Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

OBJECTIVE: Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. DATA SOURCE: Medicare Fee-for-Service Data, 2018. STUDY DESIGN: We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. DATA EXTRACTION METHODS: We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. PRINCIPAL FINDINGS: In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. CONCLUSIONS: There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

The characteristics and practice proficiency of nurse practitioners who care for older adults.

Roughly 54 million Americans are 65 years of age or older. Given the number of comorbid diseases reported in older adults, healthcare tailored to the specific needs of this population is imperative. Nurse practitioners (NPs) are uniquely positioned to provide care to older adults; yet little is known about the geriatric-oriented NP workforce. In this study, four professional organizations distributed a survey link to their members who were queried on their demographic, employment, and practice characteristics; one organization's members responded to a previous survey, providing two time points for comparison. Compared with 2016 respondents, there was minimal growth in diversity, fewer who practice in suburban or rural areas, and restrictions on clinical education related to the ongoing pandemic. The findings from this study should alert policymakers of the need to address the development of an adequate workforce of clinicians who specialize in geriatrics.

The Alter Program: A Nurse-Led, Dementia-Friendly Program for African American Faith Communities and Families Living With Dementia.

Dementia is a stigmatizing condition requiring enhanced awareness and understanding. Churches are a trusted source of support for African Americans, a demographic disproportionately affected by dementia. However, many African American churches are not equipped with the knowledge and means to provide safe environments, resources, and spiritual and social support for their parishioners living with dementia and their families. This protocol is written to detail the design and implementation of a nurse-led, dementia-friendly congregation program, Alter. The Alter program was developed to increase dementia awareness, develop a supportive, faith-based dementia-friendly infrastructure, and create a community supporting the well-being of African Americans living with dementia and their families. Engagement in this program aims to improve brain health status of older adults, improve physical and mental health outcomes, reduce dementia stigma, and enhance personal agency. Improved outcomes for persons living with dementia translate into lower use of acute and emergency services due to more stability in community care. It is expected that the churches participating in this program will be recognized by their community as a great resource for dementia information and support. The long-term goal of the Alter program is to be widely adapted in various health systems to reduce health disparities associated with dementia in the African American community.

Experiences of Black American Dementia Caregivers During the COVID-19 Pandemic.

Dementia caregivers are responsible for the daily care and management of individuals who are among the most vulnerable to the serious consequences of COVID-19. This qualitative study explores the experience of Black dementia caregivers during the COVID-19 pandemic in the United States. Nineteen Black dementia caregivers were recruited to participate in semi-structured focus groups held in April 2021. Four overarching themes were constructed during analysis: social isolation, decreased well-being, the good and bad of telehealth, and challenges fulfilling health care needs. The results indicate the experience of Black dementia caregivers overlaps with existing literature on the experiences of dementia caregivers of other races during COVID-19. These results can assist in addressing the specific needs and improving the experiences of dementia caregivers in current and future public health crises.

The Academic-Practice Partnership: Educating Future Nurses.

Strong partnerships are essential to lead the innovative change needed to prepare future nurses who demonstrate quality and safety competence. Successful models involve senior leadership, a shared vision, mutual goals, mutual respect, and an access to shared knowledge. The academic-practice partnership between a private university-based school of nursing and its affiliated health care system facilitated the implementation of a new Accelerated Bachelor of Science in Nursing (ABSN) program track to provide a seamless education to practice pathway for graduate nurses educated with quality and safety competencies and to meet the workforce demands of the health care system. The academic-practice model is based on the Guiding Principles outlined by the American Association of Colleges of Nursing-American Organization of Nurse Leaders (AACN-AONL) Task Force on Academic Practice Partnerships. As a result of this partnership, 84% of the program's graduates accepted a position with the health care partner as an advanced medical-surgical nurse, and student outcomes in quality and safety competencies were encouraging.

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system.

OBJECTIVES: To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up. DESIGN: Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package. SETTING: Three academic emergency departments that each implemented EQUIPPED over three successive years. PARTICIPANTS: Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects. INTERVENTION(S): EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge. MAIN OUTCOME MEASURE(S): Implementation process components assembled through successive implementation. RESULTS: Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model. CONCLUSIONS: Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.

Patient and caregiver outcomes at the integrated memory care clinic.

The purpose of this longitudinal cohort study was to explore the outcomes of persons living with dementia (PLWD) and their caregivers during their first 9 months at the Integrated Memory Care Clinic (IMCC). IMCC advanced practice registered nurses provide dementia care and primary care simultaneously and continuously to PLWD until institutionalization. Changes were examined in caregivers' psychological well-being (perceived stress, depressive symptoms, caregiver burden, and anxiety) and health status and in PLWDs' quality of life and neuropsychiatric symptoms. Data were collected at baseline, then 3 and 6 months post-baseline. Forty-two caregivers completed all 3 assessments. Most variables remained unchanged. Statistically significant improvements in 5 sub-scales of the Neuropsychiatric Inventory were observed: caregivers' distress regarding their PLWDs' delusions and anxiety, and PLWDs' severity of delusions, depression, and total symptom severity. Further testing of the IMCC is required, including in quasi-experimental studies, to determine its efficacy.

Creating New Models of Care Through Academic-Clinical Partnership.

There are many documented instances of academic nurses creating faculty practice opportunities to support their faculty and students. Fewer articles have been published about the value of these shared models to clinical partners. Advanced practice nurses from the academic and clinical departments at Emory University and Emory Healthcare codesigned a new model of care that addresses the health system's need to achieve better experiences and health outcomes for patients living with dementia. The nurse-led clinical practice, called Integrated Memory Care Clinic, is an innovative example of joint planning and design by academic and clinical nurses to advance the teaching, practice, and research mission of the School of Nursing as well as help satisfy the health system's ability to achieve the Triple Aim.

Chronic Stress, Social Isolation, and Perceived Loneliness in Dementia Caregivers.

Caregivers of individuals with dementia are at risk for chronic stress and social isolation. These exogenous factors may lead to perceived stress and perceived loneliness-psychosocial endogenous (subjective) elements of caregiving experience. Chronic stress and perceived loneliness may disrupt neuroendocrine and neuroimmunological regulation, creating low-grade systemic inflammation, promoting proinflammatory gene expression, and expediting cellular aging (endogenous physiological factors). These disturbances may enhance caregivers' risk for chronic conditions of inflammatory pathogenesis. Thus, caregivers' perceived stress and perceived loneliness may form a symptom cluster that can serve as a marker of risks for physical and mental illness. Due to the overwhelming reliance on family caregivers within the increasing population of individuals with dementia, it is essential that clinicians inquire about caregivers' perceived stress and perceived loneliness, are competent in supporting and educating caregivers, and are knowledgeable about specific resources for caregivers. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 36-43.].

The benefits of being a senior mentor: Cultivating resilience through the mentorship of health professions students.

Senior Mentor Programs (SMPs) pair community-dwelling older adults with health professions students to facilitate knowledge, improve communication skills, and promote positive attitudes regarding the aging process. Although evidence exists that SMPs meet these goals, the programs' psychosocial impact on the senior mentors remains unexplored. The current study assessed 101 mostly female (64.4%) senior mentors (M age = 77.6) pre- and postprogram. Although mentors had no change in the amount of perceived ageism experienced or expectation of experiencing ageism, their concern/anxiety over ageism significantly decreased from pre- (M = 21.58) to posttest (M = 20.19). Qualitative thematic analysis indicated meaningfulness of program and scheduling difficulties as prevalent themes. Mentors who reported less concern about ageism following the program were more likely to have experienced ageism in the year prior to the program and to attend religious services more often, another potential intergenerational contact. These results highlight possible benefits of mentor service for older adults.

Feasibility of a Low-Cost, Interactive Gaming System to Assess Balance in Older Women.

The use of low-cost interactive game technology for balance rehabilitation has become more popular recently, with generally good outcomes. Very little research has been undertaken to determine whether this technology is appropriate for balance assessment. The Wii balance board has good reliability and is comparable to a research-grade force plate; however, recent studies examining the relationship between Wii Fit games and measures of balance and mobility demonstrate conflicting findings. This study found that the Wii Fit was feasible for community-dwelling older women to safely use the balance board and quickly learn the Wii Fit games. The Ski Slalom game scores were strongly correlated with several balance and mobility measures, whereas Table Tilt game scores were not. Based on these findings, the Ski Slalom game may have utility in the evaluation of balance problems in community-dwelling older adults.

Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients.

Gait speed assessment is a rapid, simple and objective measure for predicting risk of unfavorable outcomes which may provide better prognostic and reliable information than existing geriatric ED (Emergency Department) screening tools. This descriptive pilot project was designed to determine feasibility of implementing gait speed screening into routine nursing practice by objectively identifying patients with sub-optimal gait speeds. Participants included community-dwelling adults 65 years and older with plans for discharge following ED treatment. Patients with a gait speed <1.0 m/s were identified as "high-risk" for an adverse event, and referred to the ED social worker for individualized resources prior to discharge. Thirty-five patients were screened and nurse initiated gait speed screens were completed 60% of the time. This project demonstrates ED gait speed screening may be feasible. Implications for practice should consider incorporating gait speed screening into routine nursing assessment to improve provider ED decision-making and disposition planning.

Teaching the teachers: faculty development in inter-professional education.

AIMS: The purpose of this study is to evaluate changes in self-concept for the knowledge, skills and attitudes toward inter-professional teamwork of facilitators who participated in training and an inter-professional team training event. BACKGROUND: Inter-professional education requires dedicated and educated faculty. METHODS: A pretest posttest quasi-experimental design was used for the evaluation. Fifty-three facilitators were asked to complete pre-post questionnaires to measure inter-professional team self-concept (IPTSC), assessing self-concept for the knowledge, skills, and attitudes required for performing in an inter-professional team. RESULTS: Post-session scores on inter-professional team knowledge, skills and attitudes were significantly higher (F(1, 31) = 5.59, p = .02). CONCLUSION: A facilitator development course and participation in the teaching event had a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork.

Caregiving While Black: A Novel, Online Culturally Tailored Psychoeducation Course for Black Dementia Caregivers.

BACKGROUND AND OBJECTIVES: Psychoeducation interventions using distance learning modalities to engage caregivers in active learning environments have demonstrated benefits in enhancing caregiving mastery. However, few of these programs have been specifically adapted to develop mastery in Black caregivers. RESEARCH DESIGN AND METHODS: A multimethod approach was carried out to assess Caregiving While Black (CWB), including pre-post surveys and in-depth interviews. This psychoeducation course addresses the cultural realities of caring for a person living with dementia as a Black American. Caregivers engaged in online asynchronous education related to healthcare navigation, home life management, and self-care. Primary (caregiving mastery) and secondary outcomes (anxiety, depression, perceived stress, burden, perceived ability to manage behavioral and psychological symptoms) were assessed at baseline and post-course (10 weeks). RESULTS: Thirty-two Black caregivers from across the United States completed the course within the allotted time frame. Paired sample t test analyses revealed significant reductions in caregiver burden and role strain. Caregiver mastery from baseline to completion increased by 0.45 points with an effect size of 0.26 (Cohen's d). Twenty-nine caregivers participated in an optional post-course interview, and thematic analysis led to the construction of 5 overarching themes: Comfortability with a Culturally Tailored Course; Experiences Navigating the Course Platform; Utility of Course Resources; Time as a Barrier and Facilitator; Familial and Community Engagement. DISCUSSION AND IMPLICATIONS: Pilot findings convey a need to continue creating and receiving feedback on culturally tailored psychoeducation programs for dementia caregivers. The next steps include applying results to fuel the success of the next iteration of CWB.

Impact of electronic information exchange on repeat imaging during 30-day readmissions among Medicare beneficiaries.

OBJECTIVES: We examined the association between electronic health information sharing and repeat imaging in readmissions among older adults with and without Alzheimer disease (AD). STUDY DESIGN: Cohort study using national Medicare data. METHODS: Among Medicare beneficiaries with 30-day readmissions in 2018, we examined repeat imaging on the same body system during the readmission. This was evaluated between fragmented and nonfragmented (same-hospital) readmissions and across categories of electronic information sharing via health information exchanges (HIEs) in fragmented readmissions: admission and readmission hospitals share the same HIE, admission and readmission hospitals participate in different HIEs, one or both do not participate in HIE, or HIE data missing. This relationship was evaluated using unadjusted and adjusted logistic regression. RESULTS: Overall, 14.3% of beneficiaries experienced repeat imaging during their readmission. Compared with nonfragmented readmissions, fragmented readmissions were associated with 5% higher odds of repeat imaging on the same body system in older adults without AD. This was not mitigated by the presence of electronic information sharing: Fragmented readmissions to hospitals that shared an HIE had 6% higher odds of repeat imaging (adjusted OR, 1.06; 95% CI, 1.00-1.13). There was no difference seen in the odds of repeat imaging for older adults with AD. CONCLUSIONS: Despite substantial investment, HIEs as currently deployed and used are not associated with decreased odds of repeat imaging in readmissions.

Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries.

Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.

Cognitive assessment in primary care: Practical recommendations.

ABSTRACT: Primary care clinicians play a critical role in both the identification and management of cognitive impairment due to common diseases. Primary care practices should incorporate feasible, reliable, and helpful tools into existing workflow to recognize and support people living with dementia and their care partners.

Ambulance use and subsequent fragmented hospital readmission among older adults.

BACKGROUND: Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%-25% of readmissions. Mode of transport to the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions. METHODS: We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics. RESULTS: The study included 1,186,600 30-day readmissions. Of these, 46.8% (n = 555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations. CONCLUSIONS: Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient-, hospital-, and system-level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.

Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults.

Importance: When an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals. Objective: To determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries. Design, Setting, and Participants: This cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022. Exposures: Same hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals. Main Outcomes and Measures: The main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions. Results: The cohort included 275 189 admission-readmission pairs, representing 268 768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P < .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.

The Impact of Health Information Exchange on In-Hospital and Postdischarge Mortality in Older Adults with Alzheimer Disease Readmitted to a Different Hospital Within 30 Days of Discharge: Cohort Study of Medicare Beneficiaries.

BACKGROUND: Although electronic health information sharing is expanding nationally, it is unclear whether electronic health information sharing improves patient outcomes, particularly for patients who are at the highest risk of communication challenges, such as older adults with Alzheimer disease. OBJECTIVE: To determine the association between hospital-level health information exchange (HIE) participation and in-hospital or postdischarge mortality among Medicare beneficiaries with Alzheimer disease or 30-day readmissions to a different hospital following an admission for one of several common conditions. METHODS: This was a cohort study of Medicare beneficiaries with Alzheimer disease who had one or more 30-day readmissions in 2018 following an initial admission for select Hospital Readmission Reduction Program conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia) or common reasons for hospitalization among older adults with Alzheimer disease (dehydration, syncope, urinary tract infection, or behavioral issues). Using unadjusted and adjusted logistic regression, we examined the association between electronic information sharing and in-hospital mortality during the readmission or mortality in the 30 days following the readmission. RESULTS: A total of 28,946 admission-readmission pairs were included. Beneficiaries with same-hospital readmissions were older (aged 81.1, SD 8.6 years) than beneficiaries with readmissions to different hospitals (age range 79.8-80.3 years, P<.001). Compared to admissions and readmissions to the same hospital, beneficiaries who had a readmission to a different hospital that shared an HIE with the admission hospital had 39% lower odds of dying during the readmission (adjusted odds ratio [AOR] 0.61, 95% CI 0.39-0.95). There were no differences in in-hospital mortality observed for admission-readmission pairs to different hospitals that participated in different HIEs (AOR 1.02, 95% CI 0.82-1.28) or to different hospitals where one or both hospitals did not participate in HIE (AOR 1.25, 95% CI 0.93-1.68), and there was no association between information sharing and postdischarge mortality. CONCLUSIONS: These results indicate that information sharing between unrelated hospitals via a shared HIE may be associated with lower in-hospital, but not postdischarge, mortality for older adults with Alzheimer disease. In-hospital mortality during a readmission to a different hospital was higher if the admission and readmission hospitals participated in different HIEs or if one or both hospitals did not participate in an HIE. Limitations of this analysis include that HIE participation was measured at the hospital level, rather than at the provider level. This study provides some evidence that HIEs can improve care for vulnerable populations receiving acute care from different hospitals.