The association of increasing resilience with positive health outcomes among older adults.

Our objective was to investigate three levels of resilience (low, medium, and high), identify associated characteristics, and measure the impact of increasing resilience on quality of life (QOL), healthcare utilization and expenditures, and preventive services compliance. The study sample was identified from adults age ≥65 who completed surveys during May-June 2019 (N=3,573). Other protective factors, including purpose-in-life, optimism, locus of control, and social connections, were dichotomized as high/low and counted with equal weighting (0 to 4). Among survey respondents, the prevalence of low, medium, and high resilience levels was 27%, 29%, and 44%, respectively. The strongest predictors of medium and high resilience included increasing number of other protective factors, lower stress, and no depression. Individuals with medium and high resilience had significantly higher QOL and lower healthcare utilization and expenditures. Resilience strategies integrated into healthy aging programming could be associated with improvements in QOL and/or healthcare utilization and expenditure outcomes.

The impact of internal locus of control on healthcare utilization, expenditures, and health status across older adult income levels.

Our objectives were to 1) determine the prevalence of locus of control (LOC) dimensions stratified by older adult income levels; 2) characterize internal LOC attributes within income subgroups; and 3) investigate LOC associations with healthcare utilization and expenditures; self-rated health and functionality. The survey sample was identified from adults age ≥65 years with diagnosed pain conditions. Internal LOC characteristics were determined from logistic regressions; outcomes regression-adjusted. Among respondents, internal prevalence for low (N = 554), medium (N = 1,394) and high income (N = 2040) was 27%, 30% and 30%, respectively. Internal was associated with high resilience, less stress, exercise and less opioid use across income levels. Lower-income internal was additionally associated with diverse social networks, physical therapy and less drug use. Those with high internal generally had lower healthcare utilization and expenditures; better self-rated health and functionality. Internal LOC is a powerful positive resource associated with better health outcomes, especially influential for lower income.

Characteristics associated with transition from opioid initiation to chronic opioid use among opioid-naïve older adults.

Our primary objective was to determine the prevalence and characteristics of opioid-naïve older adults who initiated opioids and transitioned to chronic use. Study populations included older adults ≥ 65years with continuous medical and drug plan enrollment one-year prior to opioid initiation (pre-period) through one-year after initiation (post-period). Characteristics were determined using multivariate logistic regression. Among eligible insureds (N = 180,498), 70% used only the initial opioid prescription; 30% continued to use opioids requiring ≥ 2 prescriptions with ≥ 15 days' supply. Overall, 6% transitioned to chronic use > 90days. Characteristics associated with chronic use included: (1) Low income, older, females, in poor health, with new/chronic back pain; (2) opioid initiation with long-acting opioids or tramadol; (3) prescriptions for other pain, sleep or antipsychotic medications; and (4) indications of pre and/or post mental health issues. Careful screening, monitoring and/or alternative non-opioid pain management strategies may be warranted for those at risk for chronic opioid use.

Self-Reported Hearing Loss in Older Adults Is Associated With Higher Emergency Department Visits and Medical Costs.

Hearing loss is common among older adults. Thus, it was of interest to explore differences in health care utilization and costs associated with hearing loss and hearing aid use. Hearing loss and hearing aid use were assessed through self-reports and included 5 categories: no hearing loss, aided mild, unaided mild, aided severe, and unaided severe hearing loss. Health care utilization and costs were obtained from medical claims. Those with aided mild or severe hearing loss were significantly more likely to have an emergency department visit. Conversely, those with aided severe hearing loss were about 15% less likely to be hospitalized. Individuals with unaided severe hearing loss had the highest annual medical costs ($14349) compared with those with no hearing loss ($12118, P < .001). In this study, those with unaided severe hearing loss had the highest medical costs. Further studies should attempt to better understand the relationship between hearing loss, hearing aid use, and medical costs.

Need for Comprehensive Health Care Quality Measures for Older Adults.

Research indicates that older adults receive only about half of their recommended care, with varying quality and limited attention to social issues impacting their health through the most commonly used quality measures. Additionally, many existing measures neglect to address nonclinical social determinants of health. Evidence of the need for more comprehensive measures for seniors is growing. The primary purpose of this article, which is supported by a limited review of literature, is to describe gaps among current quality measures in addressing certain nonclinical needs of older adults, including key social determinants of health. In doing so, the authors describe their position on the need for expanded measures to incorporate these factors to improve care and quality of life. The authors conducted a limited review of the literature to inform this article, focusing specifically on selected measures for older adults rather than a broader systematic review of all measures. Most research identified was related to clinical practice guidelines rather than quality measures of care as applied to older adults. Furthermore, the literature reviewed reflected limited evidence of efforts to tailor quality measures for the unique social needs of older adults, confirming a potential gap in this area. A growing need exists for improved quality measures specifically designed to help providers address the unique social needs of older adults. Filling this gap will improve overall understanding of seniors and help them to achieve optimal health and successful aging.

The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults.

Inadequate health literacy (HL) is associated with impaired healthcare choices leading to poor quality-of-care. Our primary purpose was to estimate the prevalence of inadequate HL among two populations of AARP® Medicare Supplement insureds: sicker and healthier populations; to identify characteristics of inadequate HL; and to describe the impact on patient satisfaction, preventive services, healthcare utilization, and expenditures. Surveys were mailed to insureds in 10 states. Multivariate regression models were used to identify characteristics and adjust outcomes. Among respondents (N = 7334), 23% and 16% of sicker and healthier insureds, respectively, indicated inadequate HL. Characteristics of inadequate HL included male gender, older age, more comorbidities, and lower education. Inadequate HL was associated with lower patient satisfaction, lower preventive service compliance, higher healthcare utilization and expenditures. Inadequate HL is more common among older adults in poorer health, further compromising their health outcomes; thus they may benefit from expanded educational or additional care coordination interventions.

Care Coordination Challenges Among High-Needs, High-Costs Older Adults in a Medigap Plan.

PURPOSE OF THE STUDY: Many adults 65 years or older have high health care needs and costs. Here, we describe their care coordination challenges. PRIMARY PRACTICE SETTING: Individuals with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York). METHODOLOGY AND SAMPLE: The three groups included the highest needs, highest costs (the "highest group"), the high needs, high costs (the "high group"), and the "all other group." Eligibility was determined by applying an internally developed algorithm based upon a number of criteria, including hierarchical condition category score, the Optum ImpactPro prospective risk score, as well as diagnoses of coronary artery disease, congestive heart failure, or diabetes. RESULTS: The highest group comprised 2%, although consumed 12% of health care expenditures. The high group comprised 20% and consumed 46% of expenditures, whereas the all other group comprised 78% and consumed 42% of expenditures. On average, the highest group had $102,798 in yearly health care expenditures, compared with $34,610 and $7,634 for the high and all other groups, respectively. Fifty-seven percent of the highest group saw 16 or more different providers annually, compared with 21% and 2% of the high and all other groups, respectively. Finally, 28% of the highest group had prescriptions from at least seven different providers, compared with 20% and 5% of the high and all other groups, respectively. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Individuals with high health care needs and costs have visits to numerous health care providers and receive multiple prescriptions for pharmacotherapy. As a result, these individuals can become overwhelmed trying to manage and coordinate their health care needs. Care coordination programs may help these individuals coordinate their care.

Using Propensity to Succeed Modeling to Increase Utilization and Adherence in a Nurse HealthLine Telephone Triage Program.

Propensity to succeed modeling was used to identify characteristics associated with higher utilization of a telephone triage program and adherence to nurse recommendations among callers. Characteristics significantly associated with calling the telephone triage service and engaging in triage services were being female and having an elevated health risk score. Callers most likely to adhere to nurse recommendations were younger than 85 years of age, had called on a weekday, and had received a recommendation to seek care at an emergency department or a doctor's office visit. Additional analyses suggest the propensity to succeed modeling is stable and valid.

The Impact of Obesity on Health Care Utilization and Expenditures in a Medicare Supplement Population.

Objective: Obesity is a contributor to increased chronic conditions resulting in higher utilization of medical services among broad populations of older adults. The objective of this study was to evaluate the magnitude of the impact of weight on health care use patterns among Medicare Supplement insureds. Method: We estimated the impact of weight as a function of body mass index (BMI) on health care utilization and expenditures using propensity weighted multivariate regression models. The outcomes were controlled initially for demographics and socioeconomics and then additionally for chronic conditions and health status. Results: Among the 9,484 survey respondents, 22.9% were obese. Those categorized as obese were significantly more likely to incur inpatient admissions and orthopedic procedures. Annualized health care expenditures were US$1,496 higher for obese compared with normal weight. The excess utilization and expenditures associated with obesity were explained by chronic conditions and poor health status. Conclusion: Obesity-related expenditures associated with medical management are largely preventable and may benefit from interventions that target lifestyle behaviors and weight management among older adults.

Disparities Among Those With Advance Directives in a Medicare Supplement Population.

Advance directives (ADs) detail patients' end-of-life (EOL) care preferences. We estimated AD prevalence rates among a Medicare Supplement population and determined characteristics associated with having ADs. We also estimated the impact of having an AD on EOL Medicare expenditures among respondents who later died. Survey respondents with an AD (72%) were significantly more likely to be female, older, nonminority, higher income and education, and have more comorbid conditions. Following regression adjustments, EOL expenditures were significantly lower for those with ADs in the last 3 months (-US$11 189) and 1 month (-US$6092) prior to death. Patients with ADs specifying their wishes for EOL care had significantly lower medical expenditures during the last few months of life. However, disparities exist among those with ADs that may warrant interventions.

Homebound older adults: Prevalence, characteristics, health care utilization and quality of care.

The purpose of this study was to estimate prevalence rates of homebound older adults, their characteristics and the impact of homebound status on health care utilization, expenditures and quality of medical care measures. Surveys were sent to new enrollees (n = 25,725) in AARP(®) Medicare Supplement plans (insured through UnitedHealthcare) to screen for serious chronic conditions, ambulatory disabilities and eligibility for care coordination programs. Health care utilization and expenditures were determined from paid claims. Member-level quality measures considered compliance with medication adherence and care patterns. Among survey respondents, 19.6% were classified as being homebound. The strongest predictors of being homebound included serious memory loss, being older, having more chronic conditions, taking more prescription medications and having multiple hospitalizations. Homebound had significantly higher health care utilization and expenditures. Homebound were more likely to be noncompliant with medication adherence and care pattern rules. Ongoing screening and subsequent interventions for new enrollees classified as homebound may be warranted.

Propensity to Succeed: Prioritizing Individuals Most Likely to Benefit from Care Coordination.

The objective was to develop a propensity to succeed (PTS) process for prioritizing outreach to individuals with Medicare Supplement (ie, Medigap) plans who qualified for a high-risk case management (HRCM) program. Demographic, socioeconomic, health status, and local health care supply data from previous HRCM program participants and nonparticipants were obtained from Medigap membership and health care claims data and public data sources. Three logistic regression models were estimated to find members with higher probabilities of engaging in the HRCM program, receiving high quality of care once engaged, and incurring enough monetary savings related to program participation to more than offset program costs. The logistic regression model intercepts and coefficients yielded the information required to build predictive models that were then applied to generate predicted probabilities of program engagement, high quality of care, and cost savings a priori for different members who later qualified for the HRCM program. Predicted probabilities from the engagement and cost models were then standardized and combined to obtain an overall PTS score, which was sorted from highest to lowest and used to prioritize outreach efforts to those newly eligible for the HRCM program. The validity of the predictive models also was estimated. The PTS models for engagement and financial savings were statistically valid. The combined PTS score based on those 2 components helped prioritize outreach to individuals who qualified for the HRCM program. Using PTS models may help increase program engagement and financial success of care coordination programs.

Pharmaceutical Cost-Saving Strategies and their Association with Medication Adherence in a Medicare Supplement Population.

BACKGROUND: On average, Medicare Supplement insureds take about seven unique prescription medications each year, resulting in substantial out-of-pocket drug copayments, in addition to Medicare Supplement and Part D premiums. To help alleviate this financial burden, many individuals resort to cost-saving strategies that are not trackable by Part D insurance plans, likely resulting in an underestimation of medication adherence rates. OBJECTIVE: We aimed to estimate utilization rates of cost-saving strategies, measure member characteristics associated with these strategies and estimate if these strategies are associated with medication adherence. DESIGN: This was a cross-sectional analysis of a 2012-2013 survey of AARP® Medicare Supplement plan insureds with Part D pharmaceutical coverage. PARTICIPANTS: The study included 5,784 community-dwelling survey respondents ≥ 65 years of age, living in ten states and with self-reported use of prescription medications. MAIN MEASURES: Self-reported use of cost-saving strategies included: obtaining free samples from physicians, splitting pills so medications lasted longer, purchasing medications from other countries and/or over the internet, or purchasing medications through the Veterans Administration. Propensity weighted multivariate regressions were utilized to determine characteristics associated with the use of such strategies and the association with medication adherence as measured from Medicare Part D claims. KEY RESULTS: Among those taking medications, 39.6% used cost-saving strategies. Those using these strategies were significantly (p < 0.05) more likely to be male, non-minority, have more comorbid conditions, have more disabilities and use more medications. Few variables were significantly related to pharmaceutical nonadherence, but those who were nonadherent were significantly more likely to use more medications, split pills, obtain free samples from their physicians and be male. CONCLUSION: Cost-saving strategies are used extensively as a means to augment Medicare Part D coverage. These strategies are associated with measured medication nonadherence and likely result in underreporting of medication adherence rates. Pharmacy management programs should consider these additional medication sources in assisting plan members to problem solve cost-related medication management issues.

Evaluation of a high-risk case management pilot program for Medicare beneficiaries with Medigap coverage.

The objective was to evaluate the 3-year experience of a high-risk case management (HRCM) pilot program for adults with an AARP Medicare Supplement (Medigap) Insurance Plan. Participants were provided in-person visits as well as telephonic and mailed services to improve care coordination from December 1, 2008, to December 31, 2011. Included were adults who had an AARP Medigap Insurance Plan, resided in 1 of 5 pilot states, and had a Hierarchical Condition Category score>3.74, or were referred into the program. Propensity score weighting was used to adjust for case-mix differences among 2015 participants and 7626 qualified but nonparticipating individuals. Participants were in the program an average of 15.4 months. After weighting, multiple regression analyses were used to estimate differences in quality of care and health care expenditures between participants and nonparticipants. Increased duration in the program was associated with fewer hospital readmissions. Additionally, participants were significantly more likely to have recurring office visits and recommended laboratory tests. The program demonstrated $7.7 million in savings over the 3 years, resulting in a return on investment of $1.40 saved for every dollar spent on the program. Savings increased each year from 2009 to 2011 and with longer length of engagement. The majority of savings were realized by the federal Medicare program. This study focused on quality of care and savings for an HRCM program designed solely for Medicare members with Medicare Supplement coverage. This program had a favorable impact on quality of care and demonstrated savings over a 3-year period.

Big Data, Little Data, and Care Coordination for Medicare Beneficiaries with Medigap Coverage.

Most healthcare data warehouses include big data such as health plan, medical, and pharmacy claims information for many thousands and sometimes millions of insured individuals. This makes it possible to identify those with multiple chronic conditions who may benefit from participation in care coordination programs meant to improve their health. The objective of this article is to describe how large databases, including individual and claims data, and other, smaller types of data from surveys and personal interviews, are used to support a care coordination program. The program described in this study was implemented for adults who are generally 65 years of age or older and have an AARP(®) Medicare Supplement Insurance Plan (i.e., a Medigap plan) insured by UnitedHealthcare Insurance Company (or, for New York residents, UnitedHealthcare Insurance Company of New York). Individual and claims data were used first to calculate risk scores that were then utilized to identify the majority of individuals who were qualified for program participation. For efficient use of time and resources, propensity to succeed modeling was used to prioritize referrals based upon their predicted probabilities of (1) engaging in the care coordination program, (2) saving money once engaged, and (3) receiving higher quality of care. To date, program evaluations have reported positive returns on investment and improved quality of healthcare among program participants. In conclusion, the use of data sources big and small can help guide program operations and determine if care coordination programs are working to help older adults live healthier lives.

Factors driving engagement decisions in care coordination programs.

PURPOSE OF THE STUDY: To find out why individuals choose to engage, disengage, or not to engage in care coordination programs that are meant to improve their health and better navigate the medical care system. PRIMARY PRACTICE SETTING: Care coordination program designed for individuals with an AARP Medicare Supplement Insurance Plan. METHODOLOGY AND SAMPLE: A 2-phase study was used involving insureds eligible for disease, depression, or case management programs. The study focused on those who participated in these programs (i.e., the engaged group), those who left the programs after starting their participation (the disengaged group), and those who never engaged in these programs. A telephone survey was conducted first, followed by focus groups and in-depth telephone interviews to address interesting findings from the survey. RESULTS: The top reasons for program engagement included believing that the program would be helpful (39%), liking its convenience (14%), and because participation was at no additional cost (9%). The top reasons for not engaging included not seeing potential benefit from engagement (28%) and being comfortable with current health care processes (19%). Reasons given for disengaging included lack of time (15%), not believing the program was helpful (13%), not understanding what the program provided (13%), or being unaware of the program (11%). Among the key findings from the focus groups were that individuals who felt they were not getting sufficient support from their medical providers or those needing a sounding board were more likely to engage. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This study provides valuable insight regarding how to best engage individuals with such a plan and who are qualified for care coordination programs. These results suggest that those most motivated to engage are those who are well informed of the program benefits and have a perceived need, such as living alone and needing a sounding board.

Obese older adults report high satisfaction and positive experiences with care.

BACKGROUND: Obese, older adults often have multiple chronic conditions resulting in multiple health care encounters. However, their satisfaction and experiences with care are not well understood. The objective of this study was to examine the independent impact of obesity on patient satisfaction and experiences with care in adults 65 years of age and older with Medigap insurance. METHODS: Surveys were mailed to 53,286 randomly chosen adults with an AARP® Medicare Supplement Insurance Plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York) in 10 states. Following adjustment for non-response bias, multivariate regression modeling was used to adjust for demographic, socioeconomic and health status differences to estimate the independent impact of weight on satisfaction and experiences with care. Outcome variables included four global and four composite measures of satisfaction and experiences with care. RESULTS: 21.4% of the respondents were obese. Relative to normal weight, obesity was significantly associated with higher patient satisfaction and better experiences with care in seven of the eight ratings measured. CONCLUSIONS: Obese individuals were more satisfied and had better experiences with care. Obese individuals had more office visits and discussions about nutrition, exercise and medical checks. This may have led to increased attentiveness to care, explaining the increase in satisfaction and better experiences with care. Given the high level of satisfaction and experiences with care in older, obese adults, opportunities exist for clinicians to address weight concerns in this population.

An emergency room decision-support program that increased physician office visits, decreased emergency room visits, and saved money.

The objective of this study was to evaluate an Emergency Room having a Decision-Support (ERDS) program designed to appropriately reduce ER use among frequent users, defined as 3 or more visits within a 12-month period. To achieve this, adults with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York) were eligible to participate in the program. These included 7070 individuals who elected to enroll in the ERDS program and an equal number of matched nonparticipants who were eligible but either declined or were unreachable. Program-related benefits were estimated by comparing the difference in downstream health care utilization and expenditures between engaged and not engaged individuals after using propensity score matching to adjust for case mix differences between these groups. As a result, compared with the not engaged, engaged individuals experienced better care coordination, evidenced by a greater reduction in ER visits (P=0.033) and hospital admissions (P=0.002) and an increase in office visits (P<0.001). The program was cost-effective, with a return on investment (ROI) of 1.24, which was calculated by dividing the total program savings ($3.41 million) by the total program costs ($2.75 million). The ROI implies that for every dollar invested in this program, $1.24 was saved, most of which was for the federal Medicare program. In conclusion, the decrease in ER visits and hospital admissions and the increase in office visits may indicate the program helped individuals to seek the appropriate levels of care.

Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

Why do older adult women fall short of the recommended follow-up care for coronary artery disease?

BACKGROUND: Many women with coronary artery disease (CAD), commonly referred to as coronary heart disease, do not receive an annual office visit to manage their disease. We set out to determine what barriers factor into women not receiving an office visit to manage their disease. METHODS: A purposive sample of 26 eligible women (≥65 years of age) diagnosed with CAD completed in-depth, qualitative interviews. Systematic analysis of the content of interviews was performed on transcripts from these interviews. Participants with an AARP Medicare Supplement Insurance Plan insured by UnitedHealthcare insurance company that did not receive an annual office visit were eligible. In addition, we surveyed 100 physicians to obtain their thoughts about why women may not schedule at least one annual visit to manage their CAD. RESULTS: The most common barriers identified were skepticism of heart problems, having to take the initiative to schedule the appointment, and dealing with seemingly more pressing health problems. Many of these barriers identified were substantiated in a survey of physicians that treat women with CAD, but the relative rankings of the importance of these problems differed somewhat. CONCLUSIONS: Many women were skeptical about their heart health and often lacked the initiative to schedule a follow-up appointment. Most agreed that they would make an appointment if contacted by their doctor's office. Many of these women were receptive to the idea of receiving educational information by mail. Active involvement by doctors' offices to schedule appointments may help improve care, as might mail-based reminders.