Special Focus Facilities vs Special Focus Facility Candidates: What is the Difference?

OBJECTIVES: This study compares Special Focus Facilities (SFFs) and Special Focus Facility Candidate Facilities (SFFcs) on organizational traits and quality outcomes to evaluate the effectiveness of the SFF program as a quality improvement intervention and inform potential areas for program reform. DESIGN: This is a retrospective analysis. SETTINGS AND PARTICIPANTS: Using data from the Centers for Medicare and Medicaid Services archives for 2020, this retrospective study analyzed 247 nursing facilities (50 SFFs and 197 SFFcs). METHODS: Variables of interest were staffing, profit status, facility size, certification status, number of residents, and complaint citations: t tests, χ2, Fisher's Exact test, and multivariate analysis of variance were used to compare the 2 groups. RESULTS: From an organizational perspective, SFFs and SFFcs are minimally different. Both groups had similar facility size, profit status, hospital affiliation, continuing care retirement community status, and Medicare/Medicaid certification. Large and for-profit facilities were overrepresented in both groups. SFFs and SFFcs exhibited statistical differences in the number of complaint deficiencies. The groups had no significant difference in staffing levels, category, severity of complaints, or incident reports. CONCLUSIONS AND IMPLICATION: The study's findings suggest that the SFF program, while resource-intensive, is minimally impactful. The similarities between SFFs and SFFcs raise questions about the program's effectiveness in improving nursing facility care. Previous adjustments to the program may not have successfully achieved the desired quality improvements. This research highlights the need to further evaluate the SFF program's effectiveness as a quality improvement intervention. It also underscores the importance of addressing biases and subjectivity in state survey agency processes, which affect the enrollment of nursing facilities. The study underscores the flaws within the nursing home monitoring system and the 5-star quality rating system, especially when comparing small samples between states.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home.

OBJECTIVES: Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN: Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT: Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES: Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS: We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS: Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes.

BACKGROUND: Antipsychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of antipsychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD. METHODS: In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analyzed using logistic (predictors) and linear regression (association with outcome) analyses. RESULTS: The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioral and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, antipsychotic use was associated with having less ADL improvement at HHC discharge (ß = -0.70, p < 0.001). CONCLUSIONS: HHC patients living with ADRD were more likely to use antipsychotics and to experience worse functional outcomes when using antipsychotics. Antipsychotics should be systematically reviewed and, if contraindicated or unnecessary, deprescribed. Efforts are needed to improve HHC patients' access to nonpharmacological interventions and to provide education for caregivers regarding behavioral approaches to manage symptoms in ADRD.

How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks.

PURPOSE: Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC. METHODS: A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping. FINDINGS: Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication. IMPLICATIONS: Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.

Differential Effects of an Emergency Department-to-Home Care Transitions Intervention in an Older Adult Population: A Latent Class Analysis.

BACKGROUND: Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. OBJECTIVES: We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. RESEARCH DESIGN: Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. SUBJECTS: Participants were ED patients (age 60 y and above) discharged to a community residence. MEASURES: Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. RESULTS: We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03). CONCLUSIONS: Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.

Postgraduate dental resident education: A pilot in age-friendly "mentation" training.

OBJECTIVE: Postdoctoral dental education in caring for older adults lacks didactic and clinical training in mentation topics, one of the core elements of the Age-Friendly Health Systems (AFHS) framework. Our primary goal was to launch a pilot project in clinical geriatrics focusing on older adults' mentation concerns, with a secondary goal to improve dental residents' confidence and competence in dental care and oral health. BACKGROUND: Age-friendly care elements are not routinely incorporated into the dental education of residents caring for older adults with cognitive impairment or dementia. Therefore, we implemented a pilot educational project, providing the missing educational opportunity for residents in geriatric training covering cognitive impairment and focusing on Alzheimer's disease and related dementias. MATERIALS AND METHODS: We designed educational sessions through a needs assessment, focus group discussions, and expert validation. We developed three e-Learning modules covering mentation concerns and dementia screening. We tested the modules in a pilot study of 15 dental postdoctoral residents as an essential part of their clinical practice. RESULTS: The dementia dental learning module increased the residents' satisfaction with didactic preparedness (4.45  ± $ \pm \ $ 0.97) and knowledge acquisition (4.36  ± $ \pm \ $ 0.84). Residents strongly believed that learning about the AFHS-mentation topic would improve patient care. CONCLUSION: Our pilot study is a pioneer project in support of a new AFHS-themed dental curriculum for clinical education. Further expansion of the age-friendly principles to include mobility, medications, and what matters to older adults will establish a model framework of redesigned geriatric dental education for academic centers.

Older Adults Receiving Rehabilitation Services Are More Likely to Get Bathing and Toileting Equipment Installed.

IMPORTANCE: Adaptive equipment, such as shower grab bars and modified toilet seating, is effective but underused in the United States. To change this, a better understanding of how equipment ends up being installed is needed. We hypothesized that rehabilitation services were a major mechanism. OBJECTIVE: To examine the association between receipt of rehabilitation services and installation of adaptive equipment. DESIGN: Observational cohort of the National Health and Aging Trends Study in 2015 and 2016. SETTING: Community. PARTICIPANTS: A total of 416 community-dwelling adults age 65 yr or older who needed bathing equipment and 454 who needed toileting equipment. OUTCOMES AND MEASURES: Study outcomes were the installation of bathing or toileting equipment. The primary independent variable was the receipt of rehabilitation services between 2015 and 2016. RESULTS: Among older adults who needed equipment in 2015, 34.3% had bathing equipment and 19.2% had toileting equipment installed by 2016. In multivariate logistic regression analyses, rehabilitation services were associated with installation of bathing (odds ratio [OR] = 5.07, 95% confidence interval [CI] [2.60, 9.89]) and toileting equipment (OR = 2.67, 95% CI [1.48, 4.84]). CONCLUSIONS AND RELEVANCE: A minority of those in need have adaptive equipment installed within a year. In the current health care system, rehabilitation providers play a major role in equipment installation. What This Article Adds: Rehabilitation providers are involved in the installation of adaptive bathroom equipment among older persons who need it. Still, most in need of equipment do not have it after a year, suggesting that further work is needed to increase access to rehabilitation providers and develop other avenues for obtaining equipment.

How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials.

OBJECTIVE: To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE: Published literature. STUDY DESIGN: Scoping review. DATA EXTRACTION METHODS: The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS: Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT: "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS: "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.

Multimethod Process Evaluation of a Community Paramedic Delivered Care Transitions Intervention for Older Emergency Department Patients.

OBJECTIVE: We assessed fidelity of delivery and participant engagement in the implementation of a community paramedic coach-led Care Transitions Intervention (CTI) program adapted for use following emergency department (ED) visits. METHODS: The adapted CTI for ED-to-home transitions was implemented at three university-affiliated hospitals in two cities from 2016 to 2019. Participants were aged ≥60 years old and discharged from the ED within 24 hours of arrival. In the current analysis, participants had to have received the CTI. Community paramedic coaches collected data on program delivery and participant characteristics at each transition contact via inventories and assessments. Participants provided commentary on the acceptability of the adapted CTI. Using a multimethod approach, the CTI implementation was assessed quantitatively for site- and coach-level differences. Qualitatively, barriers to implementation and participant satisfaction with the CTI were thematically analyzed. RESULTS: Of the 863 patient participants, 726 (84.1%) completed their home visits. Cancellations were usually patient-generated (94.9%). Most planned follow-up visits were successfully completed (94.6%). Content on the planning for red flags and post-discharge goal setting was discussed with high rates of fidelity overall (95% and greater), while content on outpatient follow-up was lower overall (75%). Differences in service delivery between the two sites existed for the in-person visit and the first phone follow-up, but the differences narrowed as the study progressed. Participants showed a 24.6% increase in patient activation (i.e., behavioral adoption) over the 30-day study period (p < 0.001).Overall, participants reported that the program was beneficial for managing their health, the quality of coaching was high, and that the program should continue. Not all participants felt that they needed the program. Community paramedic coaches reported barriers to CTI delivery due to patient medical problems and difficulties with phone visit coordination. Coaches also noted refusal to communicate or engage with the intervention as an implementation barrier. CONCLUSIONS: Community paramedic coaches delivered the adapted CTI with high fidelity across geographically distant sites and successfully facilitated participant engagement, highlighting community paramedics as an effective resource for implementing such patient-centered interventions.

Implementation considerations of deprescribing interventions: A scoping review.

Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.

Scalar Assessment of the Family Caregiver Activation in Transitions Tool: An Exploratory Factor Analysis.

The Family Caregiver Activation in Transitions (FCAT) tool in its current, non-scalar form is not pragmatic for clinical use as each item is scored and intended to be interpreted individually. The purpose of the current study was to create a scalar version of the FCAT to facilitate better care communications between hospital staff and family caregivers. We also assessed the scale's validity by comparing the scalar version of the measure against patient health measures. Data were collected from 463 family caregiver-patient dyads from January 2016 to July 2019. An exploratory factor analysis was performed on the 10-item FCAT, resulting in a statistically homogeneous six-item scale focused on current caregiving activation factors. The measure was then compared against patient health measures, with no significant biases found. The six-item scalar FCAT can provide hospital staff insight into the level of caregiver activation occurring in the patient's health care and help tailor care transition needs for family caregiver-patient dyads. [Journal of Gerontological Nursing, 48(12), 35-42.].

The invisible gap: Older adults' communication with health care providers about concomitant use of alcohol and medications.

The purpose of this study was to assess the impact of a new educational intervention, Communicating with your Health Care Providers, which was designed to assist older adults in communicating with their physicians and other health care providers and improving their knowledge about concomitant alcohol and medication risks. A randomized control trial was conducted in older adult centers in an urban community. Participants were assigned to either the intervention group or a control group that received traditional services. The intervention group received educational material about health, physical and other aging changes, medication use and possible adverse interactions between alcohol and medications, as well as strategies to initiate communication with physicians and other health care providers. The outcomes measured were: (1) interest in communicating with physicians and health care providers; (2) perception of the importance of communication; and (3) knowledge about concomitant alcohol and medication use. MANCOVA tests indicated that the intervention group had greater knowledge about the risks of combining alcohol with prescription medications than the control group, as well as greater interest in having health care discussions with their physicians and other health care providers. These findings may be translated into future educational programming for community centers.

Coaching older adults discharged home from the emergency department: The role of competence and emotion in following up with outpatient clinicians.

OBJECTIVE: Motivating older adults to follow up with an outpatient clinician after discharge from emergency departments (ED) is beneficial yet challenging. We aimed to answer whether psychological needs for motivation and discrete emotions observed by care transition coaches would predict this behavioral outcome. METHODS: Community-dwelling older adults following ED discharge were recruited from three EDs in two U.S. states. We examined home visit notes documented by coaches (N = 725). Retrospective chart reviews of medical records tracked participants' health care utilization for 30 days. RESULTS: Observed knowledge-based competence predicted higher likelihood of outpatient follow-up within 30 days, while observed sadness predicted a lower likelihood of follow-up within seven days following discharge. Moreover, participants who demonstrated happiness were marginally more likely to have an in-person follow-up within seven days, and those who demonstrated knowledge-based competence were more likely to have an electronic follow-up within 30 days. CONCLUSIONS: Knowledge-based competence and emotions, as observed and documented in coach notes, can predict older adults' subsequent outpatient follow-up following their ED-discharge. PRACTICE IMPLICATIONS: Intervention programs might encourage coaches to check knowledge-based competence and to observe emotions in addition to delivering the content. Coaches could also customize strategies for patients with different recommended timeframes of follow-up.

Medications Associated With Geriatric Syndromes (MAGS) and Hospitalization Risk in Home Health Care Patients.

OBJECTIVES: Polypharmacy is common in home health care (HHC). This study examined the prevalence of medications associated with geriatric syndromes (MAGS), its predictors, and association with subsequent hospitalization in HHC. DESIGN: Analysis of HHC electronic medical records, the Outcome and Assessment Information Set (OASIS), and Medicare HHC claims. SETTING AND PARTICIPANTS: A total of 6882 adults ≥65 years old receiving HHC in 2019 from a large, not-for-profit home health agency serving multiple counties in New York State. MEASURES: MAGS use was identified from active medications reconciled during HHC visits (HHC electronic medical records). MAGS use was operationalized as count and in quartiles. Hospitalization during the HHC episode was operationalized as a time-to-event variable (ie, number of days from HHC admission to hospitalization). We used regression analyses to identify predictors of MAGS use, and survival analyses to examine the association between MAGS and hospitalization. RESULTS: Nearly all (98%) of the HHC patients used at least 1 MAGS and 41% of all active medications used by the sample were MAGS. More MAGS use was found in HHC patients who were community-referred, taking more medications, and having more diagnoses, depressive symptoms, and functional limitations. Adjusted for covariates, higher MAGS quartiles were not independently associated with the risk of hospitalization, but higher MAGS quartiles combined with multimorbidity (ie, having ≥10 diagnoses) were associated with a 2.3-fold increase in hospitalization risk (hazard ratio 2.24; 95% confidence interval: 1.61-3.13; P < .001), relative to the lowest quartile of MAGS use and having <10 diagnoses. CONCLUSIONS AND IMPLICATIONS: More than 40% of medications taken by HHC patients are MAGS. Multimorbidity and MAGS use collectively increased the risk of hospitalization by up to 2.3 times. HHC clinicians should carefully review patients' medications and use information about MAGS to facilitate discussion about deprescribing with patients and their prescribers.

A Multi-Component Transition of Care Improvement Project to Reduce Hospital Readmissions Following Ischemic Stroke.

Background: Ischemic stroke (IS) is a common cause of hospitalization which carries a significant economic burden and leads to high rates of death and disability. Readmission in the first 30 days after hospitalization is associated with increased healthcare costs and higher risk of death and disability. Efforts to decrease the number of patients returning to the hospital after IS may improve quality and cost of care. Methods: Improving care transitions to reduce readmissions is amenable to quality improvement (QI) initiatives. A multi-component QI intervention directed at IS patients being discharged to home from a stroke unit at an academic comprehensive stroke center using IS diagnosis-driven home care referrals, improved post-discharge telephone calls, and timely completion of discharge summaries was developed. The improvement project was implemented on July 1, 2019, and evaluated for the 6 months following initiation in comparison to the same 6-month period pre-intervention in 2018. Results: Following implementation, a statistically significant decrease in 30-day all-cause same-hospital readmission rates from 7.4% to 2.8% (p = .031, d = 1.61) in the project population and from 6.6% to 3% (p = .010, d = 1.43) in the overall IS population was observed. Improvement was seen in all process measures as well as in patient satisfaction scores. Conclusions: An evidence-based bundled process improvement intervention for IS patients discharged to home was associated with decreased hospital readmission rates following IS.

Care transitions intervention reduces ED revisits in cognitively impaired patients.

Introduction: About half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population. Methods: We conducted a pre-planned subgroup analysis of community-dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED-to-home transitions. The parent study recruited ED patients from three university-affiliated hospitals from 2016 to 2019. Subjects eligible for this sub-analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression. Results: Of our sub-sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow-up found no significant effects. Discussion: Community-dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.

Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial.

BACKGROUND: Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge. METHODS: We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. RESULTS: Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). CONCLUSIONS: The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes.

OBJECTIVES: Nursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents. DESIGN: The 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.0 were analyzed. We implemented generalized estimating equation models to examine micropolitan-urban differences in ED rates and Blinder-Oaxaca decompositions to quantify the contributions of NH and market factors. SETTING AND PARTICIPANTS: The study cohort included 12,883 unique privately owned, freestanding NHs from urban and micropolitan areas. MEASURES: Quarterly risk-adjusted rates of any ED visits, outpatient ED visits, and PAED visits were calculated from Medicare claims and MDS. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and Area Health Resources File. RESULTS: Over the study period, risk-adjusted rates averaged 10.2%, 3.4%, and 3.3% for any ED, outpatient ED, and PAED visits, respectively. Compared with urban NHs, micropolitan NHs reported similar rates of any ED, but significantly higher rates of outpatient ED and PAED (ß = 0.20% and 0.27%; both P < .05). Observable differences in NH characteristics (eg, number of beds, percentage Medicare or Medicaid residents, and employment of nurse practitioners and physician assistants) explained more than 20% of the micropolitan-urban differences in rates of outpatient ED and PAED visits; market factors (mainly Medicare Advantage penetration) explained about 46% of the differences in rates of outpatient ED visits. CONCLUSIONS AND IMPLICATIONS: Compared with urban NHs, micropolitan NHs tend to utilize more avoidable emergency care that can be partially explained by facility size, payer mix, use of nurse practitioners and physician assistants, and market structure.

Machine learning-assisted screening for cognitive impairment in the emergency department.

BACKGROUND/OBJECTIVES: Despite a high prevalence and association with poor outcomes, screening to identify cognitive impairment (CI) in the emergency department (ED) is uncommon. Identification of high-risk subsets of older adults is a critical challenge to expanding screening programs. We developed and evaluated an automated screening tool to identify a subset of patients at high risk for CI. METHODS: In this secondary analysis of existing data collected for a randomized control trial, we developed machine-learning models to identify patients at higher risk of CI using only variables available in electronic health record (EHR). We used records from 1736 community-dwelling adults age > 59 being discharged from three EDs. Potential CI was determined based on the Blessed Orientation Memory Concentration (BOMC) test, administered in the ED. A nested cross-validation framework was used to evaluate machine-learning algorithms, comparing area under the receiver-operator curve (AUC) as the primary metric of performance. RESULTS: Based on BOMC scores, 121 of 1736 (7%) participants screened positive for potential CI at the time of their ED visit. The best performing algorithm, an XGBoost model, predicted BOMC positivity with an AUC of 0.72. With a classification threshold of 0.4, this model had a sensitivity of 0.73, a specificity of 0.64, a negative predictive value of 0.97, and a positive predictive value of 0.13. In a hypothetical ED with 200 older adult visits per week, the use of this model would lead to a decrease in the in-person screening burden from 200 to 77 individuals in order to detect 10 of 14 patients who would fail a BOMC. CONCLUSION: This study demonstrates that an algorithm based on EHR data can define a subset of patients at higher risk for CI. Incorporating such an algorithm into a screening workflow could allow screening efforts and resources to be focused where they have the most impact.