Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

OBJECTIVE: Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. DATA SOURCE: Medicare Fee-for-Service Data, 2018. STUDY DESIGN: We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. DATA EXTRACTION METHODS: We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. PRINCIPAL FINDINGS: In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. CONCLUSIONS: There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

Impact of electronic information exchange on repeat imaging during 30-day readmissions among Medicare beneficiaries.

OBJECTIVES: We examined the association between electronic health information sharing and repeat imaging in readmissions among older adults with and without Alzheimer disease (AD). STUDY DESIGN: Cohort study using national Medicare data. METHODS: Among Medicare beneficiaries with 30-day readmissions in 2018, we examined repeat imaging on the same body system during the readmission. This was evaluated between fragmented and nonfragmented (same-hospital) readmissions and across categories of electronic information sharing via health information exchanges (HIEs) in fragmented readmissions: admission and readmission hospitals share the same HIE, admission and readmission hospitals participate in different HIEs, one or both do not participate in HIE, or HIE data missing. This relationship was evaluated using unadjusted and adjusted logistic regression. RESULTS: Overall, 14.3% of beneficiaries experienced repeat imaging during their readmission. Compared with nonfragmented readmissions, fragmented readmissions were associated with 5% higher odds of repeat imaging on the same body system in older adults without AD. This was not mitigated by the presence of electronic information sharing: Fragmented readmissions to hospitals that shared an HIE had 6% higher odds of repeat imaging (adjusted OR, 1.06; 95% CI, 1.00-1.13). There was no difference seen in the odds of repeat imaging for older adults with AD. CONCLUSIONS: Despite substantial investment, HIEs as currently deployed and used are not associated with decreased odds of repeat imaging in readmissions.

Cognitive assessment in primary care: Practical recommendations.

ABSTRACT: Primary care clinicians play a critical role in both the identification and management of cognitive impairment due to common diseases. Primary care practices should incorporate feasible, reliable, and helpful tools into existing workflow to recognize and support people living with dementia and their care partners.

Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults.

Importance: When an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals. Objective: To determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries. Design, Setting, and Participants: This cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022. Exposures: Same hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals. Main Outcomes and Measures: The main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions. Results: The cohort included 275 189 admission-readmission pairs, representing 268 768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P < .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.

The Impact of Health Information Exchange on In-Hospital and Postdischarge Mortality in Older Adults with Alzheimer Disease Readmitted to a Different Hospital Within 30 Days of Discharge: Cohort Study of Medicare Beneficiaries.

BACKGROUND: Although electronic health information sharing is expanding nationally, it is unclear whether electronic health information sharing improves patient outcomes, particularly for patients who are at the highest risk of communication challenges, such as older adults with Alzheimer disease. OBJECTIVE: To determine the association between hospital-level health information exchange (HIE) participation and in-hospital or postdischarge mortality among Medicare beneficiaries with Alzheimer disease or 30-day readmissions to a different hospital following an admission for one of several common conditions. METHODS: This was a cohort study of Medicare beneficiaries with Alzheimer disease who had one or more 30-day readmissions in 2018 following an initial admission for select Hospital Readmission Reduction Program conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia) or common reasons for hospitalization among older adults with Alzheimer disease (dehydration, syncope, urinary tract infection, or behavioral issues). Using unadjusted and adjusted logistic regression, we examined the association between electronic information sharing and in-hospital mortality during the readmission or mortality in the 30 days following the readmission. RESULTS: A total of 28,946 admission-readmission pairs were included. Beneficiaries with same-hospital readmissions were older (aged 81.1, SD 8.6 years) than beneficiaries with readmissions to different hospitals (age range 79.8-80.3 years, P<.001). Compared to admissions and readmissions to the same hospital, beneficiaries who had a readmission to a different hospital that shared an HIE with the admission hospital had 39% lower odds of dying during the readmission (adjusted odds ratio [AOR] 0.61, 95% CI 0.39-0.95). There were no differences in in-hospital mortality observed for admission-readmission pairs to different hospitals that participated in different HIEs (AOR 1.02, 95% CI 0.82-1.28) or to different hospitals where one or both hospitals did not participate in HIE (AOR 1.25, 95% CI 0.93-1.68), and there was no association between information sharing and postdischarge mortality. CONCLUSIONS: These results indicate that information sharing between unrelated hospitals via a shared HIE may be associated with lower in-hospital, but not postdischarge, mortality for older adults with Alzheimer disease. In-hospital mortality during a readmission to a different hospital was higher if the admission and readmission hospitals participated in different HIEs or if one or both hospitals did not participate in an HIE. Limitations of this analysis include that HIE participation was measured at the hospital level, rather than at the provider level. This study provides some evidence that HIEs can improve care for vulnerable populations receiving acute care from different hospitals.

Ambulance use and subsequent fragmented hospital readmission among older adults.

BACKGROUND: Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%-25% of readmissions. Mode of transport to the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions. METHODS: We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics. RESULTS: The study included 1,186,600 30-day readmissions. Of these, 46.8% (n = 555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations. CONCLUSIONS: Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient-, hospital-, and system-level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.

Experiences of Black American Dementia Caregivers During the COVID-19 Pandemic.

Dementia caregivers are responsible for the daily care and management of individuals who are among the most vulnerable to the serious consequences of COVID-19. This qualitative study explores the experience of Black dementia caregivers during the COVID-19 pandemic in the United States. Nineteen Black dementia caregivers were recruited to participate in semi-structured focus groups held in April 2021. Four overarching themes were constructed during analysis: social isolation, decreased well-being, the good and bad of telehealth, and challenges fulfilling health care needs. The results indicate the experience of Black dementia caregivers overlaps with existing literature on the experiences of dementia caregivers of other races during COVID-19. These results can assist in addressing the specific needs and improving the experiences of dementia caregivers in current and future public health crises.

The characteristics and practice proficiency of nurse practitioners who care for older adults.

Roughly 54 million Americans are 65 years of age or older. Given the number of comorbid diseases reported in older adults, healthcare tailored to the specific needs of this population is imperative. Nurse practitioners (NPs) are uniquely positioned to provide care to older adults; yet little is known about the geriatric-oriented NP workforce. In this study, four professional organizations distributed a survey link to their members who were queried on their demographic, employment, and practice characteristics; one organization's members responded to a previous survey, providing two time points for comparison. Compared with 2016 respondents, there was minimal growth in diversity, fewer who practice in suburban or rural areas, and restrictions on clinical education related to the ongoing pandemic. The findings from this study should alert policymakers of the need to address the development of an adequate workforce of clinicians who specialize in geriatrics.

Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being.

BACKGROUND: The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal. PURPOSE: To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49). METHODOLOGY: Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics. RESULTS: Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life. CONCLUSIONS: Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being. IMPLICATIONS: Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed.

Promoting Caregiver Mastery in Black American Dementia Caregivers.

Over 6 million older Americans live with Alzheimer's disease and related dementias; Black American older adults' prevalence is more than twice that of non-Hispanic White older adults. The Black American dementia caregiving experience can be encapsulated within the Black Family Socioecological Context Model, which provides a conceptual basis for examining social determinants of health at individual, family, community, and societal levels with careful consideration for how the intersection of race, gender, and class of Black American dementia caregivers influences the multiple dimensions of their caregiving experiences. Family dynamics, community setting, and health care systems have a potentially bidirectional influence on these caregivers, which is shaped by historical and ongoing systemic and institutional racism and general disenfranchisement. This Forum article outlines how the Social Cognitive Theory offers ways for Black American dementia caregivers to achieve a sense of mastery within the complicated and fraught ecology within which their caregiving occurs. We propose a research agenda to create programs and interventions for enhancing a sense of mastery among Black American dementia caregivers. Two concepts in particular, "constraints" and "efficacy expectations," provide ways to create a systematic approach to developing successful coping strategies for the constraints perceived by individuals as they undertake and function in the caregiving role. The recognition of the complexity of the caregiving ecosystem and intersectionality of caregivers' experience and identity emphasize the importance of individualization: Each caregiver's experience of this ecosystem-and therefore each Black American dementia caregiver's way to mastery within it-will be uniquely shaped and experienced.

The Academic-Practice Partnership: Educating Future Nurses.

Strong partnerships are essential to lead the innovative change needed to prepare future nurses who demonstrate quality and safety competence. Successful models involve senior leadership, a shared vision, mutual goals, mutual respect, and an access to shared knowledge. The academic-practice partnership between a private university-based school of nursing and its affiliated health care system facilitated the implementation of a new Accelerated Bachelor of Science in Nursing (ABSN) program track to provide a seamless education to practice pathway for graduate nurses educated with quality and safety competencies and to meet the workforce demands of the health care system. The academic-practice model is based on the Guiding Principles outlined by the American Association of Colleges of Nursing-American Organization of Nurse Leaders (AACN-AONL) Task Force on Academic Practice Partnerships. As a result of this partnership, 84% of the program's graduates accepted a position with the health care partner as an advanced medical-surgical nurse, and student outcomes in quality and safety competencies were encouraging.

Caregivers' Experience at an Integrated Memory Care Clinic.

The Integrated Memory Care Clinic is a patient-centered medical home led by advanced practice RNs (APRNs) who provide dementia care and primary care simultaneously and continuously. We explored the experiences of 12 informal caregivers of persons living with dementia during their first year at the Clinic. Data were analyzed via directed content analysis. Caregivers described the Clinic as "the only place you should go to for dementia [care]." Caregivers felt a sense of belonging to the Clinic, valued APRNs' competence and staff's dedication, and round-the-clock telephone access to APRNs. Caregivers also acknowledged that "we're all out here swimming on our own." They expressed their sense of being overwhelmed and needing more services and medical and non-medical resources, and more prognostic information on dementia. Although the Clinic is beneficial for caregivers, caregiving demands exceed the supply of services and resources at the Clinic. [Research in Gerontological Nursing, 14(2), 69-78.].

Patient and caregiver outcomes at the integrated memory care clinic.

The purpose of this longitudinal cohort study was to explore the outcomes of persons living with dementia (PLWD) and their caregivers during their first 9 months at the Integrated Memory Care Clinic (IMCC). IMCC advanced practice registered nurses provide dementia care and primary care simultaneously and continuously to PLWD until institutionalization. Changes were examined in caregivers' psychological well-being (perceived stress, depressive symptoms, caregiver burden, and anxiety) and health status and in PLWDs' quality of life and neuropsychiatric symptoms. Data were collected at baseline, then 3 and 6 months post-baseline. Forty-two caregivers completed all 3 assessments. Most variables remained unchanged. Statistically significant improvements in 5 sub-scales of the Neuropsychiatric Inventory were observed: caregivers' distress regarding their PLWDs' delusions and anxiety, and PLWDs' severity of delusions, depression, and total symptom severity. Further testing of the IMCC is required, including in quasi-experimental studies, to determine its efficacy.

Creating New Models of Care Through Academic-Clinical Partnership.

There are many documented instances of academic nurses creating faculty practice opportunities to support their faculty and students. Fewer articles have been published about the value of these shared models to clinical partners. Advanced practice nurses from the academic and clinical departments at Emory University and Emory Healthcare codesigned a new model of care that addresses the health system's need to achieve better experiences and health outcomes for patients living with dementia. The nurse-led clinical practice, called Integrated Memory Care Clinic, is an innovative example of joint planning and design by academic and clinical nurses to advance the teaching, practice, and research mission of the School of Nursing as well as help satisfy the health system's ability to achieve the Triple Aim.

Integrated Memory Care Clinic: Design, Implementation, and Initial Results.

The Integrated Memory Care Clinic (IMCC) is a patient-centered medical home as defined by the National Committee for Quality Assurance directed by advanced practice registered nurses (APRNs) caring for persons living with dementia (PLWD); physicians provide specialty consultation but do not direct care or care planning. The IMCC incorporates geriatric nursing, social work, and APRNs from neurology, gerontology, palliative care, and geriatric psychiatry. APRNs provide comprehensive, coordinated primary care for dementia, other chronic conditions, and minor acute illnesses. Partnering with PLWD and families and taking a palliative-oriented, dementia-informed medical home approach, the IMCC aims to reduce dementia burden. This study describes the first 12 months of IMCC's operation with 139 enrolled PLWD-caregiver dyads. All patients have a diagnosis of dementia or mild cognitive impairment; most have Alzheimer's disease (53.2%). Patients have an average of 5.8 medical conditions and 6.9 prescriptions; 38.1% have an advanced directive, a medical power of attorney, or a living will. Mean age is 78.6, 63.3% are female, and 30.9% are African American. Mean Montreal Cognitive Assessment score is 12.6. Most require assistance in activities of daily living. Many display neuropsychiatric symptoms. The most prevalent comorbidities are hypertension, dyslipidemia, and depression. The rate of ambulatory-sensitive hospitalizations declined from 6.7% in December 2015 to less than 1% in May 2016. Caregivers were highly satisfied. We observed nonsignificant improvements in neuropsychiatric symptom severity (p=.07), caregiver distress (p=.69), and caregiver competence (p=.18). IMCC is a novel care model for PLWD and their caregivers and may be a more sustainable model than traditional primary care for this growing vulnerable population. J Am Geriatr Soc 66:2401-2407, 2018.

Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients.

Gait speed assessment is a rapid, simple and objective measure for predicting risk of unfavorable outcomes which may provide better prognostic and reliable information than existing geriatric ED (Emergency Department) screening tools. This descriptive pilot project was designed to determine feasibility of implementing gait speed screening into routine nursing practice by objectively identifying patients with sub-optimal gait speeds. Participants included community-dwelling adults 65 years and older with plans for discharge following ED treatment. Patients with a gait speed <1.0 m/s were identified as "high-risk" for an adverse event, and referred to the ED social worker for individualized resources prior to discharge. Thirty-five patients were screened and nurse initiated gait speed screens were completed 60% of the time. This project demonstrates ED gait speed screening may be feasible. Implications for practice should consider incorporating gait speed screening into routine nursing assessment to improve provider ED decision-making and disposition planning.

Feasibility of a Low-Cost, Interactive Gaming System to Assess Balance in Older Women.

The use of low-cost interactive game technology for balance rehabilitation has become more popular recently, with generally good outcomes. Very little research has been undertaken to determine whether this technology is appropriate for balance assessment. The Wii balance board has good reliability and is comparable to a research-grade force plate; however, recent studies examining the relationship between Wii Fit games and measures of balance and mobility demonstrate conflicting findings. This study found that the Wii Fit was feasible for community-dwelling older women to safely use the balance board and quickly learn the Wii Fit games. The Ski Slalom game scores were strongly correlated with several balance and mobility measures, whereas Table Tilt game scores were not. Based on these findings, the Ski Slalom game may have utility in the evaluation of balance problems in community-dwelling older adults.

Teaching the teachers: faculty development in inter-professional education.

AIMS: The purpose of this study is to evaluate changes in self-concept for the knowledge, skills and attitudes toward inter-professional teamwork of facilitators who participated in training and an inter-professional team training event. BACKGROUND: Inter-professional education requires dedicated and educated faculty. METHODS: A pretest posttest quasi-experimental design was used for the evaluation. Fifty-three facilitators were asked to complete pre-post questionnaires to measure inter-professional team self-concept (IPTSC), assessing self-concept for the knowledge, skills, and attitudes required for performing in an inter-professional team. RESULTS: Post-session scores on inter-professional team knowledge, skills and attitudes were significantly higher (F(1, 31) = 5.59, p = .02). CONCLUSION: A facilitator development course and participation in the teaching event had a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork.

Clinical care of persons with dementia in the emergency department: a review of the literature and agenda for research.

The segment of older adults who present to the emergency department (ED) with cognitive impairment ranges from 21% to 40%. Difficulties inherent in the chaotic ED setting combined with dementia may result in a number of unwanted clinical outcomes, but strategies to minimize these outcomes are lacking. A review of the literature was conducted to examine the practices undertaken in the care of persons with dementia (PWD) specific to the ED setting. PubMed and Cumulative Index to Nursing and Allied Health Literature were searched for published articles specific to the care of PWD provided in the ED. All English-language articles were reviewed; editorials and reflective journals were excluded. Seven articles ultimately met inclusion criteria; all provided Level 7 evidence: narrative review or opinions from authorities. The articles recommended clinical practices that can be categorized into five themes: assessment of cognitive impairment, dementia communication strategies, avoidance of adverse events, alterations to the physical environment, and education of ED staff. Many recommendations are extrapolated from residential care settings. Review results indicate that there is minimal guidance for the care of PWD specific to the ED setting. There are no empirical studies of the care (assessment, interventions) of PWD in the ED. The existing (Level 7) recommendations lack a research base to support their effectiveness or adoption as evidence-based practice. There is a significant opportunity for research to identify and test ways to meet the needs of PWD in the ED to ensure a safe visit, accurate diagnosis, and prudent transfer to the most appropriate level of care.