Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage.

Importance: Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM. Objective: To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes. Design, Setting, and Participants: This was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023. Exposures: Enrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM. Main Outcomes and Measures: Received care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality. Results: The study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group. Conclusions and Relevance: The findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.

Potentially Inappropriate Medication Use in Community-Dwelling Older Adults Living with Dementia.

BACKGROUND: The Beers Criteria identifies potentially inappropriate medications (PIMs) that should be avoided in older adults living with dementia. OBJECTIVE: The aim of this study was to provide estimates of the prevalence and persistence of PIM use among community-dwelling older adults living with dementia in 2011-2017. METHODS: Medicare claims data were used to create an analytic dataset spanning from 2011 to 2017. The analysis included community-dwelling Medicare fee-for-service beneficiaries aged 65 and older who were enrolled in Medicare Part D plans, had diagnosis for dementia, and were alive for at least one calendar year. Dementia status was determined using Medicare Chronic Conditions Date Warehouse (CCW) Chronic Condition categories and Charlson Comorbidity Index. PIM use was defined as 2 or more prescription fills with at least 90 days of total days-supply in a calendar year. Descriptive statistics were used to report the prevalence and persistence of PIM use. RESULTS: Of 1.6 million person-year observations included in the sample, 32.7% used one or more PIMs during a calendar year in 2011-2017. Breakdown by drug classes showed that 14.9% of the sample used anticholinergics, 14.0% used benzodiazepines, and 11.0% used antipsychotics. Conditional on any use, mean annual days-supply for all PIMs was 270.6 days (SD = 102.7). The mean annual days-supply for antipsychotic use was 302.7 days (SD = 131.2). CONCLUSION: Significant proportion of community-dwelling older adults with dementia used one or more PIMs, often for extended periods of time. The antipsychotic use in the community-dwelling older adults with dementia remains as a significant problem.

Understanding drivers of micro-level disparities in childhood body mass index, overweight, and obesity within low-income, minority communities.

The focus of childhood obesity disparities has been mainly on macro-level disparities, such as, between lower versus higher socioeconomic groups. But, less is known about micro-level disparities, that is disparities within minority and low-income populations. The present study examines individual and family level predictors of micro-level obesity disparities. We analyze data on 497 parent-child dyads living in public housing communities in Watts, Los Angeles. Cross-sectional multivariable linear and logistic regression models were estimated to examine whether individual and family level factors predict children's BMI z-scores, overweight, and obesity in the sample overall and separately by child's gender and age group. Child characteristics of our study sample included mean age 10.9 years, 74.3% Hispanic, 25.7% Non-Hispanic Black, 53.1% female, 47.5% with household income below $10,000, 53.3% with overweight or obesity, and 34.6% with obesity. Parental BMI was the strongest and most consistent predictor of child zBMI, overweight, and obesity, even after controlling for parent's diet and activity behaviors and home environment. The parenting practice of limiting children's screentime was also protective of unhealthy BMI in younger children and females. Home environment, parental diet and activity behaviors, and parenting practices related to food and bedtime routines were not significant predictors. Overall, our findings show that there is considerable heterogeneity in child BMI, overweight, and obesity even within low-income communities with similar socioeconomic and built environments in their neighborhoods. Parental factors play an important role in explaining micro-level disparities and should be an integral part of obesity prevention strategies in low-income minority communities.

Standardized assessment of cognitive function of post-acute care patients.

BACKGROUND: The assessment of cognitive function in post-acute care (PAC) settings is important for understanding an individual's condition and care needs, developing better person-directed care plans, predicting resource needs and understanding case mix. Therefore, we tested the feasibility and reliability of cognitive function assessments, including the Brief Interview for Mental Status (BIMS), Confusion Assessment Method (CAM©), Expression and Understanding, and Behavioral Signs and Symptoms for patients in PAC under the intent of the IMPACT Act of 2014. METHODS: We conducted a national test of assessments of four standardized cognitive function data elements among patients in PAC. One hundred and forty-three PAC settings (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. At least one of four cognitive function data elements were assessed in 3026 patients. We assessed descriptive statistics, percent of missing data, time to complete, and interrater reliability between paired research nurse and facility staff assessors, and assessor feedback. RESULTS: The BIMS, CAM©, Expression and Understanding, and Behavioral Signs and Symptoms demonstrated low rates of missing data (less than 2%), high percent agreement, and substantial support from assessors. The prevalence of Behavioral Signs and Symptoms was low in our sample of PAC settings. CONCLUSION: Findings provide support for feasibility of implementing standardized assessment of all our cognitive function data elements for patients in PAC settings. The BIMS and CAM© were adopted into federal Quality Reporting Programs in the fiscal year/calendar year 2020 final rules. Future work could consider implementing additional cognitive items that assess areas not covered by the BIMS and CAM©.

Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate.

BACKGROUND: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings. METHODS: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors. RESULTS: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74-0.98). CONCLUSION: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.

Developing standardized patient assessment data elements for Medicare post-acute care assessments.

BACKGROUND: To support interoperability and care planning across provider types, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the submission of standardized patient assessment data using the assessment instruments provided by the Centers for Medicare & Medicaid Services (CMS). CMS was tasked with developing standardized assessment data elements (SADEs) within clinical categories named in the IMPACT Act. METHOD: We used environmental scans, subject matter expert, and stakeholder input to identify candidate SADEs; tested candidate data elements in alpha testing; revised SADEs and training protocols based on alpha analyses and stakeholder feedback; tested SADEs across post-acute care (PAC) settings in a national field test that included 3121 patients across 143 home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities in 14 markets across the United States; and analyzed data and stakeholder input from national testing. Field testing measured the time required for assessment, percent completion, and inter-rater reliability. We analyzed qualitative feedback from stakeholder focus groups and technical expert panels. We also obtained survey and focus group feedback from data collectors. RESULTS: We developed a mixed-method, multi-stakeholder procedure to identify and gather input on SADE for cross-setting use. This process yielded feasible and reliable SADEs for PAC settings that assess pain, cognitive status, mood, and medication reconciliation. The success of this work depended on working iteratively with diverse stakeholders and providing qualitative as well as quantitative evidence. CONCLUSIONS: The procedures applied in this project for developing and adopting SADEs for PAC, as well as the challenges and strategies to overcome challenges, should be considered in future item and quality measure development.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities.

OBJECTIVE: To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES: Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN: We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS: We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS: In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS: Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery.

BACKGROUND: Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. METHODS: Seventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. RESULTS: Surgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. CONCLUSION: Participation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.

The Role of School Environments in Explaining Racial-Ethnic Disparities in Body Mass Index Among U.S. Adolescents.

PURPOSE: Policymakers have focused substantial efforts on how school environments can be used to combat obesity. Given this intense focus, this article examined whether disparities in body mass index (BMI) noted among black and Hispanic adolescents relative to whites were explained by the well-documented differences in the school socioeconomic characteristics, and food and physical activity environment. METHODS: Data from the fifth- and eighth-grade waves of the Early Childhood Longitudinal Study-Kindergarten Class were analyzed. Unadjusted linear regression models of BMI percentile that included only indicators for child's race/ethnicity were estimated first followed by adjusted models that iteratively added sets of child, family, and ultimately school covariates. Separate models were estimated by grade and gender. School covariates included detailed indicators for the school socioeconomic characteristics, and the food and physical activity environments. RESULTS: For Hispanic boys and girls and for black boys, substantial shares of the disparities in BMI were explained by differences in birth weight, BMI at school entry, and current child and family characteristics. Substantial disparities in BMI remained among black girls relative to white girls. Characteristics of the child's school during fifth and eighth grade-specifically, the schools' socioeconomic characteristics as well as measures of the food and physical activity environment-did not explain the disparities for any of the demographic groups. CONCLUSIONS: Differences in the school environment had little additional explanatory power suggesting that interventions seeking to reduce BMI disparities should focus on early school years and even before school entry.

How will provider-focused payment reform impact geographic variation in Medicare spending?

OBJECTIVES: The Institute of Medicine has recently argued against a value index as a mechanism to address geographic variation in spending and instead promoted payment reform targeted at individual providers. It is unknown whether such provider-focused payment reform reduces geographic variation in spending. STUDY DESIGN: We estimated the potential impact of 3 Medicare provider-focused payment policies-pay-for-performance, bundled payment, and accountable care organizations-on geographic variation in Medicare spending across Hospital Referral Regions (HRRs). We compared geographic variation in spending, measured using the coefficient of variation (CV) across HRRs, between the baseline case and a simulation of each of the 3 policies. METHODS: Policy simulation based on 2008 national Medicare data combined with other publicly available data. RESULTS: Compared with the baseline (CV, 0.171), neither pay-for-performance nor accountable care organizations would change geographic variation in spending (CV, 0.171), while bundled payment would modestly reduce geographic variation (CV, 0.165). CONCLUSIONS: In our models, the bundled payment for inpatient and post acute care services in Medicare would modestly reduce geographic variation in spending, but neither accountable care organizations nor pay-for-performance appear to have an impact.

A qualitative analysis of the impact of healthcare personnel influenza vaccination requirements in California.

OBJECTIVE: Using qualitative methods, we explored the implementation of California's 2007 influenza immunization requirements of hospital-based health care personnel (HCP). METHODS: We conducted nine case studies of California hospitals with different HCP vaccination rates and policies. Case studies consisted of interviewing 13 hospital representatives and analyzing relevant hospital documents, including influenza policies. We also conducted 13 semi-structured phone interviews with key state and county public health officials, union representatives, and officials of various professional healthcare organizations. RESULTS: Our qualitative results suggest that California's vaccination requirements likely did not increase influenza vaccination uptake among HCP. The law was not strong enough to compel hospitals with low and medium vaccination rates to improve their vaccination efforts, and hospitals with high vaccination rates were able to comply fully with the law by continuing to do what they were already doing - namely offering vaccinations to HCP, providing education about the risks of influenza and the benefits of vaccination, and obtaining signed declinations from those who refuse vaccination. Nonetheless, we found that by publicly raising the issue of influenza vaccination in the context of public safety and healthcare quality, California's law encouraged hospitals to develop and implement data systems to monitor the effectiveness of vaccination promotion efforts and prompted discussions, and, in some cases, adoption of stricter vaccination requirements at hospital or county levels. CONCLUSIONS: Our findings generally support the literature that suggests that permissive influenza vaccination requirements, though politically feasible, provide little direct incentive for hospitals to focus efforts on increasing HCP vaccination rates.

Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.

OBJECTIVES: To systematically document the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals. DESIGN: Systematic review. Studies were identified through existing reviews, searching five electronic databases, screening reference lists, and contacting topic experts for studies published through August 2011. SETTING: U.S. acute care hospitals. PARTICIPANTS: Studies reporting in-hospital falls for intervention groups and concurrent (e.g., controlled trials) or historic comparators (e.g., before-after studies). INTERVENTION: Fall prevention interventions. MEASUREMENTS: Incidence rate ratios (IRR, ratio of fall rate postintervention or treatment group to the fall rate preintervention or control group) and ratings of study details. RESULTS: Fifty-nine studies met inclusion criteria. Implementation strategies were sparsely documented (17% not at all) and included staff education, establishing committees, seeking leadership support, and occasionally continuous quality improvement techniques. Most interventions (81%) included multiple components (e.g., risk assessments (often not validated), visual risk alerts, patient education, care rounds, bed-exit alarms, and postfall evaluations). Fifty-four percent did not report on fall prevention measures applied in the comparison group, and 39% neither reported fidelity data nor described adherence strategies such as regular audits and feedback to ensure completion of care processes. Only 45% of concurrent and 15% of historic control studies reported sufficient data to compare fall rates. The pooled postintervention incidence rate ratio (IRR) was 0.77 (95% confidence interval = 0.52-1.12, P = .17; eight studies; I(2) : 94%). Meta-regressions showed no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR. CONCLUSION: Promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls.

A preliminary evaluation of the paid feeding assistant regulation: impact on feeding assistance care process quality in nursing homes.

PURPOSE: The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality. DESIGN AND METHODS: Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality. RESULTS: Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents. IMPLICATIONS: Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.