Health care provider evaluation of a substitutive model of hospital at home.

OBJECTIVE: To evaluate Hospital at Home (HaH), a substitute for inpatient care, from the perspectives of participating providers. RESEARCH DESIGN: Multivariate general estimating equations regression analyses of a patient-specific survey of providers delivering HaH care in a prospective, nonrandomized clinical trial. SUBJECTS: Eleven physicians and 26 nurses employed in 3 Medicare-Advantage plans and 1 Veterans Administration medical center. MEASURES: Problems with care; benefits; problem-free index. RESULTS: Case response rates were 95% and 82% for physicians and nurses, respectively. The overall problem-free index was high (mean 4.4, median 5, scale 1-5). "Major" problems were cited for 14 of 84 patients (17%), most relating to logistic issues without adverse patient outcomes. Positive effects included quicker patient functional recovery, greater opportunities for patient teaching, and increased communication with family caregivers. In multivariate analysis, the problem-free index was lower for nurses compared with physicians in one site; for patients with cellulitis; and for patients with a higher acuity (APACHE II) score. HaH physicians and nurses differed in their judgments of hours of continuous nursing required by patients. CONCLUSIONS: The health care provider evaluation of substitutive HaH care was positive, providing support for the viability of this innovative model of care. Without provider support, no new model of care will survive. These findings also provide insight into areas to attend to in implementation. Organizations considering adoption of the HaH should monitor provider views to promote quality improvement in HaH.

Nursing home characteristics related to medicare costs for residents with and without dementia.

OBJECTIVES: To evaluate the relationship of nursing home characteristics to Medicare costs overall and by dementia status. DESIGN: New admissions followed for 2 years. Setting. Random stratified sample of 55 Maryland nursing homes. PARTICIPANTS: Sample of 1257 residents. MEASURES: Records, interview, and observation. RESULTS: Medicare costs were lower in facilities that have a better environmental quality, hospice beds, and more food service workers; costs were higher in hospital-based facilities and those that have a higher Medicaid case mix, X-ray, and some specified types of staff. Across all characteristics, costs for residents with dementia were consistently two-thirds the cost of other residents. DISCUSSION: In terms of dementia status, resident characteristics drive Medicare costs, as opposed to facility characteristics. Using alternative residential settings for individuals with dementia may increase Medicare costs of nursing home residents and Medicare costs of residents with dementia who are cared for in settings less able to attend to medical needs.

Satisfaction with hospital at home care.

OBJECTIVES: To examine differences in satisfaction with acute care between patients who received treatment in a physician-led substitutive Hospital at Home program and those who received usual acute hospital care. DESIGN: Survey questionnaire of participants in prospective, nonrandomized clinical trial. SETTING: Three Medicare-managed care health systems and a Department of Veterans Affairs Medical Center. PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in Hospital at Home and 130 in the acute care hospital. INTERVENTION: Treatment in a Hospital at Home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: A 40-question survey measuring nine domains of care for patients and a 37-question survey measuring eight domains of care for family members. RESULTS: A higher proportion of patients were satisfied with treatment in Hospital at Home than with the acute care hospital in eight of nine domains, and this difference was statistically different in four domains. Hospital at Home patients were more likely than acute hospital patients to be satisfied with their physician (adjusted odds ratio (AOR) = 3.84, 95% confidence interval (CI) = 1.32-11.19), comfort and convenience of care (AOR = 6.52, 95% CI = 1.97-21.56), admission processes (AOR = 5.90, 95% CI = 2.21-5.76), and the overall care experience (AOR = 2.98, 95% CI = 1.08-8.21). Family members of patients treated in Hospital at Home were also more likely to be satisfied with multiple domains of care. CONCLUSION: Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.

Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients.

BACKGROUND: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. OBJECTIVE: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. DESIGN: Prospective quasi-experiment. SETTING: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. PARTICIPANTS: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. INTERVENTION: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. RESULTS: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001). LIMITATIONS: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. CONCLUSIONS: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.

Outcomes of infection in nursing home residents with and without early hospital transfer.

OBJECTIVES: To compare outcomes of infection in nursing home residents with and without early hospital transfer. DESIGN: Observational cohort study. SETTING: Fifty-nine nursing homes in Maryland. PARTICIPANTS: Two thousand one hundred fifty-three individuals admitted to nursing homes between 1992 and 1995. MEASUREMENTS: Incident infection was recorded when a new infectious diagnosis was documented in the medical record or nonprophylactic antibiotic therapy was prescribed. Early hospital transfer was defined as transfer to the emergency department or admission to the hospital within 3 days of infection onset. Infection, resident, and facility characteristics were entered into a multivariate model to create a propensity score for early hospital transfer. Association between early hospital transfer and outcomes of infection, namely pressure ulcers and death between Days 4 and 34 after infection onset, were examined, controlling for propensity score. RESULTS: Four thousand nine hundred ninety infections occurred in 1,301 residents. Genitourinary (28%), skin (19%), upper respiratory (13%), and lower respiratory (12%) were the most common types. Three hundred seventy-five episodes in which residents survived 3 days (7.6%) resulted in early hospital transfer. In multivariate regression, individuals with early hospital transfer had higher mortality (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.04-1.99) and, in 1-month survivors, a greater occurrence of pressure ulcers (OR 1.61, 95% CI=1.17-2.20) than those without, after adjusting for propensity score. CONCLUSION: Using observational data and propensity score methods, outcomes were worse in nursing home residents transferred to the hospital within 3 days of infection onset than in those who remained in the nursing home.

Healthcare utilization of nursing home residents: comparison between decedents and survivors.

OBJECTIVES: To determine whether residents who die while in the nursing home have higher healthcare utilization than survivors and whether the utilization in the periods before death varies with length of stay in the nursing home. DESIGN: Descriptive, longitudinal study comparing medical service use of residents who died during the study period with that of residents who remained alive in the facility. SETTING: Fifty-nine nursing homes in Maryland. Data were collected between 1992 and 1995. PARTICIPANTS: A random sample of 1,195 residents. MEASUREMENTS: Rates of hospitalization, emergency department visits, and medical visits in aggregate and in an initial 30-day and subsequent 90-day intervals after admission to the nursing home. RESULTS: Residents who died during the 2-year study period had significantly greater mean rates of utilization of all types of health care than residents who were not discharged from the nursing home, even when controlling for dementia diagnosis, age, functional status, and number of comorbid conditions. Those who died within a month of admission had significantly more emergency department and medical visits than those who died after a longer stay. CONCLUSION: The pattern of high healthcare utilization before death is consistent with studies of the overall Medicare population that show an increase in Medicare expenditures in the period before death.

Mortality and adverse health events in newly admitted nursing home residents with and without dementia.

OBJECTIVES: To evaluate the association between dementia and mortality, adverse health events, and discharge disposition of newly admitted nursing home residents. It was hypothesized that residents with dementia would die at a higher rate and develop more adverse health events (e.g., infections, fevers, pressure ulcers, falls) than residents without dementia because of communication and self-care difficulties. DESIGN: An expert clinician panel diagnosed an admission cohort from a stratified random sample of 59 Maryland nursing homes, between 1992 and 1995. The cohort was followed for up to 2 years or until discharge. SETTING: Fifty-nine Maryland nursing homes. PARTICIPANTS: Two thousand one hundred fifty-three newly admitted residents aged 65 and older not having resided in a nursing home for 8 or more days in the previous year. MEASUREMENTS: Mortality, infection, fever, pressure ulcers, fractures, and discharge home. RESULTS: Residents with dementia had significantly lower overall rates of infection (relative risk (RR)=0.77, 95% confidence interval (CI)=0.70-0.85) and mortality (RR=0.61, 95% CI=0.53-0.71) than those without dementia, whereas rates of fever, pressure ulcers, and fractures were similar for the two groups. These results persisted when rates were adjusted for demographic characteristics, comorbid conditions, and functional status. During the first 90 days of the nursing home stay, residents with dementia had significantly lower rates of mortality if not admitted for rehabilitative care under a Medicare qualifying stay (RR=0.25, 95% CI=0.14-0.45), were less often discharged home (RR=0.33, 95% CI=0.28-0.38), and tended to have lower fever rates (RR=0.78, 95% CI=0.63-0.96) than residents without dementia. CONCLUSION: Newly admitted nursing home residents with dementia have a profile of health events that is distinct from that of residents without dementia, indicating that the two groups have different long-term care needs. Results suggest that further investigation of whether residents with dementia can be well managed in alternative residential settings would be valuable.

Characteristics predicting nursing home admission in the program of all-inclusive care for elderly people.

PURPOSE: This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE). DESIGN AND METHODS: DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated. RESULTS: The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for. IMPLICATIONS: Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.

Medicare cost differences between nursing home patients admitted with and without dementia.

PURPOSE: Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings. DESIGN AND METHODS: An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups. RESULTS: Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS. IMPLICATIONS: Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.

Health outcomes and medicaid costs for frail older individuals: a case study of a MCO versus fee-for-service care.

Older individuals receiving both Medicare and Medicaid benefits are known to have a disproportionate burden of illness and high medical care costs. Elder Health, Inc., a private, for-profit managed care organization operating in Maryland under capitation rates from both Medicare and Medicaid, has tailored a medical practice to these individuals, with the stated objective of providing integrated care. This study compared 200 Elder Health patients with a closely matched group of dually eligible older individuals receiving care in fee-for-service practices. There was a baseline in-home structured interview with the patient, followed 1 year later with a telephone interview. Other data sources were Medicaid claims data and Elder Health's utilization records. The outcomes of interest were the patients' health and functional status, their satisfaction with care, rates of use of medical services, and costs to Medicaid. Elder Health patients had similar general health status, better functional status, and greater satisfaction with access to care but less satisfaction with information giving than the fee-for-service group. They received more primary care and preventive services and had less than half the number of hospital days. Costs to Medicaid were nearly identical. Institutional and community-based long-term care costs were not included in the analysis.As pressures mount for the Health Care Financing Administration to expand its prepaid contracts with private health plans and the need for integrated programs increase, quantitative assessment of innovative delivery models such as Elder Health, Inc. will be essential to ensure that patients' and the publics' interests are well served.

Transitions in spousal caregiving.

PURPOSE: This study describes transitions over 5 years among community-dwelling elderly spouses into and within caregiving roles and associated health outcomes. DESIGN AND METHODS: Participants in the Caregiver Health Effects Study (n = 818) were interviewed four times over 5 years with changes in their caregiving status described. Analyses of the effect on health outcomes of transitions were performed on those for whom four observations were available (n = 428). RESULTS: Only half (49.5%) of noncaregivers at baseline remained noncaregivers at 5-year follow-up. The remainder experienced one or more transitions, including moving into the caregiving role, their own or their spouse's death, or placement of their spouse in a long-term care facility. The trajectory of health outcomes associated with caregiving was generally downward. Those who transitioned to heavy caregiving had more symptoms of depression, and poorer self-reported health and health behaviors. IMPLICATIONS: Transitions into and within the caregiving role should be monitored for adverse health effects on the caregiver, with interventions tailored to the individual's location in the caregiving trajectory.

Concurrent and long-term predictors of older adults' use of community-based long-term care services: the Caregiver Health Effects Study.

OBJECTIVE: This study examined concurrent and long-term associations between caregiver-related characteristics and the use of community long-term care services in a sample of 186 older adults caring for a disabled spouse. METHOD: We used two waves of data from the Caregiver Health Effects Study, an ancillary study of the Cardiovascular Health Study. Caregiver-related need variables as predictors of service use were of primary interest and included caregiving demands, caregiver mental and physical health, and mastery. Their contribution to service use was examined after controlling for known predictors of service use. RESULTS: At Time 1, more caregiver depressive symptoms predicted greater service use; at Time 2, more caregiver activity restriction and depressive symptoms predicted greater formal service use; increases in caregiver activity restriction and depressive symptomatology over time predicted increases in service use. DISCUSSION: Caregiver-related need variables play a significant role in defining utilization patterns of community-based long-term care services among older adults.

Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care.

OBJECTIVES: To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care. DESIGN: Survey questionnaire of participants in a prospective nonrandomized clinical trial. SETTING: Three Medicare managed care health systems and a Veterans Affairs Medical Center. PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital. INTERVENTION: Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital. MEASUREMENTS: Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores. RESULTS: Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs -0.60, P=.10, range -12.0 to 7.0; IADL 0.74 vs -0.70, P=.007, range -5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04). CONCLUSION: HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.

Health of Medicare Advantage plan enrollees at 1 year after Hurricane Katrina.

OBJECTIVE: To assess the effects of Hurricane Katrina on mortality, morbidity, disease prevalence, and service utilization during 1 year in a cohort of 20,612 older adults who were living in New Orleans, Louisiana, before the disaster and who were enrolled in a managed care organization (MCO). STUDY DESIGN: Observational study comparing mortality, morbidity, and service use for 1 year before and after Hurricane Katrina, augmented by a stratified random sample of 303 enrollees who participated in a telephone survey after Hurricane Katrina. METHODS: Sources of data for health and service use were MCO claims. Mortality was based on reports to the MCO from the Centers for Medicare & Medicaid Services; morbidity was measured using adjusted clinical groups case-mix methods derived from diagnoses in ambulatory and hospital claims data. RESULTS: Mortality in the year following Hurricane Katrina was not significantly elevated (4.3% before vs 4.9% after the hurricane). However, overall morbidity increased by 12.6% (P <.001) compared with a 3.4% increase among a national sample of Medicare managed care enrollees. Nonwhite subjects from Orleans Parish experienced a morbidity increase of 15.9% (P <.001). The prevalence of numerous treated medical conditions increased, and emergency department visits and hospitalizations remained significantly elevated during the year. CONCLUSIONS: The enormous health burden experienced by older individuals and the disruptions in service utilization reveal the long-term effects of Hurricane Katrina on this vulnerable population. Although quick rebuilding of the provider network may have attenuated more severe health outcomes for this managed care population, new policies must be introduced to deal with the health consequences of a major disaster.

Substitutive Hospital at Home for older persons: effects on costs.

OBJECTIVE: To compare the cost of substitutive Hospital at Home care versus traditional inpatient care for older patients with community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of congestive heart failure, or cellulitis. STUDY DESIGN: Prospective nonrandomized clinical trial involving 455 community-dwelling older patients in 3 Medicare managed care health systems and at a Department of Veterans Affairs medical center. METHODS: Costs were analyzed across all patients, within each of the separate health systems, and by condition. Generalized linear models controlling for confounders and using a log link and gamma family specification were used to make inferences about the statistical significance of cost differences. t Tests were used to make inferences regarding differences in follow-up utilization. RESULTS: The costs of the Hospital at Home intervention were significantly lower than those of usual acute hospital care (mean [SD], $5081 [$4427] vs $7480 [$8113]; P <.001). Laboratory and procedure expenditures were lower across all study sites and at each site individually. There were minimal significant differences in health service utilization between the study groups during the 8 weeks after the index hospitalization. As-treated analysis results were consistent with Hospital at Home costs being lower. CONCLUSIONS: Total costs seem to be lower when substitutive Hospital at Home care is available for patients with congestive heart failure or chronic obstructive pulmonary disease. This result may be related to the study-based requirement for continuous nursing input. Savings may be possible, particularly for care of conditions that typically use substantial laboratory tests and procedures in traditional acute settings.

The role of nursing home admission and dementia status on care for diabetes mellitus.

OBJECTIVES: To study the role of nursing home (NH) admission and dementia status on the provision of five procedures related to diabetes mellitus. DESIGN: Retrospective cohort study using data from a large prospective study in which an expert panel determined the prevalence of dementia. SETTING: Fifty-nine Maryland NHs. PARTICIPANTS: Three hundred ninety-nine new admission NH patients with diabetes mellitus. MEASUREMENTS: Medicare administrative claims records matched to the NH medical record data were used to measure procedures related to diabetes mellitus received in the year before NH admission and up to a year after admission (and before discharge). Procedures included glycosylated hemoglobin, fasting blood glucose, dilated eye examination, lipid profile, and serum creatinine. RESULTS: For all but dilated eye examinations, higher rates of procedures related to diabetes mellitus were seen in the year after NH admission than in the year before. Residents without dementia received more procedures than those with dementia, although this was somewhat attenuated after controlling for demographic, health, and healthcare utilization variables. Persons without dementia experience greater increases in procedure rates after admission than those with dementia. CONCLUSION: The structured environment of care provided by the NH may positively affect monitoring procedures provided to elderly persons with diabetes mellitus, especially those without dementia. Medical decisions related to the risks and benefits of intensive treatment for diabetes mellitus to patients of varying frailty and expected longevity may lead to lower rates of procedures for residents with dementia.

Comparison of stress experienced by family members of patients treated in hospital at home with that of those receiving traditional acute hospital care.

OBJECTIVES: To compare differences in the stress experienced by family members of patients cared for in a physician-led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care. DESIGN: Survey questionnaire completed as a component of a prospective, nonrandomized clinical trial of a substitutive HaH care model. SETTING: Three Medicare managed care health systems and a Veterans Affairs Medical Center. PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. INTERVENTION: Treatment in a substitutive HaH model. MEASUREMENTS: Fifteen-question survey questionnaire asking family members whether they experienced a potentially stressful situation and, if so, whether stress was associated with the situation while the patient received care. RESULTS: The mean and median number of experiences, of a possible 15, that caused stress for family members of HaH patients was significantly lower than for family members of acute care hospital patients (mean +/- standard deviation 1.7 +/- 1.8 vs 4.3 +/- 3.1, P<.001; median 1 vs 4, P<.001). HaH care was associated with lower odds of developing mean levels of family member stress (adjusted odds ratio=0.12, 95% confidence interval=0.05-0.30). CONCLUSION: HaH is associated with lower levels of family member stress than traditional acute hospital care and does not appear to shift the burden of care from hospital staff to family members.

Depression and its relationship to function and medical status, by dementia status, in nursing home admissions.

OBJECTIVE: To determine rates of depression by dementia status in a statewide sample of nursing home admissions, and associations with medical comorbidity and physical functioning. METHODS: Trained interviewers obtained information from nursing home residents, staff, significant others, and medical records. RESULTS: A total of 22.3% were classified depressed in the nondemented status and 23.6% in the demented status. Depression status was significantly associated with more physical dependencies regardless of dementia status. In the nondemented, there was also a significant positive association with number of comorbidities. One interaction, dementia with comorbidity at the highest levels of comorbidity, was significant in looking at association with depression. CONCLUSION: There is significant depressive symptomatology in nursing home admissions, which is also associated with difficulty in physical function and with the number of medical comorbidities in the nondemented. Application of the two measures used in this study represents a strategy to assess depression in all nursing home residents.

Using electronic health records to help coordinate care.

The use of electronic health records that can securely transmit patient data among physicians will help coordinate the care of 60 million Americans with multiple chronic conditions. This article summarizes the different organizations in the United States that are developing this technology. It discusses some of the problems encountered and the current initiatives to resolve them. The article concludes with three recommendations for enhancing care coordination: (1) a common health record, such as the Continuity of Care Record, to facilitate the exchange of clinical information among health providers; (2) regional governance structures to encourage the exchange of clinical data; and (3) payment by purchasers of care, both public and private, to physicians for using electronic health records.

Measuring the frequency of contact between nursing home residents and their family and friends.

BACKGROUND: The involvement of family and friends in nursing home care represents an important resource for an overburdened long-term care system. However, little guidance exists for researchers interested in measuring family involvement. OBJECTIVES: This methodological report provides an overview of approaches to measuring family involvement in nursing home care and examines agreement between family and staff on the frequency of visits and telephone calls to a resident by family and friends. Agreement is also assessed for subgroups of the sample based on characteristics of the family, staff, facility, and resident. METHODS: From a large and representative sample of nursing home residents, 823 pairs of significant others and staff were interviewed. Primary variables were reports of visitation and telephone contact received by the resident in the preceding 2 weeks according to the significant other and staff person. RESULTS: Significant other reports of visitation and telephone contact were significantly higher than staff reports (p <.001 and p <.01). Agreement (via intraclass correlation) between significant others and staff was moderate for reports of visit and telephone call frequency. With one exception, no significant differences in agreement were found between subgroups defined by characteristics of the family, staff, facility, or resident. For visits, agreement between nurse's aides and significant others was lower than between other staff persons (e.g., LPNs and RNs) and significant others (p <.05). DISCUSSION: Due to the complexity of nursing home settings as well as of the social support system of residents, researchers need to carefully consider their approach to the measurement of the involvement of family and friends in the nursing home.