Avoiding Spending While Meeting Patients' Wishes: A Model of Community-Based Palliative Care Uptake in California from 2014-2022.

BACKGROUND: Community-based palliative care can improve outcomes and avoid unnecessary spending, but the effects of its widespread adoption on health care spending in California is unknown. OBJECTIVE: To estimate the spending avoided if, by 2022, more than 100,000 Californians received community-based palliative care (CBPC) per year. DESIGN: We estimated the 6-month per-patient spending avoided through three mature CBPC programs in California and extrapolated data to predict the total avoided spending statewide over 8 years if enrollment in the three programs proceeded according to our model. RESULTS: If Californians participated in CBPC in the numbers envisioned, in 2014 there would have been a $72 million reduction in intensive hospital based care, while still respecting patients' wishes, and nearly $1.1 billion in spending could be avoided in 2022. Overall hospital spending would be reduced by more than $5.5 billion through 2022. CONCLUSIONS: Existing CBPC programs have the potential to provide care that is both in alignment with patients' wishes and avoids substantial amounts of unnecessary hospital-based spending.

Hospitalization-Associated Disability in Adults Admitted to a Safety-Net Hospital.

BACKGROUND: Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals. OBJECTIVES: To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital. DESIGN: Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders. SETTING: Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital. PARTICIPANTS: A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group. MEASUREMENTS: The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants' functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function. RESULTS: Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55-59, 22.2 % in ages 60-64, 17.4 % in ages 65-69, 30.3 % in ages 70-79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15). CONCLUSIONS: In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55-59 and those aged 70-79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital.

OBJECTIVES: To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age. DESIGN: Cross-sectional analysis. SETTING: Safety-net hospital in San Francisco, California. PARTICIPANTS: English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699). MEASUREMENTS: At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors. RESULTS: Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability. CONCLUSION: Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

Effect of racial and ethnic composition of neighborhoods in San Francisco on rates of mental health-related 911 calls.

OBJECTIVE: This study investigated the association between the racial and ethnic residential composition of San Francisco neighborhoods and the rate of mental health-related 911 calls. METHODS: A total of 1,341,608 emergency calls (28,197 calls related to mental health) to San Francisco's 911 system were made from January 2001 through June 2003. Police sector data in the call records were overlaid onto U.S. census tracts to estimate sector demographic and socioeconomic characteristics. Negative binomial regression was used to estimate the association between the percentage of black, Asian, Latino, and white residents and rates of mental health-related calls. RESULTS: A one-point increase in a sector's percentage of black residents was associated with a lower rate of mental health-related calls (incidence rate ratio=.99, p<.05). A sector's percentage of Asian and Latino residents had no significant effect. CONCLUSIONS: The observed relationship between the percentage of black residents and mental health-related calls is not consistent with known emergency mental health service utilization patterns.

Rates of unemployment and incidence of police-initiated examinations for involuntary hospitalization in Florida.

OBJECTIVE: This study tested the hypothesis that contraction of regional economies affects the incidence of involuntary admissions to psychiatric emergency services by reducing community tolerance for persons perceived as threatening to others. METHODS: This hypothesis was tested with time-series analyses of the relationship between initial claims for unemployment in Florida between July 4, 1999, and June 28, 2003, and the weekly number of men and women presented by police to be examined for involuntary psychiatric hospitalization because of danger to others. The analyses controlled for admissions presented by mental health professionals because of danger to others and for admissions presented by police because of neglect or disability. RESULTS: When the analyses controlled for autocorrelation and other covariates, claims for unemployment insurance were significantly associated with the number of men presented by police for danger to others. During the study period, police presented 5,897 men for examination because of danger to others. Increased unemployment claims were associated with approximately 309 more men being presented for examination than expected from prior presentation rates and from the number presented by mental health professionals for danger to others and by police for neglect or disability. No such association was found for women. CONCLUSIONS: Consistent with theory, this study found that presentations for involuntary admission to psychiatric services increased after contractions in the labor market. Combining the methods of this study with econometric forecasting may allow providers to anticipate better the need for psychiatric services.

Public health care utilization in a cohort of homeless adult applicants to a supportive housing program.

Supportive housing is subsidized housing with on-site or closely linked services for chronically homeless persons. Most literature describing the effects of supportive housing on health service utilization does not describe use across multiple domains of services. We conducted a retrospective cohort study of 249 applicants to a supportive housing program; 114 (45.7%) were housed in the program. We describe the pattern of service use across multiple domains (housing, physical health care, mental health care, substance abuse treatment). We examine whether enrollment in supportive housing was associated with decreased use of acute health services (emergency department (ED) and inpatient medical hospitalizations) and increased use of ambulatory services (ambulatory medical and generalist care, mental health, and substance abuse treatment) as compared to those eligible but not enrolled. Participants in both groups exhibited high rates of service utilization. We did not find a difference in change in utilization patterns between the two groups [those that received housing (intervention) and those that applied, were eligible, but did not establish residency (usual care group)] comparing the two years prior to the intervention to the two years after. The finding of high rates of maintenance of housing is, in itself, noteworthy. The consistently high use of services across multiple domains and across multiple years speaks to the level of infirmity of this population and the costs of caring for its members.

Psychiatric emergencies after the terrorist attacks of September 11, 2001.

OBJECTIVE: Population surveys suggest that the events of September 11, 2001, resulted in psychiatric emergencies in U.S. communities. This study tested the extent of such emergencies in San Francisco. METHOD: S: Interrupted time-series designs were applied to counts of emergency calls to the police during the 424-day period beginning January 1, 2001, and of voluntary and coerced admissions to psychiatric emergency services during the 1620-day period beginning July 1, 1997. RESULTS: The number of men and women who were coerced into treatment increased significantly on Thursday, September 13, but the number of voluntary admissions was as expected. The number of telephone calls from citizens that police dispatchers judged to be mental health related increased significantly on Wednesday, September 12, and remained elevated through September 13. Several additional analyses were conducted to test the stability of the findings, and the results were essentially unchanged. CONCLUSIONS: The events of September 11 may not have induced emergent mental illness in U.S. communities at relatively great distance from the attacks. However, it is possible that persons with severe mental illness were either more evident to or less tolerated by the community.