Investigating the long-term consequences of adverse medical events among older adults.

OBJECTIVE: To investigate the long-term effect of medically serious adverse medical events (AMEs) among older adults. METHODS: We linked nationally representative survey and claims data from the Medicare Current Beneficiary Survey (1998-2004) with non-response files (1999-2005) and the Area Resource File, providing 12,541 beneficiaries with 428,373 person-months for analysis. Latent class analysis was used to assign severity status to episodes. Multinomial logistic regression was used to identify AME risk factors. The long-term consequences of AMEs on Medicare expenditures were examined by population average models. Survival analyses examined the long-term risk of death. RESULTS: Nearly 19% of participants experienced at least one AME, with 62% from outpatient claims. The risk of AMEs is greater among participants in poorer health, and increases with comorbidity and with impairment in performing activities of daily living or instrumental activities of daily living. Medicare expenditures during an AME episode increased sharply and remained higher than what would have otherwise been expected in quarters following an AME episode, and failed to return to pre-AME expenditure levels. Differences in survival rates were observable long after the AME episode concluded, with only 55% of the patients sustaining an AME surviving to the end of the study. In contrast, nearly 80% of those without an AME were estimated to have survived. CONCLUSIONS: The impacts of AMEs are observable over extended periods of time and are associated with considerable excess mortality and costs. Efforts to monitor and prevent AMEs in both acute care and outpatient settings are warranted.

Expanding access to gerontological education via distance learning: the Management of Aging Services Masters Program at UMass Boston.

This article describes the online Management of Aging Services Masters Program at the University of Massachusetts Boston and reports on a recent Program review. The Program has experienced rapid growth, evolving from seven matriculating students in 2003 to 108 in 2012. It has graduated 125 students and boasts a 78% completion rate. The authors describe the Program and report on faculty and student perceptions of performance. The Program demonstrates sound pedagogical practice for online education, incorporating techniques to foster community and encourage students and faculty interaction. Distance learning holds considerable promise for expanding access to gerontological education to reach future aging services professionals.

Medicaid Expansion and Racial and Ethnic Disparities in Access to Health Care: Applying the National Academy of Medicine Definition of Health Care Disparities.

Since 2014, 32 states implemented Medicaid expansion by removing the categorical criteria for childless adults and by expanding income eligibility to 138% of the federal poverty level (FPL) for all non-elderly adults. Previous studies found that the Affordable Care Act (ACA) Medicaid expansion improved rates of being insured, unmet needs for care due to cost, number of physician visits, and health status among low-income adults. However, a few recent studies focused on the expansion's effect on racial/ethnic disparities and used the National Academy of Medicine (NAM) disparity approach with a limited set of access measures. This quasi-experimental study examined the effect of Medicaid expansion on racial/ethnic disparities in access to health care for U.S. citizens aged 19 to 64 with income below 138% of the federal poverty line. The difference-in-differences model compared changes over time in 2 measures of insurance coverage and 8 measures of access to health care, using National Health Interview Survey (NHIS) data from 2010 to 2016. Analyses used the NAM definition of disparities. Medicaid expansion was associated with significant decreases in uninsured rates and increases in Medicaid coverage among all racial/ethnic groups. There were differences across racial/ethnic groups regarding which specific access measures improved. For delayed care and unmet need for care, decreases in racial/ethnic disparities were observed. After the ACA Medicaid expansion, most access outcomes improved for disadvantaged groups, but also for others, with the result that disparities were not significantly reduced.

The Effect of the Affordable Care Act Medicaid Expansion on Disparities in Access to Care and Health Status.

Before the Affordable Care Act Medicaid expansion, nonelderly childless adults were not generally eligible for Medicaid regardless of their income, and Hispanics had much higher uninsured rates than other racial/ethnic subgroups. We estimated difference-in-differences models on Behavioral Risk Factor Surveillance data (2011-2016) to estimate the impacts of Medicaid expansion on racial/ethnic disparities in insurance coverage, access to care, and health status in this vulnerable subpopulation. Uninsured rates among all poor childless adults declined by roughly 9 percentage points more in states that expanded Medicaid. While expansion also had favorable impacts on most access and health outcomes among Whites in expansion states, there were relatively few such impacts among Blacks and Hispanics. Through 2016, Affordable Care Act Medicaid expansion was more effective in improving access and health outcomes among White low-income childless adults than mitigating racial/ethnic disparities.

Agency and market area factors affecting home health agency supply changes.

OBJECTIVE: To use the natural experiment created by the Medicare interim payment system (IPS) to study supply change behavior of home health agencies (HHAs) in local market areas. DATA SOURCES: One hundred percent Medicare home health claims for 1996 and 1999, linked with Medicare Provider of Service and Denominator files, and the Area Resource File. STUDY DESIGN: Medicare home health care (HHC) claims data were used to distinguish HHAs that changed the local market supply of Medicare HHC by their market exit or by significant expansion or contraction of their geographic service area between 1996 and 1999 from other HHAs. Multinomial logit models were estimated to analyze how characteristics of agencies and the market areas in which they served were associated with these different agency-level supply changes. PRINCIPAL FINDINGS: Changes in local HHA supply stemming from geographic service area expansions and contractions rivaled those owing to agency closures and market entries. Agencies at greater risk of closure and service area contraction tended to be smaller, newer, freestanding agencies, operating with more visit-intensive practice styles in markets with more competitor agencies. Except for having much less visit-intensive practice styles, similar attributes characterized agencies that increased local supply through service area expansion. CONCLUSIONS: Supply changes by HHAs largely reflected rational market responses by agencies to significant changes in financial incentives associated with the Medicare IPS. Recently certified agencies were among the most dynamic providers. Supply changes were more likely among agencies operating in more competitive market environments.

Vulnerable populations at risk of potentially avoidable hospitalizations: the case of nursing home residents with Alzheimer's disease.

This study explores whether nursing home residents with Alzheimer's disease and related dementias (ADRD) are affected differently by facility-level risk factors of ambulatory care-sensitive (ACS) conditions, a measure of timely access to medical care. Three years of quarterly Medicaid reimbursement data from over 525 Massachusetts nursing homes were linked with four years of Medical Provider Analysis and Review hospital claims data and facility-level attribute data to investigate whether facility effects differed by resident ADRD status. The findings suggest that nursing home residents with ADRD are more likely to be hospitalized for certain ACS conditions, including gastroenteritis and kidney/ urinary tract infections. Availability of increased registered nurse staffing levels and on-site nurse practitioners appears to attenuate this risk. Although findings suggest that ACS hospitalization measures may represent a useful approach to monitoring nursing home care, additional effort is needed to understand the extent to which severity of illness and/or comorbidities affect the measurement of these hospitalizations.

Discretionary hospitalization of nursing home residents with and without Alzheimer's disease: a multilevel analysis.

UNLABELLED: This study analyzes facility variations in hospital admission rates of nursing home (NH) residents with and without Alzheimer's disease (AD) or related dementia with the aim of better understanding how facility-level contextual factors differentially affect hospitalization risks. METHOD: The sample population consists of 19,217 and 18,399 Medicaid residents with and without AD, respectively, from 546 NHs in Massachusetts between 1991 and 1993. Hospital use is measured as annual nonpsychiatric discretionary hospital admissions to short-term general hospitals. Multilevel estimation methods are used to obtain facility and market area parameter estimates. RESULTS: There was greater interfacility variation in discretionary hospital admission rates of AD residents than residents without AD, particularly among more vulnerable subgroups of AD residents. DISCUSSION: The findings underscore the importance of licensed nursing personnel in reducing discretionary hospitalizations among NH residents with AD.

Hospital choice of rural Medicare beneficiaries: patient, hospital attributes, and the patient-physician relationship.

OBJECTIVE: To examine how patient and hospital attributes and the patient-physician relationship influence hospital choice of rural Medicare beneficiaries. DATA SOURCES: Medicare Current Beneficiary Survey (MCBS), Health Care Financing Administration (HCFA) Provider of Services (POS) file, American Hospital Association (AHA) Annual Survey, and Medicare Hospital Service Area (HSA) files for 1994 and 1995. STUDY DESIGN: The study sample consisted of 1,702 hospitalizations of rural Medicare beneficiaries. McFadden's conditional logit model was used to analyze hospital choices of rural Medicare beneficiaries. The model included independent variables to control for patients' and hospitals' attributes and the distance to hospital alternatives. PRINCIPAL FINDINGS: The empirical results show strong preferences of aged patients for closer hospitals and those of greater scale and service capacity. Patients with complex acute medical conditions and those with more resources were more likely to bypass their closest rural hospitals. Beneficiaries were more likely to bypass their closest rural hospital if they had no regular physician, had a shorter patient-physician tie, were dissatisfied with the availability of health care, and had a longer travel time to their physician's office. CONCLUSIONS: The significant influences of patients' socioeconomic, health, and functional status, their satisfaction with and access to primary care, and their strong preferences for certain hospital attributes should inform federal program initiatives about the likely impacts of policy changes on hospital bypassing behavior.

Regional differences in functional status among the aged.

This study investigated regional differences in functional status among aged Medicare beneficiaries in the United States, and the degree to which population risk factors and certain geographic/environmental attributes of communities accounted for the regional differences. Four years of the Medicare Current Beneficiary Survey (1992-1995) were pooled together yielding 37,150 person-year observations of functional status for a sample of aged Medicare beneficiaries residing in the community or nursing homes. Multinomial logit models, estimated on a four-category functional status scale, produced strong empirical evidence of substantial regional differences in the prevalence of functional independence, functional limitations, IADL limitations, and ADL limitations, that could not be attributed to regional population composition, socio-demographic factors, lifestyle characteristics, and chronic medical conditions. Although such population risk factors accounted for much of the regional variations in functional status among older men, the notably higher prevalence of IADL and ADL limitations among older women residing in the Deep South could not be similarly attributed to such risk factors. Rather, the empirical results suggest that a significant portion of the harmful effects associated with residence in the Deep South among older women may be attributed to a higher prevalence of residence in counties characterized by lower population density and/or higher poverty concentration.

Variations in hospitalization rates among nursing home residents: the role of facility and market attributes.

PURPOSE: This study examined the contribution of facility-level and area market-level attributes to variations in hospitalization rates among nursing home residents. DESIGN AND METHODS: Three years (1991-1994) of state quarterly Medicaid case-mix reimbursement data from 527 nursing homes (NH) in Massachusetts were linked with Medicare Provider Analysis and Review hospital claims and nursing facility attribute data to produce a longitudinal, analytical file containing 72,319 person-quarter observations. Logistic regression models were used to estimate the influence of facility-level and market-level factors on hospital use, after controlling for individual-level resident attributes, including: NH diagnoses, resident-level quality of care indicators, and diagnostic cost grouping classification from previous hospital stays. RESULTS: Multivariate findings suggest that resident heterogeneity alone does not account for the wide variations in hospitalization rates across nursing homes. Instead, facility characteristics such as profit status, nurse staffing patterns, NH size, chain affiliation, and percentage of Medicaid and Medicare reimbursed days significantly influence NH residents' risk of hospitalization. Broader area market factors also appear to contribute to variations in hospitalization rates. IMPLICATIONS: Variations in hospitalization rates may reflect underutilization, as well as overutilization. Continued efforts toward identifying medically necessary hospitalizations are needed.

Risk of mortality and nursing home institutionalization after injury.

OBJECTIVES: To evaluate the effects of unintentional injuries on the risks of nursing home institutionalization and mortality in older adults. DESIGN: A retrospective analysis of data from the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. SETTING: Noninstitutionalized community residents. PARTICIPANTS: Older adult panel members (N = 12,031) with continuous Medicare eligibility not enrolled in managed care in a cohort starting between 1998 and 2001. MEASUREMENTS: Cox regression and competing risk survival models were estimated using time-varying injury-status dummy variables and control variables for outcomes measured as time until death and institutionalization, respectively. RESULTS: Almost 4% of persons were institutionalized, 15% died, 14% had a sentinel injury, and 3% had two or more minor nonsentinel injuries within 1-year period. Persons hospitalized for sentinel injury had elevated institutionalization and mortality risks during an injury episode and after the episode ended. Persons receiving outpatient treatment for sentinel injuries had elevated institutionalization risk during injury episodes (subhazard ratio [SHR] = 6.78, 95% confidence interval [CI] = 3.72-12.37) and elevated mortality risk after episodes (hazard ratio [HR] = 1.60, 95% CI = 1.28-2.00). Persons with multiple minor nonsentinel injuries within a year also had elevated mortality (HR = 1.56, 95% CI = 1.15-2.11) and institutionalization (SHR = 3.55, 95% CI = 2.25-5.67) risks. CONCLUSION: Mortality and institutionalization risks extend well beyond the acute episode of treatment for sentinel and repeated minor injuries. More research is needed on longer-term health outcomes of injury survivors to inform development of evidence-based quality-of-care indicators.

The effect of sentinel injury on Medicare expenditures over time.

OBJECTIVES: To examine the long-term effect of sentinel injury (unintentional injury involving serious health-related consequences) among older adults on Medicare expenditures. DESIGN: Secondary data analysis of the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare Beneficiaries. SETTING: Noninstitutionalized community dwellers. PARTICIPANTS: Older adults (N = 12,318) continuously enrolled in Medicare Fee-for-Service under Old Age Survivors Insurance Benefits surveyed between October 1998 and December 2004. MEASUREMENTS: Monthly total Medicare expenditures served as the dependent variable. Injury status (preinjury, injury episode, postinjury) was identified from Medicare claims and specified as a set of dummy variables. Injury episodes began with the first index injury claim identified and ended when no further injury claims were found within 180 days. Population-averaged models using generalized estimating equation techniques were estimated to explore changes in Medicare expenditures over time after adjusting for casemix differences. A case-crossover design was used to compare monthly Medicare expenditures before and after sentinel injury events. RESULTS: Fifteen percent of beneficiaries sustained at least one sentinel injury. Medicare expenditures increased sharply during sentinel injury episodes (ß = 1.703, P < .001) and remained at least 28% higher than would otherwise be expected for 27 uninterrupted months following injury. Additive Medicare expenditures associated with sentinel injury over 3 years were estimated at $28,885. CONCLUSION: Consequences of sentinel injury in older adults extend well beyond the period typically considered to be an acute injury episode. Better understanding of the long-term consequences of injury-related outcomes is needed to achieve public health goals of reducing injury and improving injury-related medical care.

Predictors of home healthcare nurse retention.

PURPOSE: To examine the level of job satisfaction and test a theoretical model of the direct and indirect effects of job satisfaction, and individual nurse and agency characteristics, on intent to stay and retention for home healthcare nurses. DESIGN: A descriptive correlation study of home healthcare nurses in six New England states. METHODS: Home healthcare nurse job satisfaction self-report data was collected with the HHNJS survey questionnaire & Retention Survey Questionnaire. FINDINGS: Based on a structural equation model, job tenure and job satisfaction were the strongest predictors of nurse retention. CONCLUSIONS: Understanding the variables associated with home healthcare nurse retention can help agencies retain nurses in a time of severe nurse shortages and increased patient demand. CLINICAL RELEVANCE: Predicted nursing shortages and increasing demand have made the retention of experienced, qualified nursing staff essential to assure access to high-quality home healthcare services in the future.

Employer retention strategies and their effect on nurses' job satisfaction and intent to stay.

Faced with a nursing shortage and anticipated increase in demand, home care agencies are implementing retention strategies with little knowledge of their effectiveness. The purpose of this study is to describe the strategies implemented and their effect on nurse job satisfaction and intention to leave. Data were collected from a random sample of 123 New England agencies during in-person interviews. Most agencies reported implementing multiple recruitment and retention strategies. Regression results suggest that the effects of employer retention strategy on nurses' intent to stay are the indirect result of its effects on job satisfaction. The only retention intervention that made a statistically significant difference in job satisfaction was shared governance, and no retention strategy directly affected nurses' intention to stay in their jobs.

Nursing home performance on select publicly reported quality indicators and resident risk of hospitalization: grappling with policy implications.

This study examines how resident risk of hospitalization varies in relation to facility performance on select quality indicators (QIs). Using a 15% sample, three years of Medicaid reimbursement data from over 525 nursing homes (NHs) were linked with four years of hospital claims data and facility-level data to investigate whether residents of NHs with worse (better) than expected performance on QIs experienced increased (decreased) risk of hospitalization. Logistic regression results indicate that variations in hospitalization risk among NH residents are explained in part by facility performance on QIs. Residents from NHs with more decubitus ulcers, with greater use of physical restraints, and with a higher than expected incidence of unexplained weight loss/gain experienced increased risk of hospitalization.

Home health and home care in Massachusetts after the Balanced Budget Act of 1997: implications of cost containment pressures for service authorizations.

This paper explores the response of the Massachusetts state-funded home care program for the elderly when its clients encountered barriers to the receipt of home health services because of HMO enrollment and the implementation of the Balanced Budget Act of 1997. Clients of three regional case management agencies serving the Massachusetts state home care program whose home care services were interrupted because of hospitalization between January 1 and April 30, 1999 and whose services were resumed after they returned home were studied. Detailed data are reported that show how the long-term personal assistance services provided through the state program were often complemented by temporary home health services after elders returned home. The multivariate analysis revealed that the authorization of state-funded personal care services was keyed to the status of home health aide services. After hospitalization, the presence of a home health aide reduced the likelihood of authorization of personal care. At final assessment, the situation was reversed, that is, the withdrawal of a home health aide increased the likelihood of authorization of personal care. The findings suggest that more restrictive Medicare reimbursement policies for home health services led to greater state expenditures for personal care services. In other words, less generous Medicare financing shifted a greater portion of the burden of financing home care to the state of Massachusetts. These findings raise important policy questions about the balance of responsibility between the federal government and states to provide financing of home care services for the elderly.