-1.5 (P < .001) and 3.2-4.3 (P < .001) more days at home than those discharged from 1-star (lowest quality) SNFs. CONCLUSIONS: Improved understanding of what is contributing to differences in home time could help guide efforts into optimizing post-SNF discharge outcomes.

Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture.

BACKGROUND AND OBJECTIVES: Nursing homes (NHs) care for 70% of Americans dying with dementia. Many consider deaths in NHs rather than hospitals as preferable for most of these residents. NH characteristics such as staff teamwork, communication, and other components of patient safety culture (PSC), together with state minimum NH nurse staffing requirements, may influence location of death. We examined associations between these variables and place of death (NH/hospital) among residents with dementia. RESEARCH DESIGN AND METHODS: Cross-sectional study of 11,957 long-stay NH residents with dementia, age 65+, who died in NHs or hospitals shortly following discharge from one of 800 U.S. NHs in 2017. Multivariable logistic regression systematically estimated effects of PSC on odds of in-hospital death among residents with dementia, controlling for resident, NH, county, and state characteristics. Logistic regressions also determined moderating effects of state minimum NH nurse staffing requirements on relationships between key PSC domains and location of death. RESULTS: Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death. This effect was stronger in NHs located in states with higher minimum NH nurse staffing requirements. DISCUSSION AND IMPLICATIONS: Promoting communication openness in NHs across nursing disciplines may help avoid unnecessary hospitalization at the end of life, and merits particular attention as NHs address nursing staff mix while adhering to state staffing requirements. Future research to better understand unintended consequences of staffing requirements is needed to improve end-of-life care in NHs.

Pain Management in Home Health Care: Relationship With Dementia and Facility Admissions.

BACKGROUND: Pain is common yet under-studied among older Medicare home health (HH) patients with Alzheimer's disease and related dementias (ADRD). AIMS: Examine (1) the association between ADRD and severe pain in Medicare HH patients; and (2) the impact of severe pain and ADRD on unplanned facility admissions in this population. DESIGN: Analysis of the Outcome and Assessment Information Set (OASIS) and Medicare claims data. SETTINGS/PARTICIPANTS: 6,153 patients ≥65 years receiving care from a nonprofit HH agency in 2017. METHODS: Study outcomes included presence of severe pain and time-to-event measures of unplanned facility admissions (hospital, nursing home, or rehabilitation facilities). ADRD was identified using ICD-10 diagnosis codes and cognitive impairment symptoms. Logistic regression and Cox proportional hazard models were used to examine, respectively, the association between ADRD and severe pain, and the independent and interaction effects of severe pain and ADRD on unplanned facility admission. RESULTS: Patients with ADRD (n = 1,525, 24.8%) were less likely to have recorded severe pain than others (16.4% vs. 23.6%, p < .001). Adjusting for demographics, comorbidities, mental and physical functional status, and use of HH services, having severe pain was related to a 35% increase (hazard ratio [HR] = 1.35, p = .002) in the risk of unplanned facility admission, but the increase in such risk was the same whether or not the patient had ADRD. CONCLUSIONS: HH patients with ADRD may have under-recognized pain. Severe pain is a significant independent predictor of unplanned facility admissions among HH patients.

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.

End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics.

OBJECTIVES: Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics. DESIGN: Cross-sectional. OUTCOMES: Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition. SETTING AND PARTICIPANTS: Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge. METHODS: National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions. RESULTS: As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD. CONCLUSIONS AND IMPLICATIONS: Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.

Skilled Nursing Facility Patients Discharged to Home Health Agency Services Spend More Days at Home.

OBJECTIVES: To investigate the association of the utilization of Medicare-certified home health agency (CHHA) services with post-acute skilled nursing facility (SNF) discharge outcomes that included home time, rehospitalization, SNF readmission, and mortality. DESIGN: Retrospective cohort study. SETTING: New York State fee-for-service Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care and discharged to the community in 2014. PARTICIPANTS: A total of 25,357 older adults. MEASUREMENTS: The outcomes included days spent alive in the community ("home time"), rehospitalization, SNF readmission, and mortality within 30- and 90-day post-SNF discharge periods. The primary independent variables were SNF five-star overall quality rating and receipt of CHHA services within 7 days of SNF discharge. Zero-inflated negative binomial regression and logistic regression models characterized the association of CHHA linkage with home time and other outcomes, respectively. RESULTS: Following SNF discharge, 17,657 (69.6%) patients received CHHA services. In analyses that adjusted for patient-, market-, and other SNF-level factors, older adults discharged from higher quality SNFs were more likely to receive CHHA services. In analyses that adjusted for patient- and market-level factors, receipt of post-SNF CHHA services was associated with 2.03 and 4.17 (P < .001) more days in the community over 30- and 90-day periods. Receiving CHHA services was also associated with decreased odds for rehospitalization (odds ratio [OR] = .68; P < .001; OR = .91; P = .008), SNF readmission (OR = .36; P < .001; OR = .62; P < .001), and death (OR = .34; P < .001; OR = .63; P < .001) over 30- and 90-day periods, respectively. CONCLUSION: Among older adults discharged from a post-acute SNF stay, those who received CHHA services had better discharge outcomes. They were less likely to experience admissions to institutional care settings and had a lower mortality risk. Future efforts that examine how the type and intensity of CHHA services affect outcomes would build on this work. J Am Geriatr Soc 68:1573-1578, 2020.

Relationship of Medicare-Medicaid Dual Eligibility and Dementia With Unplanned Facility Admissions Among Medicare Home Health Care Recipients.

Objective: The objective of this study was to examine the effects of dementia and Medicare-Medicaid dual eligibility on unplanned facility admission among older Medicare home health (HH) recipients. Method: This study involves a secondary analysis of data from the Outcome and Assessment Information Set (OASIS) and billing records (i.e., International Classification of Diseases, 10th Revision [ICD-10] codes) of 6,153 adults ≥ 65 years receiving HH from a nonprofit HH agency in CY 2017. Results: Among dual eligible patients with dementia, 39.3% had an unplanned facility admission of any type, including the hospital, nursing home, or rehabilitation facility. In the multivariable Cox proportional hazard model of time-to-facility admission, dual eligible patients with dementia were more than twice as likely as Medicare-only patients without dementia to have an unplanned facility admission (hazard ratio = 2.35; 95% confidence interval: 1.28, 4.33; p = .006). Discussion: Low income and dementia have interactive effects on facility admissions. Among Medicare HH recipients, dual eligible patients with dementia are the most vulnerable group for unplanned facility admission.