Prevalence and predictors of incident ADRD diagnosis following a Medicare home health episode.

INTRODUCTION: Home health (HH) may be an important source of care for those with early-stage/undiagnosed Alzheimer's Disease and Related Dementias (ADRD), but little is known regarding prevalence or predictors of incident ADRD diagnosis following HH. METHODS: Using 2010-2012 linked Master Beneficiary Summary File (MBSF) and HH assessment data for 40,596 Medicare HH patients, we model incident ADRD diagnosis within 1 year of HH via multivariable logistic regression. RESULTS: Among HH patients without diagnosed ADRD, 10% received an incident diagnosis within 1 year. In adjusted models, patients were three times more likely to receive an incident ADRD diagnosis if they had HH clinician-reported impaired overall cognition (compared to patients without reported impairment) and twice as likely if they were community-referred (compared to hospital-referred patients). DISCUSSION: There is a pressing need to develop tailored HH clinical pathways and protect access to community-referred HH to support community-living older adults with early-stage/undiagnosed ADRD.

Improving transitions and outcomes of sepsis survivors (I-TRANSFER): a type 1 hybrid protocol.

BACKGROUND: This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal.  METHODS: Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions and Outcomes of Sepsis Survivors (I-TRANSFER) intervention compared to usual care on 30-day rehospitalization and emergency department use among sepsis survivors receiving HHC. The study design includes a baseline period with no intervention, a six-month start-up period followed by a one-year intervention period in partnership with five dyads of acute and HHC sites. In addition to the usual care/control periods from the dyad sites, additional survivors from national data will serve as control observations for comparison, weighted to produce covariate balance. The hypotheses will be tested using generalized mixed models with covariates guided by the Andersen Behavioral Model of Health Services. We will produce insights and generalizable knowledge regarding the context, processes, strategies, and determinants of I-TRANSFER implementation. DISCUSSION: As the largest HHC study of its kind and the first to transform this novel evidence through implementation science, this study has the potential to produce new knowledge about the impact of timely attention in HHC to alleviate symptoms and support sepsis survivor's recovery at home. If effective, the impact of this intervention could be widespread, improving the quality of life and health outcomes for a growing, vulnerable population of sepsis survivors. A national advisory group will assist with widespread results dissemination.

Live Discharge From Hospice Due to Acute Hospitalization: The Role of Neighborhood Socioeconomic Characteristics and Race/Ethnicity.

BACKGROUND: Acute hospitalization is a frequent reason for live discharge from hospice. Although risk factors for live discharge among hospice patients have been well documented, prior research has not examined the role of neighborhood socioeconomic characteristics, or how these characteristics relate to racial/ethnic disparities in hospice outcomes. OBJECTIVE: To examine associations between neighborhood socioeconomic characteristics and risk for live discharge from hospice because of acute hospitalization. The authors also explore the moderating role of race/ethnicity in any observed relationship. RESEARCH DESIGN: Retrospective cohort study using electronic medical records of hospice patients (N=17,290) linked with neighborhood-level socioeconomic data (N=55 neighborhoods). Multilevel models were used to identify the independent significance of patient and neighborhood-level characteristics for risk of live discharge because of acute hospitalization. RESULTS: Compared with the patients in the most well-educated and affluent sections of New York City [quartile (Q)4], the odds of live discharge from hospice because of acute hospitalization were greater among patients who resided in neighborhoods where lower proportions of residents held college degrees [Q1 adjusted odds ratio (AOR), 1.36; 95% confidence interval (CI), 1.06-1.75; Q2 AOR, 1.41; 95% CI, 1.07-1.84] and median household incomes were lower (Q1 AOR, 1.42; 95% CI, 1.10-1.85; Q2 AOR, 1.43; 95% CI, 1.10-1.85; Q3 AOR, 1.39; 95% CI, 1.07-1.80). However, these observed relationships were not equally distributed by patient race/ethnicity; the association of neighborhood socioeconomic disadvantage and risk for live discharge was significantly lower among Hispanic compared with white patients. CONCLUSIONS: Findings demonstrate neighborhood socioeconomic disadvantage poses a significant risk for live discharge from hospice. Additional research is needed to clarify the social mechanisms underlying this association, including greater attention to the experiences of hospice patients from under-represented racial/ethnic groups.

Home Healthcare Clinical Notes Predict Patient Hospitalization and Emergency Department Visits.

BACKGROUND: About 30% of home healthcare patients are hospitalized or visit an emergency department (ED) during a home healthcare (HHC) episode. Novel data science methods are increasingly used to improve identification of patients at risk for negative outcomes. OBJECTIVES: The aim of the study was to identify patients at heightened risk hospitalization or ED visits using HHC narrative data (clinical notes). METHODS: This study used a large database of HHC visit notes (n = 727,676) documented for 112,237 HHC episodes (89,459 unique patients) by clinicians of the largest nonprofit HHC agency in the United States. Text mining and machine learning algorithms (Naïve Bayes, decision tree, random forest) were implemented to predict patient hospitalization or ED visits using the content of clinical notes. Risk factors associated with hospitalization or ED visits were identified using a feature selection technique (gain ratio attribute evaluation). RESULTS: Best performing text mining method (random forest) achieved good predictive performance. Seven risk factors categories were identified, with clinical factors, coordination/communication, and service use being the most frequent categories. DISCUSSION: This study was the first to explore the potential contribution of HHC clinical notes to identifying patients at risk for hospitalization or an ED visit. Our results suggest that HHC visit notes are highly informative and can contribute significantly to identification of patients at risk. Further studies are needed to explore ways to improve risk prediction by adding more data elements from additional data sources.

Neighborhood Environment and Disparities in Health Care Access Among Urban Medicare Beneficiaries With Diabetes: A Retrospective Cohort Study.

Older adults' health is sensitive to variations in neighborhood environment, yet few studies have examined how neighborhood factors influence their health care access. This study examined whether neighborhood environmental factors help to explain racial and socioeconomic disparities in health care access and outcomes among urban older adults with diabetes. Data from 123 233 diabetic Medicare beneficiaries aged 65 years and older in New York City were geocoded to measures of neighborhood walkability, public transit access, and primary care supply. In 2008, 6.4% had no office-based "evaluation and management" (E&M) visits. Multilevel logistic regression indicated that this group had greater odds of preventable hospitalization in 2009 (odds ratio = 1.31; 95% confidence interval: 1.22-1.40). Nonwhites and low-income individuals had greater odds of a lapse in E&M visits and of preventable hospitalization. Neighborhood factors did not help to explain these disparities. Further research is needed on the mechanisms underlying these disparities and older adults' ability to navigate health care. Even in an insured population living in a provider-dense city, targeted interventions may be needed to overcome barriers to chronic illness care for older adults in the community.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice.

Importance: Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied. Objective: To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services. Design, Setting, and Participants: This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024. Exposure: Live hospice discharge. Main Outcomes and Measures: Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death. Results: This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions. Conclusion and Relevance: This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

Using Natural Language Processing to Identify Home Health Care Patients at Risk for Diagnosis of Alzheimer's Disease and Related Dementias.

This study aimed to: (1) validate a natural language processing (NLP) system developed for the home health care setting to identify signs and symptoms of Alzheimer's disease and related dementias (ADRD) documented in clinicians' free-text notes; (2) determine whether signs and symptoms detected via NLP help to identify patients at risk of a new ADRD diagnosis within four years after admission. This study applied NLP to a longitudinal dataset including medical record and Medicare claims data for 56,652 home health care patients and Cox proportional hazard models to the subset of 24,874 patients admitted without an ADRD diagnosis. Selected ADRD signs and symptoms were associated with increased risk of a new ADRD diagnosis during follow-up, including: motor issues; hoarding/cluttering; uncooperative behavior; delusions or hallucinations; mention of ADRD disease names; and caregiver stress. NLP can help to identify patients in need of ADRD-related evaluation and support services.

HomeADScreen: Developing Alzheimer's disease and related dementia risk identification model in home healthcare.

BACKGROUND: More than 50 % of patients with Alzheimer's disease and related dementia (ADRD) remain undiagnosed. This is specifically the case for home healthcare (HHC) patients. OBJECTIVES: This study aimed at developing HomeADScreen, an ADRD risk screening model built on the combination of HHC patients' structured data and information extracted from HHC clinical notes. METHODS: The study's sample included 15,973 HHC patients with no diagnosis of ADRD and 8,901 patients diagnosed with ADRD across four follow-up time windows. First, we applied two natural language processing methods, Word2Vec and topic modeling methods, to extract ADRD risk factors from clinical notes. Next, we built the risk identification model on the combination of the Outcome and Assessment Information Set (OASIS-structured data collected in the HHC setting) and clinical notes-risk factors across the four-time windows. RESULTS: The top-performing machine learning algorithm attained an Area under the Curve = 0.76 for a four-year risk prediction time window. After optimizing the cut-off value for screening patients with ADRD (cut-off-value = 0.31), we achieved sensitivity = 0.75 and an F1-score = 0.63. For the first-year time window, adding clinical note-derived risk factors to OASIS data improved the overall performance of the risk identification model by 60 %. We observed a similar trend of increasing the model's overall performance across other time windows. Variables associated with increased risk of ADRD were "hearing impairment" and "impaired patient ability in the use of telephone." On the other hand, being "non-Hispanic White" and the "absence of impairment with prior daily functioning" were associated with a lower risk of ADRD. CONCLUSION: HomeADScreen has a strong potential to be translated into clinical practice and assist HHC clinicians in assessing patients' cognitive function and referring them for further neurological assessment.

COVID-19 Sero-Prevalence and Risk Factors in a Sample of Community Health Center Employees in New York State.

OBJECTIVE: To document COVID-19 sero-prevalence, prior testing, symptom experiences, and risk factors in a sample of community health center (CHC) workers. METHODS: Descriptive statistics and log-binomial regression were used to analyze an electronic employee survey linked with COVID-19 antibody results. The sample included 378 employees who completed the survey; 325 had complete lab data. RESULTS: The sero-positivity rate was 15.4%. One third of sero-positive participants had no previous COVID-19 symptoms or were unsure. Working on-site only and/or with direct patient contact was not associated with sero-positivity. Employees in their 20s were more likely to test positive than employees ages 50+, controlling for sex, race, and region (PR = 2.96; P < 0.05). CONCLUSIONS: With CHCs central to COVID-19 response and vaccination efforts, public health messaging should remind CHC workers, especially younger employees, of their risks of community-based exposure.

Clinical and Demographic Profiles of Home Care Patients With Alzheimer's Disease and Related Dementias: Implications for Information Transfer Across Care Settings.

Home health care (HHC) clinicians serving individuals with Alzheimer's disease and related dementias (ADRD) do not always have information about the person's ADRD diagnosis, which may be used to improve the HHC plan of care. This retrospective cohort study examined characteristics of 56,652 HHC patients with varied documentation of ADRD diagnoses. Data included clinical assessments and Medicare claims for a 6-month look-back period and 4-year follow-up. Nearly half the sample had an ADRD diagnosis observed in the claims either prior to or following the HHC admission. Among those with a prior diagnosis, 63% did not have it documented on the HHC assessment; the diagnosis may not have been known to the HHC team or incorporated into the care plan. Patients with ADRD had heightened risk for adverse outcomes (e.g., urinary tract infection and aspiration pneumonia). Interoperable data across health care settings should include ADRD-specific elements about diagnoses, symptoms, and risk factors.

Survival in hospice patients with dementia: the effect of home hospice and nurse visits.

BACKGROUND: Hospice patients with dementia are at increased risk for live discharge and long lengths of stay (>180 days), causing patient and family caregiver stress and burden. The location and timing of clinician visits are important factors influencing whether someone dies as expected, in hospice, or experiences a live discharge or long length of stay. OBJECTIVE: Examine how home hospice and nurse visit frequency relate to dying in hospice within the Medicare-intended 6-month period. DESIGN: Retrospective cohort study. SETTING: Non-profit hospice agency. PARTICIPANTS: Three thousand eight hundred and thirty seven patients with dementia who received hospice services from 2013 to 2017. METHODS: Multivariable survival analyses examined the effects of receiving home hospice (vs. nursing home) and timing of nurse visits on death within 6 months of hospice enrollment, compared to live discharge or long length of stay. Models adjust for relevant demographic and clinical factors. RESULTS: Thirty-nine percent (39%) of patients experienced live discharge or long length of stay. Home hospice patients were more likely to experience live discharge or long length of stays (HR for death: 0.77, 95%CI: 0.69-0.86, p < 0.001). Frequency of nurse visits was inversely associated with live discharge and long lengths of stay (HR for death: 2.87, 95%CI: 2.47-3.33, p < 0.001). CONCLUSION: Nearly 40% of patients with dementia in our study experienced live discharge or a long length of stay. Additional research is needed to understand why home hospice may result in live discharge or a long length of stay for patients with dementia. Nurse visits were associated with death, suggesting their responsiveness to deteriorating patient health. Hospice guidelines may need to permit longer stays so community-dwelling patients with dementia, a growing segment of hospice patients, can remain continuously enrolled in hospice and avoid burden and costs associated with live discharge.

Driving Status and Transportation Disadvantage Among Medicare Beneficiaries.

Transportation disadvantage may have important implications for the health, well-being, and quality of life of older adults. This study used the 2015 National Health Aging Trends Study, a nationally representative study of Medicare beneficiaries aged 65 and over (N = 7,498), to generate national estimates of transportation modalities and transportation disadvantage among community-dwelling older adults in the United States. An estimated 10.8 million community-dwelling older adults in the United States rarely or never drive. Among nondrivers, 25% were classified as transportation disadvantaged, representing 2.3 million individuals. Individuals with more chronic medical conditions and those reliant on assistive devices were more likely to report having a transportation disadvantage (p < .05). Being married resulted in a 50% decreased odds of having a transportation disadvantage (p < .01). Some individuals may be at higher risk for transportation-related barriers to engaging in valued activities and accessing care, calling for tailored interventions such as ride-share services combined with care coordination strategies.

Free-Text Documentation of Dementia Symptoms in Home Healthcare: A Natural Language Processing Study.

BACKGROUND: Little is known about symptom documentation related to Alzheimer's disease and related dementias (ADRD) by home healthcare (HHC) clinicians. OBJECTIVE: This study: (1) developed a natural language processing (NLP) algorithm that identifies common neuropsychiatric symptoms of ADRD in HHC free-text clinical notes; (2) described symptom clusters and hospitalization or emergency department (ED) visit rates for patients with and without these symptoms. METHOD: We examined a corpus of -2.6 million free-text notes for 112,237 HHC episodes among 89,459 patients admitted to a non-profit HHC agency for post-acute care with any diagnosis. We used NLP software (NimbleMiner) to construct indicators of six neuropsychiatric symptoms. Structured HHC assessment data were used to identify known ADRD diagnoses and construct measures of hospitalization/ED use during HHC. RESULTS: Neuropsychiatric symptoms were documented for 40% of episodes. Common clusters included impaired memory, anxiety and/or depressed mood. One in three episodes without an ADRD diagnosis had documented symptoms. Hospitalization/ED rates increased with one or more symptoms present. CONCLUSION: HHC providers should examine episodes with neuropsychiatric symptoms but no ADRD diagnoses to determine whether ADRD diagnosis was missed or to recommend ADRD evaluation. NLP-generated symptom indicators can help to identify high-risk patients for targeted interventions.

Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors.

OBJECTIVE: To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. DESIGN: Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. SETTING AND PARTICIPANTS: National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N = 165,228). METHODS: We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. RESULTS: The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. CONCLUSIONS AND IMPLICATIONS: Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.

Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia.

OBJECTIVES: The end-of-life trajectory for persons with dementia is often protracted and difficult to predict, placing these individuals at heightened risk of live discharge from hospice. Risks for live discharge due to condition stabilization or failure to decline among patients with dementia are not well established. Our aim was to identify demographic, health, and hospice service factors associated with live discharge due to condition stabilization or failure to decline among hospice patients with dementia. DESIGN: Retrospective cohort study. SETTING: A large not-for-profit agency in New York City. PARTICIPANTS: A total of 2629 hospice patients with dementia age 65 years and older. MEASUREMENTS: Primary outcome was live discharge from hospice due to condition stabilization or failure to decline (vs death). Measures include demographic factors (race/ethnicity, Medicaid, sex, age, marital status, parental status), health characteristics (primary dementia diagnosis, comorbidities, functional status, prior hospitalization), and hospice service (location, length of service, number and timing of nurse visits). RESULTS: Logistic regression models indicated that compared with white hospice patients with dementia, African American and Hispanic hospice patients with dementia experienced increased risk of live discharge (African American: adjusted odds ratio [aOR] = 2.42; 95% confidence interval [CI] = 1.34-4.38; Hispanic: aOR = 2.99; 95% CI = 1.81-4.94). Home hospice (aOR = 7.57; 95% CI = 4.04-14.18), longer length of service (aOR = 1.04; 95% CI = 1.04-1.05), and more days between nurse visits and discharge (aOR = 1.86; 95% CI = 1.56-2.21) were also associated with live discharge. CONCLUSION: To avoid burdensome and disruptive transitions out of hospice in patients with dementia, interventions to reduce live discharge due to condition stabilization or failure to decline should be tailored to meet the needs of African American, Hispanic, and home hospice patients. Policies regarding sustained hospice eligibility should account for the variable and protracted end-of-life trajectory of patients with dementia. J Am Geriatr Soc 68:551-558, 2020.

The Homecare Aide Workforce Initiative: Implementation and Outcomes.

Improved training and support are thought to improve retention among direct care workers. However, few studies have examined actual retention. This study examined satisfaction and retention among home health aides enrolled in the "Homecare Aide Workforce Initiative" (HAWI) at three New York agencies. Data included surveys of HAWI trainees and new hires and payroll data for HAWI graduates and others. Three months after hire, 91% of HAWI hires reported they were "very satisfied" or "satisfied" with the job; 57% reported they were "not at all likely" to leave their job in the coming year. At 365 days, 60% were still working. In logistic regression, the odds of being retained at 3, 6, and 12 months were significantly higher among HAWI graduates than non-HAWI new hires. Although not a randomized trial, the study demonstrates an association between participation in an innovative entry-level workforce program and superior 3-, 6-, and 12-month retention.

An international perspective on improving occupational conditions for direct care workers in home health.

The occupational health and safety of direct care workers in the home health setting has been the focal point of a somewhat scarce, though highly important, body of research. Although the demand for home care services continues to expand with the rapidly growing population of older adults worldwide, home care workers - such as home health aides and personal care attendants - do not have the same level of protections by workplace safety policies such as those implemented in hospitals and nursing homes. This commentary synthesizes international perspectives on the occupational health and safety of home care workers, including the problem of workers' rights violations and abuse by clients and their families. Prior policy and practice efforts have focused on improving the training, supervision, job satisfaction, and retention of home care workers, but have focused less on addressing issues of abuse. This paper recommends potential strategies to be developed and tested to provide a stronger support system for home care workers, more fully integrate them into the care team, and improve the occupational health and safety of this diverse, rapidly expanding workforce.

A Conceptual Framework for Examining Healthcare Access and Navigation: A Behavioral-Ecological Perspective.

This paper introduces a conceptual framework for investigating individual ability to navigate healthcare in the contexts of the built environment, social environment, and healthcare infrastructure in which a person is embedded. Given the complexity of healthcare delivery in the United States, consumers are expected to have an increasingly sophisticated set of skills in order to effectively navigate and benefit from the healthcare resources available to them. Addressing barriers to navigation in vulnerable populations may be essential to reducing health disparities. This paper builds on previous conceptual developments in the areas of healthcare use, navigation, and ecological perspectives on health in order to present a behavioral-ecological framework for examining healthcare navigation and access. The model posits that healthcare navigation is an ecologically informed process not only because of the spatial distribution of health services, but because of the spatial distribution of individual and environmental factors that influence decision-making and behavior with respect to service use. The paper discusses areas for further research on healthcare navigation, challenges for research, and implications for reducing health disparities.

Individual and Environmental Determinants of Provider Continuity Among Urban Older Adults With Heart Failure: A Retrospective Cohort Study.

Objective: Continuity in patient-provider relationships is important to providing high-quality care for older adults with chronic conditions. We investigated individual and environmental determinants of provider continuity for office-based physician visits among urban older adults with heart failure. Method: We linked Medicare claims with data on neighborhood characteristics for a retrospective cohort of community-dwelling Medicare beneficiaries with heart failure in New York City (N = 50,475). Results: Mean continuity using the Bice-Boxerman index was 0.33 (SD = 0.22) (possible range of 0 [no continuity] to 1 [perfect continuity]). Multivariable regression indicated that provider continuity was higher among older, female, and dually eligible beneficiaries. Those with more chronic conditions had higher continuity, controlling for number of medical specialties seen. Continuity was lower for beneficiaries in neighborhoods with high median income and high primary care density. Conclusion: Individual and environmental predictors of provider continuity among urban older adults with heart failure could help to identify those at risk of care fragmentation.

Can the care transitions measure predict rehospitalization risk or home health nursing use of home healthcare patients?

The Care Transitions Measure (CTM) was designed to assess the quality of patient transitions from the hospital. Many hospitals are using the measure to inform their efforts to improve transitional care. We sought to determine if the measure would have utility for home healthcare providers by predicting newly admitted patients at heightened risk for emergency department use, rehospitalization, or increased home health nursing visits. The CTM was administered to 495 home healthcare patients shortly after hospital discharge and home healthcare admission. Follow-up interviews were completed 30 and 60 days post hospital discharge. Interview data were supplemented with agency assessment and service use data. We did not find evidence that the CTM could predict home healthcare patients having an elevated risk for emergent care, rehospitalization, or higher home health nursing use. Because Medicare/Medicaid-certified home healthcare providers already use a comprehensive, mandated start of care assessment, the CTM may not provide them additional crucial information. Process and outcome measurement is increasingly becoming part of usual care. Selection of measures appropriate for each service setting requires thorough site-specific evaluation. In light of our findings, we cannot recommend the CTM as an additional measure in the home healthcare setting.