Psychiatric comorbidity and the long-term care of people with aids

Objectives To examine the association of comorbid psychiatric disorders with admission and discharge characteristics for patients residing at a long-term care facility designated for acquired immunodeficiency syndrome (AIDS). Methods Demographic and clinical characteristics were obtained by systematic chart review for all patients (N=180) admitted to the facility from its opening in October 1995 through December 1999. Lifetime history of severe and persistent psychiatric disorders (major depression, bipolar and psychotic disorders) was determined by current diagnosis on baseline clinical evaluation or a documented past history. Results Forty-five patients (25%) had comorbid psychiatric disorders. At admission, patients with comorbidity were more likely to be ambulatory (80% vs. 62%,P=.03) and had fewer deficits in activities of daily living (27% vs. 43%,P=.05). After controlling for human immunodeficiency virus (HIV) disease severity, patients with comorbidity had significantly lower discharge rates (relative risk=0.43,95% confidence interval 0.23–0.78,P=.0001) and death rates (relative risk=0.53,95% confidence interval 0.42–0.68,P=.009). Conclusions Patients with AIDS and comorbid psychiatric disorders at this facility had more favorable admission characteristics and were less likely to be discharged or to die. They may have been admitted earlier in their disease course for reasons not exclusively due to HIV infection. Once admitted, community-based residential alternatives may be unavailable as a discharge option. These findings are unlikely to be an anomaly and may become more pronounced with prolonged survival due to further therapeutic improvements in HIV care. Health services planners must anticipate rising demands on the costs of care for an increasing number of patients who may require long-term care and expanded discharge options for the comanagement of HIV disease and chronic psychiatric disorders. Supported in part by a Faculty Scholars award to Dr. Selwyn from the Project on Death in America, Open Society Institute     

Trajectories Over the First Year of Long-Term Care Nursing Home Residence

Objectives

To describe the trajectories in the first year after individuals are admitted to long-term care nursing homes.

Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure

OBJECTIVE: To characterize Medicare skilled nursing facility (SNF) residents who become acutely ill with heart failure (HF) and assess the association between the outcomes of rehospitalization and mortality, and severity of the acute exacerbation, comorbidity, and processes of care. DESIGN: SNF medical record review of Medicare patients who developed an acute exacerbation of heart failure (HF) during the 90 days following nursing home admission. SETTING: A total of 58 SNFs in 5 states during 1994 and 1997. PARTICIPANTS: Patients with 156 episodes of acute HF among 4693 random Medicare nursing home admissions. MEASUREMENTS: Demographic variables, symptoms, signs, comorbidity, nursing home characteristics, nurse staffing ratios, and processes of care were compared between acute HF subjects transferred to hospital and those not transferred; and between subjects who died within 30 days of an acute exacerbation and those who survived. RESULTS: After adjusting for age, disease severity, and comorbidity, residents whose change in condition was evaluated during the night shift were more likely to be hospitalized (OR 4.20, 95%CI 1.01-17.50). Residents who were prescribed an angiotensin-converting enzyme inhibitor or who received an order for skilled nursing observation more often than once a shift were 1/3 as likely to die as those who did not (OR 0.303, 95%CI 0.11-0.82), after adjusting for hypotension, delirium, do not resuscitate orders, and prior hospital length of stay. CONCLUSION: For residents who develop an acute exacerbation of HF during a SNF stay, there is an association between attributes of nursing home care and the outcomes of rehospitalization and mortality.     

Cost-effectiveness implications based on a comparison of nursing home and home health case mix.

Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states in 1982 and 1983. Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients. Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients. From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.     

PMH2 Assessment of Health-Related Quality of Life During Treatment of Opiate Dependence using the Short Form-36

In the U.S., acute general hospitals increasingly provide treatment for patients with schizophrenia.
OBJECTIVE: To estimate the average annual cost of inpatient schizophrenia care per patient in an acute general hospital setting.
METHODS: Using ICD9 codes to identify disease and procedure-level data in five state (CA, FL, MA, MD, NC) acute care, all payer, discharge databases, an average cost per admission was estimated and combined with the frequency of admission calculated from the MA database to derive a mean annual acute care inpatient cost. Physician costs were calculated by applying 1997 Medicare fees to a resource use profile derived from the databases and published treatment recommendations. All costs are reported in 1997 US$, appropriately adjusted for medical inflation and cost-to-charge ratios.
RESULTS: Of 7.5 millions discharges, 73,000 were identified as having been admitted primarily due to schizophrenia. The average length of stay was 13.5 days, with 90% of time spent in a designated psychiatric bed. Over 90% were discharged within one month, most (∼80%) to home without documentation of further services. The mean cost per stay (including physician fees) was $8,963. Most (68%) patients had only one admission, and 96% had less than five in one year, leading to annual hospitalization cost per schizophrenic patient of $13,854.
CONCLUSIONS: Of schizophrenic patients admitted to an acute general hospital, the majority are admitted only once per year, spend their stay in a designated psychiatric unit bed, and are discharged within two weeks. Although these patients may have subsequent admissions to another type of inpatient facility, the majority are not transferred to such a facility at the time of discharge.     

Reducing hospital admissions from a skilled nursing home

With good nursing care and the resources of a dedicated skilled nursing facility, many nursing home patients usually admitted to a hospital for various medical illnesses can be handled within the framework of the skilled nursing facility without necessarily incurring an increased nursing home death rate. The medical advantage to the patient and to the usually overburdened hospitals, as well as the economic advantage to the public in general, calls for a full evaluation and consideration of this alternative to the regular and ongoing practice of hospital admissions of the elderly nursing home patient. The experiences of Carmel Richmond Nursing Home, a skilled nursing facility, have shown that this alternate level of approach and care can be quite successful and beneficial to all involved, especially the nursing home patient.     

Long-term Impact of Hip Fracture on the Use of Healthcare Resources: a Population-Based Study

Objectives

To assess the impact of hip fracture (HF) on health care expenditures and resource use.

Identifying types of nursing facility stays using medicare claims data: an algorithm and validation

Nursing facilities provide skilled nursing and rehabilitative care to patients for short stays and custodial care to patients for long stays. The type of nursing facility stay (short- or long-term) is a potentially important risk factor and health outcome in health services research and is informative from both medical and fiscal perspectives. The purpose of this study was to develop and validate an algorithm to identify the use of nursing facility services and differentiate short- from long-term care using Medicare claims data. We used claims data for a 5% sample of Medicare beneficiaries to develop an algorithm to detect the use of nursing facility services and to distinguish between short- and long-term stays. We tested this algorithm using residency status from Medicaid long-term care claims for dually eligible beneficiaries and using residency status from the Medicare Current Beneficiary Survey (MCBS). Among 1,694,051 beneficiaries included in the baseline cohort, 25.6% had some indication of nursing facility residency. Using our algorithm, 59.8% of beneficiaries using any nursing facility care were classified as long-term residents. Validation of the algorithm against Medicaid long-term care claims and MCBS yielded high sensitivity and specificity. To our knowledge, this is the first paper to present a validated algorithm for identification of use of nursing facility services among Medicare beneficiaries that differentiates between short- and long-term care residency status.     

Incidence and Outcomes of SARS-CoV-2 in Post-Acute Skilled Nursing Facility Care

ObjectivesTo examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death.DesignCohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive.Setting and ParticipantsThe sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded.MethodsSARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2.ResultsThe sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment.Conclusions and ImplicationsThe absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.     

The use of acute hospital services by elderly residents of nursing and residential care homes

The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P-values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes.     

Measuring appropriate use of acute beds. A systematic review of methods and results

A systematic review of the methods used to assess appropriateness of acute bed use and the evidence on the scale of inappropriate use in different patient groups is presented. Issues of generalisability of the findings are also addressed. Criteria based tools are the accepted way of measuring inappropriate days of stay and admissions, although opinion based classification is very common. While a number of tools exist, few have been adequately tested for reliability and validity. The Appropriateness Evaluation Protocol (AEP) is the most commonly used tool, and has been tested more widely. It appears to be both reliable and valid. An estimated 29% of admissions to acute psychiatric may be inappropriate. Regarding days of care after admission, between 24 and 58% of stays were not judged to be appropriate for continued stay on an acute ward. The need for continued acute psychiatric care may become lower as patients experience continued stay in the acute setting. A lack of housing and community support was the most commonly cited reason preventing discharge. Rates of inappropriate use appear to be higher for older patients than for the general population. Wide variation in rates of inappropriate days of stay was found, but it may be safe to assume that inappropriate use is greater than 20% across a wide variety of settings. Reasons for older patients to remain in an acute hospital bed after medically necessary are typically moderate nursing care needs (i.e. long-term care). The estimates of inappropriate use in other groups was found to be highly variable. Before definitive conclusions on the inappropriate use of acute beds can be made, future research needs to take into account the methodological problems discussed here.     

Multidisciplinary patient management by means of a high social risk screening tool

OBJECTIVE: The long-term goal in this study was for the Memorial Hospital of Salem County, Inc (MHSC), to create a seamless system of continuity of care for patients. This continuity of care begins before patients require acute admission through the hospital course and extends beyond discharge and into the post-hospital setting or alternate care situation. DESIGN: In a retrospective study in 1993, through the first 6 months of 1994, it was discovered that MHSC patients experienced a longer-than-average Medicare length of stay than was seen in other hospitals. MHSC embarked on a program to reduce discharge planning request time to the social work and home care departments by using a patient screening system that began at the time of admission. The nursing, social work, and home care departments collaboratively designed a system that allowed for immediate transfer of vital discharge planning information to the social work and home care departments at the time of the patient's admission. A tool was jointly developed called the multidisciplinary patient management record. RESULTS: The benefits of this process far exceeded the cost of implementing the tool. The average skilled nursing facility length of stay decreased below the national average by almost one full day. Patients experienced earlier access to social service intervention: discharge planning needs were identified more accurately; and the social services and home care departments' productivity rose because they could anticipate problems before a crisis arose. CONCLUSIONS: Critical to the success of this overall effort was not designing the new tool, but integrating the tool into a reengineered multidisciplinary patient management process.     

Impact of the Medicare Catastrophic Coverage Act on Nursing Homes

The Medicare Catastrophic Coverage Act (MCCA) of 1988 altered eligibility and coverage for skilled nursing facility (SNF) care and changed Medicaid eligibility rules for nursing-home residents. Detailed data on the residents of a for-profit nursing-home chain and Medicare claims for a 1 percent sample of beneficiaries were used to examine the impact of the MCCA on nursing homes. The case mix of nursing-home admissions was scrutinized, specifically for length of stay, discharge disposition, rate of hospitalization, and changes in payer source. Findings revealed that, although the proportion of Medicare-financed nursing-home care increased, as did the case-mix severity of residents during the MCCA period, there was no corollary reduction in hospital use by nursing-home residents.     

A child psychiatric hospital's first and second admissions: comparative studies

This article compares first and second admissions (readmissions) to a Child Psychiatric Hospital to identify some demographic factors related to readmissions. Male children and children who were younger at the time of the initial (first) admission were more predominant in readmissions. Interestingly, the most common denominator in readmissions, irrespective of gender, race and psychiatric diagnosis, is the length of hospitalization at the time of the initial admission. Initial hospital stay was shorter in second admissions than in first admissions. This finding raises questions as to the value of early discharge of the child psychiatric patient from a hospital without providing a continuum of psychiatric care.     

A New Model for End-of-Life Care in Nursing Homes

ObjectivesThis study aimed to promote quality end-of-life (EOL) care for nursing home residents, through the establishment of advance care plan (ACP) and introduction of a new care pathway. This pathway bypassed the emergency room (ER) and acute medical wards by facilitating direct clinical admission to an extended-care facility.DesignAn audit on a new clinical initiative that entailed the Community Geriatrics Outreach Service, ER, acute medical wards, and an extended-care facility during winter months in Hong Kong.MethodsThe participants were older nursing home residents enrolled in an EOL program. We monitored the ratio of clinical to emergency admissions, ACP compliance rate, average length of stay (ALOS) in both acute hospital and an extended-care facility, and mortality rates.ResultsA total of 76 patients were hospitalized from January to March 2013. Of them, 30 (39%) were directly admitted to the extended-care facility, either through the liaison of Community Geriatrics Outreach Service (group A, 19/76, 25%) or transferred from the ER (group B, 11/76, 14%). The remaining 46 patients (group C, 61%) were admitted via the ER to acute medical wards following the usual pathway, followed by transfer to an extended-care facility if indicated. The ACP compliance rate was nearly 100%. In the extended-care unit, groups A and C had similar ALOS of 11.8 and 11.1 days, respectively, whereas group B had a shorter stay of 7.6 days. The ALOS of group C in acute medical wards was 3.5 days. The in-hospital mortality rates were comparable in groups A and C of 26% and 28%, respectively, whereas group B had a lower mortality rate of 18%.ConclusionsNearly 40% of EOL patients could be managed entirely in an extended-care setting without compromising the quality of care and survival. A greater number of patients may benefit from the EOL program by improving the collaboration between community outreach services and ER; and extending hours for direct clinical admission to an extended-care facility.     

Associations Between Psychiatric Inpatient Bed Supply and the Prevalence of Serious Mental Illness in Veterans Affairs Nursing Homes

Objectives. We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA).Methods. We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings.Results. From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43 894–40 928), the average inpatient length of stay decreased (33.1–19.0 days), and the prevalence of SMI in nursing homes rose (29.4%–43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%).Conclusions. These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment.Over the past half century, the locus of psychiatric care has shifted from long-term inpatient psychiatric hospitals to community-based outpatient care settings,1 with this “deinstitutionalization” movement resulting in a sharp decline in state psychiatric hospital beds.2 This movement is regarded as a “disaster of the past,”3 in part because of the inadequacy of outpatient services to meet the needs of symptomatic psychiatric patients.3,4 In the absence of adequate community-based services, deinstitutionalization in name often resulted in transinstitutionalization in practice, as symptomatic patients were shifted to other institutional settings, such as general hospitals and nursing homes.1Research investigating transinstitutionalization has mixed results. A 3-year follow-up of patients discharged from a state psychiatric hospital found rates of more than 20% admission to community inpatient psychiatric units, with an average of more than 75 yearly inpatient days per patient.5 Similarly, a large-scale longitudinal evaluation of the Canadian mental health system found that reductions in inpatient psychiatric beds were associated with increased utilization of general hospital psychiatric beds, a pattern that continued for more than 2 decades until community mental health services expanded to meet the needs of psychiatric patients.6 However, another evaluation of discharged state psychiatric patients found decreased rates of postdischarge jail and general hospital psychiatric unit utilization relative to the use of these services during the time that patients received state psychiatric care.7There has been limited investigation into transinstitutionalization to community nursing home settings. The only large-scale study of transinstitutionalization to nursing home care was conducted in Norway, in which the effects of downsizing psychiatric hospitals were evaluated for more than 50 years. During the first 2 decades, there was evidence for transinstitutionalization because patients previously treated in state-run psychiatric facilities were enrolled in increasing numbers in nursing homes. Similar to the Canadian evaluation, this pattern continued until community-based mental health services evolved to meet the needs of these psychiatric patients, with transinstitutionalization to nursing home care ending by the early 1970s.8Many nursing homes are unable to offer the specialized treatment required by patients discharged from state mental hospitals.9 Concerns about such shortcomings led to the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). This legislation set guidelines for standardized mental health screening and treatment within nursing homes, with the goal of reducing inappropriate admissions and improving the care of patients with psychiatric conditions already enrolled in nursing home care. Although OBRA-87 had positive effects,10,11 it also has its shortcomings.12Despite OBRA-87, available data suggest that nursing homes continue to have sizeable proportions of residents with serious psychiatric disorders. In a study of more than 9000 Veterans Health Administration (VHA) nursing home residents, nearly one fifth of residents (17.9%) met criteria for serious mental illness (SMI).13 Similar levels of SMI prevalence were found in nursing home populations outside of the VHA.14,15 It is unclear at this time whether these patients were placed appropriately into nursing home care or inappropriately admitted in the absence of adequate inpatient psychiatric services.Reductions in psychiatric inpatient bed availability have continued in recent years. There has been a national reduction from 99 223 psychiatric beds in 1990 to 55 576 beds in 2009 within hospitals.16 Meanwhile, nursing home bed availability has increased. The number of available beds within skilled nursing homes increased from 512 107 in 1990 to more than 1.5 million in 2009.16Transinstitutionalization demonstrates the interconnectedness of institutional settings.17 To date, however, few studies assessed relationships between psychiatric inpatient and long-term care services in a single health system. Although transinstitutionalization to nursing homes was observed in previous decades, it is unclear whether these patterns continued in recent years. This study examined trends in psychiatric inpatient resources in the VHA health system, in association with VHA-funded nursing home care, which includes both VHA-owned nursing homes (which are today known as Community Living Centers) and VHA-contracted community nursing homes. To further evaluate the potential for transinstitutionalization between these settings, changes in the process of inpatient psychiatric care were tracked to evaluate evidence for unmet psychiatric needs. This study had 3 primary objectives: (1) to assess trends in VHA inpatient psychiatric beds from fiscal year 1999 (FY99) to FY07, (2) to assess relationships between changes in VHA inpatient psychiatric bed supply and the prevalence of SMI in VHA nursing home residents, and (3) to assess potential relationships between VHA psychiatric inpatient bed availability and the appropriateness of VHA nursing home admissions for patients with SMI.     

Skilled nursing facility care for persons with AIDS: comparison with other patients.

We compared average daily hours of care for patients with and without acquired immunodeficiency syndrome (AIDS) in a hospital-based skilled nursing facility. Patients with AIDS averaged over an hour more direct nursing care per patient day (6.5 vs 5.4 hours). These findings support other reports of greater nursing time and higher costs of caring for nursing home patients with AIDS.     

Managing Care? Medicare Managed Care and Patient Use of Cardiologists

Objective. To examine the impact of Medicare managed care (MMC) versus Medicare fee for service (MFFS) on stent patients' use of physicians with lower resource use and better outcomes. Data Sources/Study Setting. Retrospective secondary data from 2003 through 2006 for 67,476 patients without acute myocardial infarction, staying 2 or more days in hospital, and treated by 486 physicians in Florida performing 10 or more cases per quarter. Study Design. Analysis was at the patient level. Multivariate logistic models estimated the probability of an MMC patient using a physician with a particular risk‐adjusted profile rank with respect to hospital peers. Principal Findings. No differences were found in usage of physicians with shorter admissions. Compared with MFFS, MMC patients were significantly less likely to use physicians whose average mortality was the lowest/lowest quartiles/below median among facility peers, and more likely to use a physician ranked below median on live discharges directly home (not needing home health care, skilled nursing care, or a subacute hospital convalescence). Similar results were found with emergency admissions, and where physicians both attended and treated. Conclusions. Florida percutaneous coronary interventions patients insured by MMC used physicians with worse outcome profiles than those of MFFS patients. Results were not consistent with hospital care differences, physician–patient, or payor–physician selection, but they were consistent with selection of unobservably sicker members into MMC and concentration of MMC among physicians.     

Identifying factors associated with health care use: a hospital-based risk screening index

The purpose of the current study was to identify variables near hospital admission that could effectively discriminate patients at risk for nursing home placement, long hospital stay, or readmission. Risk factors reported in the literature were used to predict hospital outcome for 532 admissions. Factors that discriminated type of outcome included: two or more chronic medical conditions, living alone or being admitted from a nursing home, dependent ambulation, poor mental status, psychiatric comorbidity, prior admission, age over 75, and being unmarried. Using these criteria, an index was developed to determine risk for placement, readmission, or lengthy stay. Use of cumulative risk scores can result in accurate prediction of outcome and may be useful in targeting patients for intervention. Performance characteristics of the risk index are discussed.