The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study.

BACKGROUND: Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs). OBJECTIVE: To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD. EXPOSURE: OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD. KEY RESULTS: The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD. CONCLUSIONS: This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

Medicare Advantage growth and skilled nursing facility finances.

OBJECTIVE: To examine the relationship between growth in Medicare Advantage (MA) enrollment and changes in finances at skilled nursing facilities (SNFs). DATA SOURCES: Medicare SNF cost reports, LTCFocus.org data, and county MA penetration rates. STUDY DESIGN: We used ordinary least squares regression with SNF and year fixed effects. Our primary outcomes were SNF revenues, expenses, profits, and occupancy. Our primary independent variable was the yearly county Medicare Advantage penetration. DATA COLLECTION/EXTRACTION: We linked facility-year data from 2012 to 2019 obtained from cost reports and LTCFocus.org to county-year MA penetration. PRINCIPAL FINDINGS: A 10 percentage point increase in county MA enrollment was associated with a $213,883.89 (95% Confidence Interval [CI]: -296,869.08, -130,898.71) decrease in revenue, a $132,456.19 (95% CI: -203,852.28, -61,060.10) decrease in expenses, and a 0.59 percentage point (95% CI: -0.97, -0.21) decrease in profit margin. A 10 percentage point increase in county MA enrollment was associated with a decline (-318.93; 95% CI: -468.84, -169.02) in the number of resident-days (a measure of occupancy) as well as a decline in the revenue per resident day ($4.50; 95% CI: -6.81, -2.20), potentially because of lower prices in MA. There was also a decline in expenses per patient day (-2.35; 95% CI: -4.76, 0.05), though this was only statistically significant at the 10% level. While increased MA enrollment was associated with a substantial decline in the number of Medicare resident days (487.53; 95% CI: -588.70, -386.37), this was partially offset by an increase in other payer (e.g., private pay) resident days (285.91; 95% CI: 128.18, 443.63). Increased MA enrollment was not associated with changes in the number of Medicaid resident days or a decrease in staffing per resident day. CONCLUSION: SNFs in counties with more MA growth had substantially greater relative declines in revenue, expenses, and profit margins. The continued growth of MA may result in significant changes in the SNF industry.

Longitudinal Care Network Changes and Associated Healthcare Utilization Among Care Recipients.

This study examines caregiver networks, including size, composition, and stability, and their associations with the likelihood of hospitalization and skilled-nursing facility (SNF) admissions. Data from the National Health and Aging Trends Study linked to Center for Medicare and Medicaid Services data were analyzed for 3855 older adults across five survey waves. Generalized estimating equation models assessed the associations. The findings indicate each additional paid caregiver was associated with higher adjusted risk ratios (aRR) for hospitalization (aRR = 1.24, 95% CI 1.10-1.41) and SNF admission (aRR = 1.28, 95% CI 1.06-1.54) among care recipients, a pattern that is also observed with the addition of unpaid caregivers (hospitalization: aRR = 1.13, 95% CI 1.06-1.20; SNF: aRR = 1.12, 95% CI 1.02-1.23). These results suggest that policies and approaches to enhance the quality and coordination of caregivers may be warranted to support improved outcomes for care recipients.

A Risk Prediction Model for Physical Restraints Among Older Chinese Adults in Long-term Care Facilities: Machine Learning Study.

BACKGROUND: Numerous studies have identified risk factors for physical restraint (PR) use in older adults in long-term care facilities. Nevertheless, there is a lack of predictive tools to identify high-risk individuals. OBJECTIVE: We aimed to develop machine learning (ML)-based models to predict the risk of PR in older adults. METHODS: This study conducted a cross-sectional secondary data analysis based on 1026 older adults from 6 long-term care facilities in Chongqing, China, from July 2019 to November 2019. The primary outcome was the use of PR (yes or no), identified by 2 collectors' direct observation. A total of 15 candidate predictors (older adults' demographic and clinical factors) that could be commonly and easily collected from clinical practice were used to build 9 independent ML models: Gaussian Naïve Bayesian (GNB), k-nearest neighbor (KNN), decision tree (DT), logistic regression (LR), support vector machine (SVM), random forest (RF), multilayer perceptron (MLP), extreme gradient boosting (XGBoost), and light gradient boosting machine (Lightgbm), as well as stacking ensemble ML. Performance was evaluated using accuracy, precision, recall, an F score, a comprehensive evaluation indicator (CEI) weighed by the above indicators, and the area under the receiver operating characteristic curve (AUC). A net benefit approach using the decision curve analysis (DCA) was performed to evaluate the clinical utility of the best model. Models were tested via 10-fold cross-validation. Feature importance was interpreted using Shapley Additive Explanations (SHAP). RESULTS: A total of 1026 older adults (mean 83.5, SD 7.6 years; n=586, 57.1% male older adults) and 265 restrained older adults were included in the study. All ML models performed well, with an AUC above 0.905 and an F score above 0.900. The 2 best independent models are RF (AUC 0.938, 95% CI 0.914-0.947) and SVM (AUC 0.949, 95% CI 0.911-0.953). The DCA demonstrated that the RF model displayed better clinical utility than other models. The stacking model combined with SVM, RF, and MLP performed best with AUC (0.950) and CEI (0.943) values, as well as the DCA curve indicated the best clinical utility. The SHAP plots demonstrated that the significant contributors to model performance were related to cognitive impairment, care dependency, mobility decline, physical agitation, and an indwelling tube. CONCLUSIONS: The RF and stacking models had high performance and clinical utility. ML prediction models for predicting the probability of PR in older adults could offer clinical screening and decision support, which could help medical staff in the early identification and PR management of older adults.

Covid-19 Surveillance Testing and Resident Outcomes in Nursing Homes.

BACKGROUND: Despite widespread adoption of surveillance testing for coronavirus disease 2019 (Covid-19) among staff members in skilled nursing facilities, evidence is limited regarding its relationship with outcomes among facility residents. METHODS: Using data obtained from 2020 to 2022, we performed a retrospective cohort study of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among staff members in 13,424 skilled nursing facilities during three pandemic periods: before vaccine approval, before the B.1.1.529 (omicron) variant wave, and during the omicron wave. We assessed staff testing volumes during weeks without Covid-19 cases relative to other skilled nursing facilities in the same county, along with Covid-19 cases and deaths among residents during potential outbreaks (defined as the occurrence of a case after 2 weeks with no cases). We reported adjusted differences in outcomes between high-testing facilities (90th percentile of test volume) and low-testing facilities (10th percentile). The two primary outcomes were the weekly cumulative number of Covid-19 cases and related deaths among residents during potential outbreaks. RESULTS: During the overall study period, 519.7 cases of Covid-19 per 100 potential outbreaks were reported among residents of high-testing facilities as compared with 591.2 cases among residents of low-testing facilities (adjusted difference, -71.5; 95% confidence interval [CI], -91.3 to -51.6). During the same period, 42.7 deaths per 100 potential outbreaks occurred in high-testing facilities as compared with 49.8 deaths in low-testing facilities (adjusted difference, -7.1; 95% CI, -11.0 to -3.2). Before vaccine availability, high- and low-testing facilities had 759.9 cases and 1060.2 cases, respectively, per 100 potential outbreaks (adjusted difference, -300.3; 95% CI, -377.1 to -223.5), along with 125.2 and 166.8 deaths (adjusted difference, -41.6; 95% CI, -57.8 to -25.5). Before the omicron wave, the numbers of cases and deaths were similar in high- and low-testing facilities; during the omicron wave, high-testing facilities had fewer cases among residents, but deaths were similar in the two groups. CONCLUSIONS: Greater surveillance testing of staff members at skilled nursing facilities was associated with clinically meaningful reductions in Covid-19 cases and deaths among residents, particularly before vaccine availability.

Changes in Health and Quality of Life in US Skilled Nursing Facilities by COVID-19 Exposure Status in 2020.

Importance: During the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects. Objective: To assess health outcomes among SNFs with and without known COVID-19 cases. Design, Setting, and Participants: This retrospective observational study used US Medicare claims and Minimum Data Set 3.0 for January through November in each year beginning in 2018 and ending in 2020 including 15 477 US SNFs with 2 985 864 resident-years. Exposures: January through November of calendar years 2018, 2019, and 2020. COVID-19 diagnoses were used to assign SNFs into 2 mutually exclusive groups with varying membership by month in 2020: active COVID-19 (≥1 COVID-19 diagnosis in the current or past month) or no-known COVID-19 (no observed diagnosis by that month). Main Outcomes and Measures: Monthly rates of mortality, hospitalization, emergency department (ED) visits, and monthly changes in activities of daily living (ADLs), body weight, and depressive symptoms. Each SNF in 2018 and 2019 served as its own control for 2020. Results: In 2018-2019, mean monthly mortality was 2.2%, hospitalization 3.0%, and ED visit rate 2.9% overall. In 2020, among active COVID-19 SNFs compared with their own 2018-2019 baseline, mortality increased by 1.60% (95% CI, 1.58% to 1.62%), hospitalizations decreased by 0.10% (95% CI, -0.12% to -0.09%), and ED visit rates decreased by 0.57% (95% CI, -0.59% to -0.55%). Among no-known COVID-19 SNFs, mortality decreased by 0.15% (95% CI, -0.16% to -0.13%), hospitalizations by 0.83% (95% CI, -0.85% to -0.81%), and ED visits by 0.79% (95% CI, -0.81% to -0.77%). All changes were statistically significant. In 2018-2019, across all SNFs, residents required assistance with an additional 0.89 ADLs between January and November, and lost 1.9 lb; 27.1% had worsened depressive symptoms. In 2020, residents in active COVID-19 SNFs required assistance with an additional 0.36 ADLs (95% CI, 0.34 to 0.38), lost 3.1 lb (95% CI, -3.2 to -3.0 lb) more weight, and were 4.4% (95% CI, 4.1% to 4.7%) more likely to have worsened depressive symptoms, all statistically significant changes. In 2020, residents in no-known COVID-19 SNFs had no significant change in ADLs (-0.06 [95% CI, -0.12 to 0.01]), but lost 1.8 lb (95% CI, -2.1 to -1.5 lb) more weight and were 3.2% more likely (95% CI, 2.3% to 4.1%) to have worsened depressive symptoms, both statistically significant changes. Conclusions and Relevance: Among skilled nursing facilities in the US during the first year of the COVID-19 pandemic and prior to the availability of COVID-19 vaccination, mortality and functional decline significantly increased at facilities with active COVID-19 cases compared with the prepandemic period, while a modest statistically significant decrease in mortality was observed at facilities that had never had a known COVID-19 case. Weight loss and depressive symptoms significantly increased in skilled nursing facilities in the first year of the pandemic, regardless of COVID-19 status.

Predictors of Acute Care Transfers From Skilled Nursing Facilities: Recommendations for Preventing Unnecessary Hospitalization.

Preventing acute care transfers from skilled nursing facilities (SNFs) is a challenge secondary to residents' associated debilitated status and comorbidities. Acute care transfers often result in serious complications and unnecessary health care expenditure. Literature implies that approximately two thirds of these acute care transfers could be prevented using proactive interventions. The purpose of the current study was to identify the predictors of acute care transfers for SNF residents in developing relevant prevention strategies. A retrospective chart review using multivariate logistic regression analysis showed increased odds of SNF hospitalization was significantly associated with impaired cognition, chronic obstructive pulmonary disease, and chronic kidney disease, whereas decreased odds of hospitalization was identified among non-Hispanic White residents. Study recommendations include prompt assessment of comorbid symptomatology among SNF residents for the timely management and prevention of unnecessary acute care transfers. [Research in Gerontological Nursing, 15(4), 172-178.].

Discontinuation of beta-blockers among nursing home residents at end of life.

BACKGROUND: Given limited life expectancy of nursing home (NH) residents, harms of continuing beta-blockers (BBs) may outweigh clinical benefits. Our objective was to describe beta-blocker discontinuation for NH residents during the last year of life, and identify characteristics associated with earlier discontinuation. METHODS: This was a retrospective cohort study that included all long-stay residents in fee-for-service Medicare who died in 2016 and were prescribed oral BBs 1 year before death. Beta-blocker discontinuation was defined as a gap in medication on hand for ≥45 days per Medicare Part D claims, measured from the last date drug was on hand. Comorbidities were obtained from Chronic Condition Warehouse, and other characteristics from the Minimum Data Set. Kaplan-Meier curves were used to describe time to first discontinuation. Findings were stratified by cardiac diagnoses, perceived life expectancy of <6 months, or elevated mortality index. RESULTS: Eighty-eight thousand two hundred and eighty-four residents were prescribed ≥1 daily BB 12 months before death. Mean age was 84.1 years and 69.2% were female. Of these, 60,573 residents (68.6%) remained on a BB in the last 45 days of life, and 57,880 residents (65.6%) had ≥1 cardiac diagnosis. Only 5239 residents (5.9%) had elevated mortality index, whereas 16,798 residents (19.0%) had perceived poor prognosis. In the last year of life, there was no difference in beta-blocker discontinuation pattern between residents with and without cardiac diagnoses. Residents with perceived poor prognosis and elevated mortality index discontinued BBs earlier. For example, mean time until discontinuation among residents with poor perceived prognosis was 245 versus 279 days in residents without such prognosis (p < 0.0001). CONCLUSIONS: BBs are commonly prescribed to NH residents in the final year of life. Overall, discontinuation occurs earlier in residents for whom clinicians perceive limited life expectancy, suggesting that improved prognostication may offer an important opportunity to reduce polypharmacy toward end of life.

Establishing Medicaid incentives for liberating nursing home patients from ventilators.

BACKGROUND: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives. METHODS: Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators. RESULTS: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days. CONCLUSIONS: This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.

Temperature and oxygen saturation in skilled nursing facility residents positive for SARS-CoV-2 prior to symptom onset.

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spreads rapidly amongst residents of skilled nursing facilities (SNFs). The rapid transmission dynamics and high morbidity and mortality that occur in SNFs emphasize the need for early detection of cases. We hypothesized that residents of SNFs infected with SARS-CoV-2 would demonstrate an acute change in either temperature or oxygen saturation (SpO2 ) prior to symptom onset. The Minnesota Department of Health (MDH) conducted a retrospective analysis of both temperature and SpO2 at two separate SNFs to assess the utility of these quantitative markers to identify SARS-CoV-2 infection prior to the development of symptoms. METHODS: A retrospective analysis was conducted of 165 individuals positive for SARS-CoV-2 who were residents of SNFs that experienced coronavirus disease 2019 (COVID-19) outbreaks during April-June 2020 in a metropolitan area of Minnesota. Age, sex, symptomology, temperature and SpO2 values, date of symptom onset, and date of positive SARS-CoV-2 test were analyzed. Temperature and SpO2 values for the period 14 days before and after the date of initial positive test were included. Descriptive analyses evaluated changes in temperature and SpO2 , defined as either exceeding a set threshold or demonstrating an acute change between consecutive measurements. RESULTS: Two (1%) residents had a temperature value ≥100°F, and 30 (18%) had at least one value ≥99°F within 14 days before symptom development. One hundred and sixteen residents (70%) had at least one SpO2 value ≤94%, while 131 (80%) had an acute decrease in SpO2 of ≥3% between consecutive values in the 14 days prior to symptom onset. CONCLUSIONS: Our results suggest that acute change in SpO2 might be useful in the identification of SARS-CoV-2 infection prior to the development of symptoms among residents living in SNFs. Facilities may consider adding SpO2 to daily temperature and symptom screening checklists to improve early detection of residents of SNFs infected with SARS-CoV-2.

Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance.

IMPORTANCE: Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE: The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS: A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES: Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS: BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS: BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance.

BACKGROUND: The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions. OBJECTIVE: The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP. RESEARCH DESIGN: We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis. RESULTS: The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312. CONCLUSIONS: SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

The patient-driven payment model: A missed opportunity for patient-centered cancer care.

Hospitalized older patients with advanced cancer who were discharged to a skilled nursing facility (SNF) for rehabilitation are unlikely to receive future cancer treatment, have high 30-day readmission rates, and high mortality yet minimal hospice use. The Medicare SNF benefit was designed to be a bridge and provide short-term nursing and rehabilitation care for patients after a hospitalization. However, advanced cancer patients churn through the health system cycling between the hospital, post-acute care facilities, and home in the last months of life. This article explores the potential impact of the patient-driven payment model, a new SNF reimbursement model introduced by the Center for Medicare and Medicaid Services in 2019, on the experience of older cancer patients. Previously, SNF reimbursement was based on the hours of rehabilitative therapy provided to patients, unintentionally incentivizing SNFs to provide more therapy resulting in long lengths of stay and increased Medicare expenditure. The new patient-driven payment model bases reimbursement on patient clinical characteristics and resources utilized during their SNF stay. We discuss the impact this payment model might have on cancer patients in the SNF setting and highlight the importance of access to palliative care for this population. We discuss challenges policymakers face in creating palliative care guidelines and developing palliative care delivery models in SNFs. We highlight the policy gaps that remain in creating a system that achieves high-quality SNF care and conclude by offering suggestions that might better incorporate a patient's illness trajectory, prognosis, and goals of care.

Safety, Feasibility, and Outcomes of Frequent, Long-Duration Rehabilitation in an Inpatient Rehabilitation Facility After Prolonged Hospitalization for Severe COVID-19: An Observational Study.

OBJECTIVE: he objective of this study was to evaluate safety, feasibility, and outcomes of 30 patients within an inpatient rehabilitation facility following hospitalization for severe Coronavirus Disease 19 (COVID-19) infection. METHODS: This was an observational study of 30 patients (ages 26-80 years) within a large, metropolitan, academic hospital following hospitalization for complications from severe COVID-19. Ninety percent of the participants required critical care, and 83% required mechanical ventilation during their hospitalization. Within an inpatient rehabilitation facility and model of care, frequent, long-duration rehabilitation was provided by occupational therapists, physical therapists, and speech language pathologists. RESULTS: The average inpatient rehabilitation facility length of stay was 11 days (ranging from 4-22 days). Patients averaged 165 min/d (ranging from 140-205 minutes) total of physical therapy, occupational therapy, and speech therapy. Twenty-eight of the 30 patients (93%) were discharged to the community. One patient required readmission from an inpatient rehabilitation facility to an acute hospital. All 30 patients improved their functional status with inpatient rehabilitation. CONCLUSION: In this cohort of 30 patients, inpatient rehabilitation after severe COVID-19 was safe and feasible. Patients were able to participate in frequent, long-duration rehabilitation with nearly all patients discharging to the community. Clinically, inpatient rehabilitation should be considered for patients with functional limitations following severe COVID-19. Given 90% of our cohort required critical care, future studies should investigate the efficacy and effectiveness of inpatient rehabilitation following hospitalization for critical illness. Frequent, long-duration rehabilitation shows promising potential to address functional impairments following hospitalization for severe COVID-19. IMPACT: Inpatient rehabilitation facilities should be considered as a discharge location for hospitalized survivors of COVID-19, especially severe COVID-19, with functional limitations precluding community discharge. Clinicians and administrators should consider inpatient rehabilitation and inpatient rehabilitation facilities to address the rehabilitation needs of COVID-19 and critical illness survivors.

Outcomes of post-acute care in skilled nursing facilities in Medicare beneficiaries with and without a diagnosis of dementia.

BACKGROUND: More than 600,000 Medicare beneficiaries with a diagnosis of dementia are discharged to skilled nursing facilities (SNFs) after hospitalization annually. However, it is unclear how their risks and benefits of a SNF stay compare to beneficiaries without a diagnosis of dementia. DESIGN: Retrospective analysis comparing SNF outcomes for Medicare beneficiaries with and without a diagnosis of dementia. SETTING: One hundred percent sample of Medicare beneficiaries from 2015 to 2016. PARTICIPANTS: Dementia was identified using validated diagnosis codes. In beneficiaries who had an acute hospitalization followed by SNF stay, we used propensity score matching to balance demographics, comorbidities, characteristics of the index hospital stay, prior hospital and SNF utilization, and cognitive status on SNF admission. MEASUREMENTS: Outcomes included unplanned hospital readmission, community discharge rate, and mortality during the SNF stay. Multivariate models were adjusted for hospital and SNF characteristics. RESULTS: Our sample included 2,418,853 Medicare beneficiaries discharged from hospital to SNF; 830,524 (34.3%) carried a diagnosis of dementia. Overall, 14.7% of the sample had a hospital readmission, 5.0% died, and 61.5% were successfully discharged to the community. In the propensity-matched cohort, beneficiaries with a diagnosis of dementia had a lower odds ratio of mortality (OR 0.87; 95% confidence interval [CI] 0.86-0.89), similar odds of hospital readmission (OR 0.99; 95% CI 0.98-1.00), and reduced odds of discharge to the community (OR 0.92; 95% CI 0.91-0.93). However, these findings varied by the severity of cognitive impairment on SNF admission: in beneficiaries with no impairment, those with a diagnosis of dementia had higher odds of adverse outcomes. In beneficiaries with severe impairment, beneficiaries with a diagnosis of dementia had lower odds of adverse outcomes. CONCLUSIONS: Cognitive dysfunction on SNF admission is a stronger predictor of outcomes than a diagnosis of dementia, suggesting the need to individualize decisions about the benefits and risks of SNF care in populations with cognitive impairment.

Health Care Resource Utilization Associated With Parkinson Disease Among Medicare Beneficiaries.

OBJECTIVE: To compare differences in health care resource utilization (HcRU) over time between Medicare beneficiaries with and without Parkinson disease (PD). METHODS: This retrospective observational study used the Chronic Conditions Data Warehouse (5% Medicare sample) between 2005 and 2015. In a propensity score-matched (age, sex, race, and comorbidity adjusted) sample of beneficiaries with and without PD, we examined all-cause HcRU due to inpatient admissions, emergency department (ED) admissions, skilled nursing facility (SNF) admissions, health care provider encounters, neurologist visits, rehabilitation service visits, and non-PD medication fills. Relative to beneficiaries without PD, we reported adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for beneficiaries with PD using generalized linear models with log link and negative binomial variance functions. RESULTS: A total of 467,064 Medicare enrollees (unmatched sample) met the inclusion criteria. Of these, 3.3% had PD. In the matched sample and relative to beneficiaries without PD, beneficiaries with PD displayed higher rates of inpatient admissions (IRR 1.29, 95% CI 1.24-1.34), ED admissions (IRR 1.31, 95% CI 1.27-1.34), SNF admissions (IRR 2.00, 95% CI 1.92-2.09), health care provider encounters (IRR 1.18, 95% CI 1.16-1.20), neurologist visits (IRR 5.57, 95% CI 5.35-5.78), rehabilitation service visits (IRR 1.47, 95% CI 1.41-1.53), and non-PD medication fills (IRR 1.10, 95% CI 1.08-1.11) over time. CONCLUSION: These results reflect patterns of medical care among Medicare beneficiaries with PD. The findings can help clinicians, payers, and policy makers make evidence-based decisions for the allocation of scarce health care resources for PD management. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that Medicare beneficiaries with PD use more health care resources than matched controls without PD.

Prevalence and Characteristics of Non-US-Born and US-Born Health Care Professionals, 2010-2018.

Importance: Immigration to the US results in greater racial/ethnic diversity. However, the contribution of immigration to the diversity of the US health care professional (HCP) work force and its contribution to health care are poorly documented. Objective: To examine the sociodemographic characteristics and workforce outcomes of non-US-born and US-born HCPs. Design, Setting, and Participants: This cross-sectional study used national US Census Bureau data on US-born and non-US-born HCPs from the American Community Survey between 2010 and 2018. Demographic characteristics and occupational data for physicians, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses or licensed vocational nurses, and other HCPs were included for analysis. Data were analyzed between December 2020 and February 2021. Exposures: Nativity status, defined as US-born HCP vs non-US-born HCP (further stratified by <10 years or ≥10 years of stay in the US). Main Outcomes and Measures: Annual hours worked, proportion of work done at night, residence in medically underserved areas and populations, and work in skilled nursing/home health settings. Inverse probability weighting of 3 nativity status groups was carried out using logistic regression. F test statistics were used to test across-group differences. Data were weighted using American Community Survey sampling weights. Results: Of a total of 657 455 HCPs analyzed (497 180 [75.5%] women; mean [SD] age, 43.7 [13.0] years; 518 317 [75.6%] White, 54 233 [10.8%] Black, and 60 680 [9.6%] Asian), non-US-born HCPs (105 331 in total) represented 17.3% (95% CI, 17.2%-17.4%) of HCPs between 2010 and 2018. They were older (mean [SD] age, 44.7 [11.6] years) and had more education (75 227 [70.1%] HCPs completed college) compared with US-born HCPs (mean [SD] age, 43.4 [13.3] years; 304 601 [55.2%] completed college). Nearly half of non-US-born HCPs (47 735 [43.0%]) were Asian. In major metropolitan areas, non-US-born HCPs represented 40% or more of all HCPs. Compared with US-born HCPs, non-US-born HCPs with less than 10 years and 10 or more years of stay worked 32.3 hours (95% CI, 19.2 to 45.4 hours) and 71.6 hours (95% CI, 65.1 to 78.2 hours) more per year, respectively. Compared with US-born HCPs, non-US-born HCPs were more likely to reside in areas with shortages of health care professionals (estimated percentage: <10 years, 75.3%; ≥10 years, 62.8% vs US-born, 8.3%) and work in home health settings (estimated percentage: <10 years, 17.5%; ≥10 years, 13.1% vs US-born, 12.8%). Conclusions and Relevance: The contributions of non-US-born HCPs to US health care are substantial and vary by profession. Greater efforts should be made to streamline their immigration process and to harmonize training and licensure requirements.