Effects of Home-Based Primary Care on Hospital Use for High-Need Medicare Patients: an Observational Study.

BACKGROUND: High-need, high-cost Medicare patients can have difficulties accessing office-based primary care. Home-based primary care (HBPC) can reduce access barriers and allow a clinician to obtain valuable information not obtained during office visit, possibly leading to reductions in hospital use. OBJECTIVE: To determine whether HBPC for high-need, high-cost patients reduces hospitalizations and Medicare inpatient expenditures. DESIGN: We conducted a matched retrospective cohort study using a difference-in-differences analysis to examine patients 2 years before and 2 years after their first home visit (HBPC group). PARTICIPANTS: The study included high-need, high-cost fee-for-service Medicare patients without prior HBPC use, of which 55,303 were new HBPC recipients and 156,142 were matched comparison patients. INTERVENTION: Receipt of at least two HBPC visits and, within 6 months of the index HBPC visit, a majority of a patient's primary care visits in the home. MAIN MEASURES: Total and potentially avoidable hospitalizations and Medicare inpatient expenditures. KEY RESULTS: HBPC reduced total hospitalization rates, but the marginal effects were not statistically significant: a reduction of 11 total hospitalizations per 1000 patients in the first year (- 0.6%, p = 0.19) and 14 in the second year (- 0.7%, p = 0.16). However, HBPC reduced potentially avoidable hospitalization rates in the second year. The estimated marginal effect was a reduction of 6 potentially avoidable hospitalizations per 1000 patients in the first year (- 1.6%, p = 0.16) and 11 in the second (- 3.1%, p = 0.01). The estimated effect of HBPC was a small decrease in inpatient expenditures of $24 per patient per month (- 1.1%, p = 0.10) in the first year and $0 (0.0%, p = 0.99) in the second. CONCLUSIONS: After high-need, high-cost patients started receiving HBPC, they did not experience fewer total hospitalizations or lower inpatient spending but may have had lower rates of potentially avoidable hospitalizations after 2 years.

The Minimum Data Set 3.0 Cognitive Function Scale.

BACKGROUND: The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents. Not all residents are able to complete the BIMS and are consequently assessed by staff. We designed a Cognitive Function Scale (CFS) integrating self-report and staff-report data and present evidence of the scale's construct validity. DESIGN: A retrospective cohort study. SUBJECTS: The subjects consisted of 3 cohorts: (1) long-stay NH residents (N=941,077) and (2) new admissions (N=2,066,580) during 2011-2012, and (3) residents with the older MDS 2.0 assessment in 2010 and the newer MDS 3.0 assessment (n=688,511). MEASURES: MDS 3.0 items were used to create a single, integrated 4-category hierarchical CFS that was compared with residents' prior MDS 2.0 Cognitive Performance Scale scores and other concurrent MDS 3.0 measures of construct validity. RESULTS: The new CFS suggests that 28% of the long-stay cohort in 2011-2012 were cognitively intact, 22% were mildly impaired, 33% were moderately impaired, and 17% were severely impaired. For the admission cohort, the CFS noted 56% as cognitively intact, 23% as mildly impaired, 17% as moderately impaired, and 4% as severely impaired. The CFS corresponded closely with residents' prior MDS 2.0 Cognitive Performance Scale scores and with performance of Activities of Daily Living, and nurses' judgments of function and behavior in both the admission and long-stay cohorts. CONCLUSIONS: The new CFS is valuable to researchers as it provides a single, integrated measure of NH residents' cognitive function, regardless of the mode of assessment.

A qualitative study of choosing home health care after hospitalization: the unintended consequences of 'patient choice' requirements.

BACKGROUND: Although hospitals are increasingly held accountable for patients' post-discharge outcomes, giving them incentive to help patients choose high-performing home health agencies, little is known about how quality reports inform decision making. OBJECTIVE: We aimed to learn how quality reports are used when choosing home care in one northeast state (Rhode Island) . DESIGN: The study consisted of focus groups with home health consumers and structured interviews with hospital case managers. PARTICIPANTS: Thirteen consumers and 28 case managers from five hospitals participated in the study. APPROACH: We identified key themes and illustrative quotes by audiotaping each session, and then three independent reviewers conducted repeated examination and content analysis. KEY RESULTS: No participants were aware of existing state or Medicare home health agency public reports. Case managers provided agency lists to consumers, who routinely asked case managers to tell them which agencies to choose or which were best; but case managers felt unable to directly respond to consumers' requests for help in making the choice, because they did not have additional information to provide and because they feared violating federal laws requiring freedom of patient choice. Case managers also felt that there was little difference in agency quality, although they acknowledged they might not be aware of problems related to post-hospital care. CONCLUSIONS: Home health consumers and hospital case managers were unaware of public reports about home health quality, which limited consumers' ability to make informed decisions and case managers' ability to assist them in that decision-making process. Case managers were otherwise prohibited from recommending specific providers to patients and viewed the 'patient choice' laws as restricting their ability to respond to patients' requests for help in choosing home health agencies. Public reports can be marketed as tools that case managers can use to help patients differentiate among providers, while supporting patient autonomy.

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care.

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.

Does home- and community-based care affect nursing home use?

A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.

Whole-body vibration therapy for osteoporosis: state of the science.

Clinical guidelines for osteoporosis recommend dietary and pharmacologic interventions and weight-bearing exercise to prevent bone fractures. These interventions sometimes have low adherence and can cause adverse effects. A proposed alternative or adjunctive treatment is whole-body vibration therapy (WBV), in which energy produced by a forced oscillation is transferred to an individual from a mechanical vibration platform. Whole-body vibration platforms are not approved by the U.S. Food and Drug Administration for medical purposes. This review provides a broad overview of important issues related to WBV therapy for prevention and treatment of osteoporosis. Relying on key informants and a search of the gray and published literature from January 2000 to August 2011, the investigators found that the designs of WBV platforms and protocols for their use vary widely. The optimal target population for the therapy is not defined. Although WBV has some theoretical advantages, key informants have voiced several concerns, including uncertain safety and potential consumer confusion between low-intensity vibration platforms intended for osteoporosis therapy and high-intensity platforms intended for exercise. Finally, the scant literature did not establish whether WBV therapy leads to clinically important increases in bone mineral density or reduces risk for fracture.

The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being.

OBJECTIVE: Quantify the effects of the COVID-19 pandemic on nursing home resident well-being. DESIGN: Quantitative analysis of resident-level assessment data. SETTING AND PARTICIPANTS: Long-stay residents living in Connecticut nursing homes. METHODS: We used Minimum Data Set assessments to measure nursing home resident outcomes observed in each week between March and July 2020 for long-stay residents (eg, those in the nursing home for at least 100 days) who lived in a nursing home at the beginning of the pandemic. We compared outcomes to those observed at the beginning of the pandemic, controlling for both resident characteristics and patterns for outcomes observed in 2017-2019. RESULTS: We found that nursing home resident outcomes worsened on a broad array of measures. The prevalence of depressive symptoms increased by 6 percentage points relative to before the pandemic in the beginning of March-representing a 15% increase. The share of residents with unplanned substantial weight loss also increased by 6 percentage points relative to the beginning of March-representing a 150% increase. We also found significant increases in episodes of incontinence (4 percentage points) and significant reductions in cognitive functioning. Our findings suggest that loneliness and isolation play an important role. Though unplanned substantial weight loss was greatest for those who contracted COVID-19 (about 10% of residents observed in each week), residents who did not contract COVID-19 also physically deteriorated (about 7.5% of residents in each week). CONCLUSIONS AND IMPLICATIONS: These analyses show that the pandemic had substantial impacts on nursing home residents beyond what can be quantified by cases and deaths, adversely affecting the physical and emotional well-being of residents. Future policy changes to limit the spread of COVID-19 or other infectious disease outbreaks should consider any additional costs beyond the direct effects of morbidity and mortality due to COVID-19.

Functional Improvement Among Short-Stay Nursing Home Residents in the MDS 3.0.

OBJECTIVES: To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0. DESIGN: Retrospective analysis of MDS admission and discharge assessments. SETTING: Nursing homes from July 1, 2011, to June 30, 2012. PARTICIPANTS: New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less. MEASUREMENTS: ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge. RESULTS: The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home residents with conditions such as cognitive impairment, delirium, dementia, heart failure, and stroke showed less improvement in ADL performance during their stay. CONCLUSION: The discharge assessment data in the MDS 3.0 provide new information to researchers and providers to examine and track ADL performance. Nursing homes can identify and track patients who require more intensive therapies or targeted interventions to achieve functional improvement during their stay. Future research can examine facility-level measures to better understand how ADL improvement varies across facilities.

Using Qualitative Methods to Create a Home Health Web Application User Interface for Patients with Low Computer Proficiency.

INTRODUCTION: Despite the investment in public reporting for a number of healthcare settings, evidence indicates that consumers do not routinely use available data to select providers. This suggests that existing reports do not adequately incorporate recommendations for consumer-facing reports or web applications. METHODS: Healthcentric Advisors and Brown University undertook a multi-phased approach to create a consumer-facing home health web application in Rhode Island. This included reviewing the evidence base review to identify design recommendations and then creating a paper prototype and wireframe. We performed qualitative research to iteratively test our proposed user interface with two user groups, home health consumers and hospital case managers, refining our design to create the final web application. RESULTS: To test our prototype, we conducted two focus groups, with a total of 13 consumers, and 28 case manager interviews. Both user groups responded favorably to the prototype, with the majority commenting that they felt this type of tool would be useful. Case managers suggested revisions to ensure the application conformed to laws requiring Medicare patients to have the freedom to choose among providers and could be incorporated into hospital workflow. After incorporating changes and creating the wireframe, we conducted usability testing interviews with 14 home health consumers and six hospital case managers. We found that consumers needed prompting to navigate through the wireframe; they demonstrated confusion through both their words and body language. As a result, we modified the web application's sequence, navigation, and function to provide additional instructions and prompts. DISCUSSION: Although we designed our web application for low literacy and low health literacy, using recommendations from the evidence base, we overestimated the extent to which older adults were familiar with using computers. Some of our key learnings and recommendations run counter to general web design principles, leading us to believe that such guidelines need to be adapted for this user group. As web applications proliferate, it is important to ensure those who are most vulnerable-who have the least knowledge and the lowest literacy, health literacy, and computer proficiency-can access, understand, and use them. CONCLUSIONS: In order for the investment in public reporting to produce value, consumer-facing web applications need to be designed to address end users' unique strengths and limitations. Our findings may help others to build consumer-facing tools or technology targeted to a predominantly older population. We encourage others designing consumer-facing web technologies to critically evaluate their assumptions about user interface design, particularly if they are designing tools for older adults, and to test products with their end users.

Finding Gertrude: The resident's voice in Minimum Data Set 3.0.

PURPOSE: The new Minimum Data Set 3.0 was designed to improve the assessment process by requiring nursing home (NH) staff to attempt to interview residents with scripted questions to assess subjective states such as pain, mood, and cognitive functioning. Although the case has been made that resident self-report is important, it is unknown whether facilities are doing so in practice. We examined the frequency of attempts to interview residents to elucidate the types of residents able to be interviewed about their clinical conditions and facility characteristics related to the likelihood of attempt. DESIGN AND METHODS: Data come from Minimum Data Set 3.0 annual assessments for 757,044 residents in 15,030 NHs during 2011-2012 and the 2011 Online Survey, Certification, and Reporting database. Hierarchical generalized linear models were conducted to test the association between resident and facility characteristics and the attempt rate of resident interview for 3 clinical domains (cognition, mood, and pain). RESULTS: Over 83% of long-stay residents attempted all 3 self-report clinical items. The rates of attempt for mood, cognition, and pain were 88%, 89%, and 92%, respectively. Results from hierarchical generalized linear models suggest that certain resident characteristics are related to the likelihood of participating in interviews, in particular neither having a diagnosis of dementia nor cognitive impairment, not exhibiting signs of delirium, nor a documented prognosis of 6 months or less to live. Residents in smaller, chain-affiliated nursing homes with fewer Medicare residents and fewer assessments per administrative nurse and registered nurse were more likely to attempt the resident interview items. IMPLICATIONS: This article documents the high rate of NH residents' participation in interviews about their clinical states. Furthermore, we identify types of residents for whom additional investigation into ways to achieve higher rates of participation is required and facility resources that are related to the likelihood of high rates of attempt.

Hospitalization of elderly Medicaid long-term care users who transition from nursing homes.

OBJECTIVES: To compare hospitalizations of dually eligible older adults who had an extended Medicaid nursing home (NH) stay and transitioned out to receive Medicaid home- and community-based services (HCBS) with hospitalizations of those who remained in the NH. DESIGN: Retrospective matched cohort study using Medicaid and Medicare claims and NH assessment data. SETTING: Community (receiving Medicaid HCBS) or NH. PARTICIPANTS: Dually eligible fee-for-service beneficiaries aged 65 and older in Arkansas, Florida, Minnesota, New Mexico, Texas, Vermont, and Washington from 2003 to 2005. Individuals who had a Medicaid NH stay of at least 90 days and transitioned to Medicaid HCBS (N = 1,169) were matched to individuals who had a Medicaid NH stay of at least 90 days and remained in the NH (N = 1,169). MEASUREMENTS: Potentially preventable hospitalizations (defined according to ambulatory-care-sensitive conditions) and all hospitalizations were examined. RESULTS: Cox proportional hazards models were used to compare the risk of hospitalization between the groups, accounting for the differing time at risk and censoring. Being a NH transitioner increased the hazard of experiencing a potentially preventable hospitalization by 40% (95% confidence interval (CI) = 1.01-1.93) over remaining in the NH. NH transitioners had a 58% (95% CI = 1.32-1.91) greater risk of experiencing any type of hospitalization than NH stayers. CONCLUSION: Individuals who transitioned from the NH to HCBS had a greater risk of hospitalization. Most of the attention in long-term care transition programs has been focused on NH readmission, but programs encouraging NH transition should recognize that individuals may be at greater risk for hospitalization after returning to the community. Planning for the medical needs of individuals who transition from an extended NH stay may improve their posttransition outcomes.

The association between long-term care setting and potentially preventable hospitalizations among older dual eligibles.

OBJECTIVE: To compare the probability of experiencing a potentially preventable hospitalization (PPH) between older dual eligible Medicaid home and community-based service (HCBS) users and nursing home residents. DATA SOURCES: Three years of Medicaid and Medicare claims data (2003-2005) from seven states, linked to area characteristics from the Area Resource File. STUDY DESIGN: A primary diagnosis of an ambulatory care sensitive condition on the inpatient hospital claim was used to identify PPHs. We used inverse probability of treatment weighting to mitigate the potential selection of HCBS versus nursing home use. PRINCIPAL FINDINGS: The most frequent conditions accounting for PPHs were the same among the HCBS users and nursing home residents and included congestive heart failure, pneumonia, chronic obstructive pulmonary disease, urinary tract infection, and dehydration. Compared to nursing home residents, elderly HCBS users had an increased probability of experiencing both a PPH and a non-PPH. CONCLUSIONS: HCBS users' increased probability for potentially and non-PPHs suggests a need for more proactive integration of medical and long-term care.

Effect of long-term care use on Medicare and Medicaid expenditures for dual eligible and non-dual eligible elderly beneficiaries.

BACKGROUND: Dual eligible Medicare and Medicaid beneficiaries consume disproportionate shares of both programs. OBJECTIVES: To compare Medicare and Medicaid expenditures of elderly dual eligible beneficiaries with non-dual eligible beneficiaries based on their long-term care (LTC) use. RESEARCH DESIGN: Secondary analysis of linked MAX and Medicare data in seven states. SUBJECTS: Dual eligible adults (65+) receiving LTC in institutions, in the community, or not at all; and Medicare non-dual eligibles. MEASURES: Medicaid acute medical and LTC expenditures per beneficiary year, Medicare expenditures. RESULTS: Among dual eligibles and non-dual eligibles, the average number of diseases and case mix scores are higher for LTC users. Adjusting for case mix virtually eliminates the difference for medical costs, but not for LTC expenditures. Adjusting for LTC status reduces the difference in LTC costs, but increases the difference in medical costs. CONCLUSIONS: Efforts to control costs for dual eligibles should target those in LTC while better coordinating medical and LTC expenditures.

Diagnosed prevalence and health care expenditures of mental health disorders among dual eligible older people.

PURPOSE: Little is known about mental health disorders (MHDs) and their associated health care expenditures for the dual eligible elders across long-term care (LTC) settings. We estimated the 12-month diagnosed prevalence of MHDs among dual eligible older adults in LTC and non-LTC settings and calculated the average incremental effect of MHDs on medical care, LTC, and prescription drug expenditures across LTC settings. METHODS: Participants were fee-for-service dual eligible elderly beneficiaries from 7 states. We obtained their 2005 Medicare and Medicaid claims data and LTC program participation data from federal and state governments. We grouped beneficiaries into non-LTC, community LTC, and institutional LTC groups and identified enrollees with any of 5 MHDs (anxiety, bipolar, major depression, mild depression, and schizophrenia) using the International Classification of Diseases Ninth Revision codes associated with Medicare and Medicaid claims. We obtained medical care, LTC, and prescription drug expenditures from related claims. RESULTS: Thirteen percent of all dual eligible elderly beneficiaries had at least 1 MHD diagnosis in 2005. Beneficiaries in non-LTC group had the lowest 12-month prevalence rates but highest percentage increase in health care expenditures associated with MHDs. Institutional LTC residents had the highest prevalence rates but lowest percentage increase in expenditures. LTC expenditures were less affected by MHDs than medical and prescription drug expenditures. IMPLICATIONS: MHDs are prevalent among dual eligible older persons and are costly to the health care system. Policy makers need to focus on better MHD diagnosis among community-living elders and better understanding in treatment of MHDs in LTC settings.