Cost and Utilization Implications of a Health Plan's Home-Based Palliative Care Program.

Background: A California-based health plan offered home-based palliative care (HBPC) to members who needed support at home but did not yet qualify for hospice. Objectives: This study compares hospital and emergency department (ED) utilization and costs and mortality for individuals receiving HBPC to a cohort not receiving palliative care services (Usual Care). Design: This is an observational retrospective study using claims data covering a prestudy period and a study period during which time half of the study population received HBPC services. Setting/Subjects: Seriously ill individuals who received HBPC were matched with those receiving Usual Care using a propensity-based matching algorithm. Intervention: Interdisciplinary teams from home health and hospice agencies provided HBPC services. Measurements: Outcome measures included hospital and ED utilization and cost before and during the study period and mortality during the study period. Results: For both groups, hospital and ED utilization and associated costs were higher during the prestudy period than during the study period. No differences were found in outcome measures between groups during the study period. Average time in the study period was longer for the HBPC group than that in the Usual Care group, indicating that they lived longer or transitioned to hospice later. Conclusion: Although individuals in both groups were living with serious illnesses for which worsening health and increased acute care utilization are expected over time, both groups had reduced acute care utilization and costs during the study period compared with the prestudy period. Reduced utilization and costs were equivalent for both groups.

Behavioral health integration in the Program of All-Inclusive Care for the Elderly (PACE): A scoping review.

BACKGROUND: The Program of All-inclusive Care for the Elderly (PACE) is a community-based care model that delivers collaborative care via an interdisciplinary team to meet the medical and social needs of older adults eligible for nursing home placement. Fifty-nine percent of PACE participants are reported to have at least one psychiatric disorder. PACE organizations (POs) function through an interdisciplinary model of care, but a behavioral health (BH) provider is not a mandated role on the interdisciplinary team. Published literature regarding how POs integrate and provide BH services is limited; however, the National PACE Association (NPA) and select POs have made significant contributions to behavioral health integration (BHI) efforts in PACE. METHODS: PubMED, EMBASE, and PsycINFO were searched for articles published between January 2000 and June 2022; hand-searching was also conducted. Research articles and items involving BH components or programming in POs were included. Evidence of BH programming and initiatives at the organization and national level was summarized. RESULTS: This review reported on nine primary items addressing BH in POs from 2004 to 2022. It found evidence of successful BH initiatives in PACE and identified a gap of published information given an evident need for BH services in the PACE participant population. Findings also indicate the NPA works to advance BH integration in POs with a dedicated workgroup that has produced the NPA BH Toolkit, BH training webinar series, and a site coaching program. CONCLUSIONS: In the absence of PACE-specific BH delivery guidelines and guidance from the federal or state level for PACE programs, BH service inclusion has been developed unevenly across POs. Assessing the landscape of BH inclusion across POs is a step toward evidence-based and standardized inclusion of BH within the all-inclusive care model.

Development of telehealth principles and guidelines for older adults: A modified Delphi approach.

The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations.

Perceptions and Uses of Telehealth in the Care of Older Adults.

Background: Clinicians identify challenges in using telehealth with older adults, yet they continue to use it at high rates. We conducted a nation-wide survey of US clinicians to assess the views and uses of telehealth for older adults (≥65 years old); as well as the perceived advantages and challenges of telehealth and use of age-friendly telehealth practices. Materials/Methods: We distributed an online survey (Wallin Opinion Research) to assess the use of telehealth and clinicians' views on advantages/challenges of telehealth in care of older adults. Respondents were eligible if they were active US clinicians with self-attestation of patient population ≥10% older adults. The survey was distributed through established professional networks. Eligible respondents received a gift card for participation, fulfilled by a third-party vendor. Survey participation was voluntary. Completion of the survey was considered consent to participate. The study was reviewed and determined exempt by the WCG's IRB Affairs Department. SPSS Version-26 was used for descriptive statistics. Results: Approximately 13,300 surveys were distributed and there were 7,246 (55%) respondents. Over half (56%) respondents were licensed independent practitioners. The majority of respondents practiced geriatric medicine (22%) or primary care (9.7%). The most common use was in hospitals (53%), long-term care facilities (47%), and outpatient (47%) settings. The majority of respondents (55%) selected "telehealth improves healthcare for older adults by enhancing engagement between stakeholders" as a top advantage. Fewer primary care clinicians (47%) reported sufficient support in the use of telehealth, as compared with clinicians in geriatrics (62%) or other specialties (60%). A majority (65%) of respondents reported use one or more age-friendly practice (40% often; 25% always). Only 5% of respondents reported that their telehealth program never utilized age-friendly practices. Discussion and Conclusion: Clinicians use telehealth in care of older adults, across clinical roles, sites, and purposes. Our survey results suggest perceived advantages of telehealth outweigh challenges, in care of older adults. This highlights an opportunity for guidance and resources to optimizing telehealth with older adults.

Hospital at Home services: An inventory of fee-for-service payments to inform Medicare reimbursement.

BACKGROUND: Hospital at Home (HaH) is a growing model of care with proven patient benefits. However, for the types of services required to provide an episode of HaH, full Medicare reimbursement is traditionally paid only if care is provided in inpatient facilities. DESIGN: This project identifies HaH services that could be reimbursable under Medicare to inform episodic care within fee-for-service (FFS) Medicare. SETTING: All data are derived from acute services provided from the Mount Sinai HaH program between 2014 and 2017 as part of a Center for Medicare and Medicaid Innovation (CMMI) demonstration program. PARTICIPANTS: The sample was limited to patients with one of the following five admitting diagnoses: urinary tract infection (n = 70), pneumonia (n = 60), cellulitis (n = 45), heart failure (n = 37), and chronic lung disease (n = 24) for a total of 236 acute episodes. MEASUREMENTS: HaH services were inventoried from three sources: electronic medical records, Medicare billing and itemized vendor billing. For each admitting diagnosis, four reimbursement scenarios were evaluated: (1) FFS Medicare without a home health episode, (2) FFS Medicare with a home health episode, (3) two-sided risk ACO with a home health episode, and (4) two-sided risk ACO without a home health episode. RESULTS: Across diagnoses, there were 1.5-1.9 MD visits and 1.5-2.7 nursing visits per episode. The Medicare FFS model without home health care had the lowest reimbursement potential ($964-$1604) per episode. The Medicare fee-for-service within ACO models with home health care had the greatest potential for reimbursement $4519-$4718. There was limited variation in costs by diagnosis. CONCLUSION AND RELEVANCE: Though existing payment models might be used to pay for many HaH acute services, significant gaps in reimbursement remain. Extending the benefits of HaH to the Medicare beneficiaries that are likely to derive the greatest benefit will require new payment models for FFS Medicare.

Using malnutrition and food insecurity screening to identify broader health-related social needs amongst older adults receiving emergency department care in the Southeastern United States: A cross-sectional study.

Unmet health-related social needs are common amongst older US adults and impact both quality of life and health outcomes. One of the ways that unmet health-related social needs impact health is through malnutrition, an imbalance in a person's intake of energy and/or nutrients. Lack of reliable access to a sufficient quantity of nutritious food is a specific health-related social need that can be assessed rapidly and, when unmet, is a direct risk factor for malnutrition and may be indicative of a broader range of unmet health-related social needs. We conducted a cross-sectional study to characterise malnutrition and food insecurity amongst older adults receiving emergency department (ED) care using brief, validated measures and to assess the burden of a broader range of health-related social needs amongst these patients. Patients were asked about their need for and willingness to receive a range of social services. The study was conducted in an academic ED serving a racially and socioeconomically diverse population in the Southeastern United States. A convenience sample of noncritically ill adults aged 60 years and older was approached between November 2018 and April 2019. Study patients (n = 127) were predominantly non-Hispanic white (67%), community dwelling (91%) and urban residents (66%) with 28% screening positive for malnutrition risk, 16% for food insecurity and 5% for both. Of those at risk for malnutrition, 25 (69%) reported ≥2 unmet health-related social needs and 14 (38%) were receptive to social services. Amongst food insecure patients, 18 (90%) reported additional unmet health-related social needs and 13 (65%) were receptive to receiving social services. In conclusion, a brief set of questions can identify subgroups of older ED patients who are food insecure or at risk for malnutrition. Individuals who screen positive for food insecurity have a high burden of unmet health-related social needs.

Reducing Emergency Department Transfers from Skilled Nursing Facilities Through an Emergency Physician Telemedicine Service.

INTRODUCTION: Transfers of skilled nursing facility (SNF) residents to emergency departments (ED) are linked to morbidity, mortality and significant cost, especially when transfers result in hospital admissions. This study investigated an alternative approach for emergency care delivery comprised of SNF-based telemedicine services provided by emergency physicians (EP). We compared this on-site emergency care option to traditional ED-based care, evaluating hospital admission rates following care by an EP. METHODS: We conducted a retrospective, observational study of SNF residents who underwent emergency evaluation between January 1, 2017-January 1, 2018. The intervention group was comprised of residents at six urban SNFs in the Northeastern United States, who received an on-demand telemedicine service provided by an EP. The comparison group consisted of residents of SNFs that did not offer on-demand services and were transferred via ambulance to the ED. Using electronic health record data from both the telemedicine and ambulance transfers, our primary outcome was the odds ratio (OR) of a hospital admission. We also conducted a subanalysis examining the same OR for the three most common chronic disease-related presentations found among the telemedicine study population. RESULTS: A total of 4,606 patients were evaluated in both the SNF-based intervention and ED-based comparison groups (n=2,311 for SNF based group and 2,295 controls). Patients who received the SNF-based acute care were less likely to be admitted to the hospital compared to patients who were transferred to the ED in our primary and subgroup analyses. Overall, only 27% of the intervention group was transported to the ED for additional care and presumed admission, whereas 71% of the comparison group was admitted (OR for admission = 0.15 [9% confidence interval, 0.13-0.17]). CONCLUSION: The use of an EP-staffed telemedicine service provided to SNF residents was associated with a significantly lower rate of hospital admissions compared to the usual ED-based care for a similarly aged population of SNF residents. Providing SNF-based care by EPs could decrease costs associated with hospital-based care and risks associated with hospitalization, including cognitive and functional decline, nosocomial infections, and falls.

A Method for Segmenting Medicare Expenditures to Inform Cost Effective Care Delivery for Older Adults.

INTRODUCTION: Faced with growing populations of older, medically complex patients, health systems are now incentivized to deliver cost-effective, high-value care. We evaluated a new method that builds upon existing Medicare spending concentration studies to further segment these expenditures, revealing use patterns to inform care redesign. METHODS: We obtained monthly Medicare expenditure data and derived baseline comparison data using typical methods for identifying a yearly high-cost subpopulation. We then applied the new methodology, ordering monthly patient expenditures from highest to lowest to more extensively segment the baseline data. Our evaluation examined the following within the new more extensive segmentation: monthly expenditure distribution, corresponding patient counts, and occupancy of specific patient subgroups within the extended segmentation of baseline data. RESULTS: Compared to the baseline data, we found further spending concentration, with 16.7 percent of high-cost patients being responsible for about two-thirds of baseline expenditures. The remaining 83.3 percent of the high-cost subpopulation exhibited lower spending, collectively accounting for about one third of baseline expenditures. Additionally, we found that unique patient subgroups occupied different segments over time, with specific subgroups comprising 8.3 percent of the study subpopulation patients migrating into and out of each highest spending segment, accounting for almost half of monthly baseline expenditures. CONCLUSIONS: With monthly health care expenditures concentrated among small numbers of migrating patients, our evaluation suggested potential cost-effectiveness in tiered care delivery models, where small subgroups receive direct, active care interactions, while the remainder experience surveillance-level care, designed to both address ongoing medical needs and to detect emergent migration.

The effect of anomalous utterances on language production.

Speakers sometimes encounter utterances that have anomalous linguistic features. Are such features registered during comprehension and transferred to speakers' production systems? In two experiments, we explored these questions. In a syntactic-priming paradigm, speakers heard prime sentences with novel or intransitive verbs as part of prepositional-dative or double-object structures (e.g., The chef munded the cup to the burglar or The doctor existed the pirate the balloon). Speakers then described target pictures eliciting the same structures, using the same or different novel or intransitive verbs. Speakers overall described targets with the same structures as the primes (abstract syntactic priming), but more so when the primes and targets had the same novel or intransitive verbs (a lexical boost), an effect that was only observed when the novel words served as the verbs in both the prime and target sentences. Such a lexical boost could only manifest if speakers formed associations between the verbs and structures in the primes during comprehension, and if these associations were then transferred to their production systems. We thus showed that anomalous utterance features are not ignored but persist (at least) in speakers' immediately subsequent production.

The roles of feedback and working memory in children's reference production.

Children's communicative perspective-taking ability was investigated in a sample of 62 5- and 6-year-olds using a spoken production referential communication task in which speakers identify target objects for listeners. We assessed whether children would make use of non-verbal negative feedback to improve their future production of referring expressions, which involve words or phrases that function in discourse to identify individual objects. We also examined whether the use of such feedback is related to cognitive resources. Results indicated that children who were given feedback from addressees produced more informative referring expressions than those who received no feedback. Furthermore, this tendency to effectively make use of feedback was greatest among children with higher working memory. These findings demonstrate that feedback can facilitate learning about referential communication and suggest that one limitation in using such feedback is the ability to hold it in mind so that it can be used to guide the production of referring expressions.

The cognitive mechanisms underlying perspective taking between conversational partners: evidence from speakers with Alzheimer׳s disease.

Successful communication requires speakers to consider their listeners׳ perspectives. Little is known about how this ability changes in Alzheimer׳s Disease (AD) although such knowledge could reveal the cognitive mechanisms fundamental to perspective-taking ability, and reveal which cognitive deficits are fundamental to communication disorders in AD. Patients with mild to moderate AD and age and education matched controls were tested in a communicative perspective-taking task, and on measures of executive control, general cognitive functioning, and lexical retrieval. Patients׳ ability to perform the perspective-taking task was significantly correlated with performance on measures of general cognitive functioning, visual scanning and construction, response conflict and attention. Measures of lexical retrieval tended not to be correlated with performance on the communication task with one exception: semantic but not letter fluency predicted a derived score of perspective-taking ability. These findings broaden our understanding of the cognitive mechanisms underlying perspective taking, and suggest that impairments in perspective taking in AD occur during utterance planning, and at a relatively early processing stage which involves rapid visual scanning and problem solving, rather than during retrieval of lexical items needed to speak. More broadly, these data reveal executive function and semantic deficits, but not problems with lexical retrieval, as more fundamental to the basis of cognitive changes associated with AD.

Individual differences in speakers' perspective taking: the roles of executive control and working memory.

Both speaking and listening require taking into account the perspective of one's communicative partner. Is perspective taking a domain-specific process internal to the language production and comprehension systems? Or is it a domain-general process regulated by the same mechanisms that are used to regulate other forms of behavior? Past research has shown that listeners' perspective taking is at least partially regulated by inhibitory control and working memory (WM), suggesting that it may be best thought of in domain-general terms. The present experiment was designed to explore individual differences in nonlinguistic executive functioning in order to assess whether domain-general mechanisms help regulate speakers' perspective-taking behavior. A group of 60 speakers participated in a referential communication task and in tasks measuring WM and executive control (EC). The results revealed that WM and EC were both predictive of the speakers' perspective taking, suggesting that perspective taking may be regulated by domain-general mechanisms.