Passing the SNF Test: A Secondary Analysis of a Sepsis Transition Intervention Trial Among Patients Discharged to Post-Acute Care

ObjectivesSepsis survivors discharged to post-acute care facilities experience high rates of mortality and hospital readmission. This study compared the effects of a Sepsis Transition and Recovery (STAR) program vs usual care (UC) on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care.DesignSecondary analysis of a multisite pragmatic randomized clinical trial.Setting and ParticipantsSepsis survivors discharged to post-acute care.MethodsWe conducted a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial who were discharged to post-acute care. IMPACTS evaluated the effectiveness of STAR, a nurse-navigator-led program to deliver best practice post-sepsis care. Subjects were randomized to receive either STAR or UC. The primary outcome was 30-day readmission and mortality. We also evaluated hospital-free days alive as a secondary outcome.ResultsOf 691 patients enrolled in IMPACTS, 175 (25%) were discharged to post-acute care [143 (82%) to skilled nursing facilities, 12 (7%) to long-term acute care hospitals, and 20 (11%) to inpatient rehabilitation]. Of these, 87 received UC and 88 received the STAR intervention. The composite 30-day all-cause mortality and readmission endpoint occurred in 26 (29.9%) patients in the UC group vs 18 (20.5%) in the STAR group [risk difference −9.4% (95% CI −22.2 to 3.4); adjusted odds ratio 0.58 (95% CI 0.28 to 1.17)]. Separately, 30-day all-cause mortality was 8.1% in the UC group compared with 5.7% in the STAR group [risk difference −2.4% (95% CI −9.9 to 5.1)] and 30-day all-cause readmission was 26.4% in the UC group compared with 17.1% in the STAR program [risk difference −9.4% (95% CI −21.5 to 2.8)].Conclusions and ImplicationsThere are few proven interventions to reduce readmission among patients discharged to post-acute care facilities. These results suggest the STAR program may reduce 30-day mortality and readmission rates among sepsis survivors discharged to post-acute care facilities.     

Using a Decision Support Algorithm for Referrals to Post-Acute Care

Objectives

Although hospital clinicians strive to effectively refer patients who require post-acute care (PAC), their discharge planning processes often vary greatly, and typically are not evidence-based.

The Post-Acute Delayed Discharge Risk Scale: Derivation and Validation With Ontario Alternate Level of Care Patients in Ontario Complex Continuing Care Hospitals

ObjectivesTo describe and validate the Post-acute Delayed Discharge Risk Scale (PADDRS), which classifies patients by risk of delayed discharge on admission to post-acute care settings using information collected with the interRAI Minimum Data Set (MDS) 2.0 assessment.DesignRetrospective cohort study of individuals admitted to Ontario Complex Continuing Care (CCC) hospitals. Person-level linkage between interRAI MDS 2.0 assessments and Cancer Care Ontario Wait Time Information System records was performed.Setting and ParticipantsSample of 30,657 patients who received care in an Ontario CCC hospital and were assessed with the interRAI MDS 2.0 assessment between January 1, 2010, and March 31, 2013.MeasuresAlternate Level of Care (ALC) designation of 30 or more days was used as the marker of delayed discharge. Scale validation was performed through computation of class-level effect sizes and receiver operating characteristic curves for each of Ontario's geographic health regions. Additionally, Clinical Assessment Protocol (CAP) decision-support tool trigger rates by PADDRS risk level were computed for problem areas that are clinically relevant with the delayed discharge outcome.ResultsOverall, 9.4% of the sample experienced the delayed discharge outcome. The PADDRS algorithm achieved an overall area under the curve (AUC) statistic of 0.74, which indicates good discriminatory ability for predicting delayed discharge. PADDRS is generalizable across geographic regions, with AUC statistics ranging between 0.61 and 0.81 across each of Ontario's 14 Local Health Integration Networks. PADDRS demonstrated strong concurrent validity, as the percentage of patients triggering CAPs increased with the risk of delayed discharge.Conclusions and ImplicationsPADDRS combines numerous important clinical factors associated with delayed discharge from a post-acute hospital into a cohesive decision-support tool for use by discharge planners. In addition to early identification of patients who are most likely to experience delayed discharge, PADDRS has applications in risk-adjusted quality measurement of discharge planning efficiency.     

Trends in Post-Acute Care in US Nursing Homes: 2001-2017

ObjectiveTo describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes’ degree of specialization in post-acute care.DesignRetrospective cohort study.Setting and ParticipantsAll US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time.MethodsWe measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization.ResultsThe average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid.Conclusions and ImplicationsOver the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care.     

Effects of Payment Changes on Trends in Post-Acute Care

Objective. To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.
Data Sources. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.
Study Design. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.
Data Extraction Methods. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.
Principal Findings. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.
Conclusions. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.     

Recovery from Coronavirus Disease 2019 among Older Adults in Post-Acute Skilled Nursing Facilities

ObjectivesTo examine functional outcomes of post-acute care for coronavirus disease 2019 (COVID-19) in skilled nursing facilities (SNFs).DesignRetrospective cohort.Setting and ParticipantsSeventy-three community-dwelling adults ≥65 years of age admitted for post-acute care from 2 SNFs from March 15, 2020, to May 30, 2020.Measure(s)COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index (FI), categorized into nonfrail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT).ResultsAmong 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean [standard deviation (SD)] age was 83.5 (8.8) and 42 (57.5%) were female, with mean FI of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among patients who tested positive for COVID-19. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge [92.0 (6.7) not frail, 81.0 (15.4) mild frailty, 48.6 (20.4) moderate-to-severe frailty; P = .002], lower PT scores on discharge [54.2 (3.9) nonfrail, 51.5 (8.0) mild frailty, 37.1 (9.7) moderate-to-severe frailty; P = .002], and lower OT score on discharge [52.9 (3.2) nonfrail, 45.8 (9.4) mild frailty, 32.4 (7.4) moderate or worse frailty; P = .001].Conclusions and ImplicationsOlder adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge.     

A Tailored Discharge Program Improves Frailty and Mood in Patients Undergoing Usual Rehabilitative Care: A Randomized Controlled Trial

ObjectiveTo investigate whether a tailored intersectoral discharge program (TIDP) impacts on multidimensional frailty, rehospitalization days, and patient-related outcome measures in older in-patients undergoing acute care and usual rehabilitative care.DesignRandomized controlled trial of TIDP vs usual rehabilitative care with a 6-month follow-up, 2019–2020, and historical control with a 6-month follow-up, 2016–2019.Setting and ParticipantsGeriatric co-managed internal medicine ward of a metropolitan university hospital. One hundred-twelve multimorbid patients older than age 60 years were consecutively assessed for eligibility and inclusion (age ≥60 years, multimorbidity, admitted for treatment of acute disease, at least 2 geriatric syndromes requiring usual rehabilitative care, and able to consent) and signed informed consent, with 110 recruited and randomized to either TIDP or usual rehabilitative care. At discharge, 104 patients were alive in the intention-to-treat group, the 6-month follow-up was completed for 91 patients. A historical control group of 468 patients was included for comparison.InterventionTIDP as intervention included contact with treating general practitioner to discuss the further treatment plan, a structured medical and lifestyle counseling to patients and caregivers at admission as well as a discharge program with internist, geriatrician, and general practitioner in shared decision making with patients.MethodsFifty-four patients underwent TIDP, 53 patients underwent usual rehabilitative care only. Rehospitalization days at follow-up as primary endpoint; multidimensional frailty and prognosis (Multidimensional Prognostic Index, Geriatric Depression Scale, Rosenberg Self-Esteem Scale, quality of life, falls, mortality, home care service need, and need of long-term care at 1-, 3- and 6-month follow-up as secondary endpoints.ResultsTIDP (median age 76.0 years, 56% female) showed significantly improved Multidimensional Prognostic Index scores at discharge compared with usual rehabilitative care (median age 78.5 years, 58% female) (0.43 vs 0.49, P = .011). Compared with usual rehabilitative care, TIDP improved self-confidence (Rosenberg Self-Esteem Scale 13.9 vs 12.4, P = .009) and mood (Geriatric Depression Scale 4 vs 5, P = .027) at follow-up. Compared with historical control (median age 77.0 years, 39 % female), usual rehabilitative care patients showed significantly lower rehospitalization rates (53% vs 70%, P = .002) and lower mortality rates (13% vs 32%, P < .001).Conclusions and ImplicationsA feasible TIDP improves frailty and mood in advanced age. In older patients undergoing potentially disabling acute treatments, usual rehabilitative care significantly reduces rehospitalization rates. Therefore, implementing geriatric treatment in general is useful to improve outcomes in older in-patients and a tailored discharge program can further increase the benefit for this frail population.     

Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities

ObjectivesMedicare Shared Savings Program (MSSP) was implemented in 2012, but the impact of the MSSP on institutional post-acute care (PAC) use, and by race/ethnicity and payer status is less studied. We studied the impact of hospital participation in the MSSP on institutional PAC use and variations by race/ethnicity and payer status among 3 Medicare patient groups: ischemic stroke, hip fracture, and elective total joint arthroplasty (TJA).DesignA retrospective analysis of 2010–2016 Medicare Provider Analysis and Review files.Setting and ParticipantsMedicare fee-for-service patients originally admitted for ischemic stroke, hip fracture, or elective TJA in MSSP-participating hospitals or nonparticipating hospitals.MethodsPatient-level linear probability models with difference-in-differences approach were used to compare the changes in institutional PAC use in MSSP-participating hospitals with nonparticipating hospitals as well as to compare the changes in differences by race/ethnicity and payer status in institutional PAC use over time.ResultsHospital participation in MSSP was significantly associated with increased institutional PAC use for the ischemic stroke cohort by 1.5 percentage points [95% confidence interval (CI) 0.00–0.3, P < .05] compared with non-MSSP participating hospitals. Regarding variations by race/ethnicity and payer status, for the elective TJA patients, racial minority patients in MSSP-participating hospitals had 3.8 percentage points greater (95% CI 0.01–0.06, P < .01) in institutional PAC use than white patients. Also, for ischemic stroke cohort, dual-eligible patients in MSSP-participating hospitals had 2.0 percentage points greater (95% CI 0.00–0.04, P < .10) in institutional PAC use than Medicare-only patients.Conclusions and ImplicationsThis study found that hospital participation in the MSSP was associated with slightly increased institutional PAC use for ischemic stroke Medicare patients. Also, compared to non-MSSP participating hospitals, MSSP-participating hospitals were more likely to discharge racial minority patients for elective TJA and dual-eligible patients for ischemic stroke to institutional PAC.     

Educating Dutch General Practitioners in Dementia Advance Care Planning: A Cluster Randomized Controlled Trial

ObjectivesAdvance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care.DesignA single-blinded cluster randomized controlled trial.Setting and participantsIn 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice.MethodsIntervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering.Results38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs.Conclusions and ImplicationsOur educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.     

Cost-Effectiveness of a Proactive Primary Care Program for Frail Older People: A Cluster-Randomized Controlled Trial

Background

A proactive integrated approach has shown to preserve daily functioning among older people in the community. The aim is to determine the cost-effectiveness of a proactive integrated primary care program.

Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia

ObjectivesHospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia.DesignRetrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to 2016.Setting and ParticipantsWe identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment.MethodsWe calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage).ResultsOf the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population.Conclusions and ImplicationsOne-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.     

Frailty and Time at Home After Post-Acute Care in Skilled Nursing Facilities

ObjectivesTo examine the association of a claims-based frailty index with time at home, defined as the number of days alive and spent out of hospital or skilled nursing facility (SNF).DesignCohort Study.Setting and ParticipantsA 5% Medicare random sample of fee-for-service beneficiaries, who had continuous part A and B enrollment in the prior 6 months, that were discharged from a short SNF admission in 2014‒2016.MethodsFrailty was measured with a validated claims-based frailty index (CFI) (range: 0‒1, higher scores indicating worse frailty) and categorized into nonfrail (CFI <0.25), mild frailty (CFI 0.25‒0.34), and moderate-to-severe frailty (CFI ≥0.35). We measured home time in the 6 months following SNF discharge (range: 0‒182 days with higher values representing more days at home and thus a better outcome). We used logistic regression to assess the association between frailty and short home time, defined as <173 days, adjusting for age, sex, race, region, a comorbidity index, clinical SNF admission characteristics in the Minimum Data Set, and SNF characteristics.ResultsIn our sample of 144,708 beneficiaries (mean age, 80.8 years, 64.9% female, 85.9% white) who were discharged to community after SNF stay, the mean CFI was 0.26 (standard deviation, 0.07). The mean home time was 165.6 (38.1) days in nonfrail, 154.4 (47.4) days in mild frailty, 145.0 (52.0) days in moderate-to-severe frailty group. After full model adjustments, moderate to severe frailty was associated with a 1.71 (95% CI 1.65‒1.78) higher odds of having short time at home in the 6 months following SNF discharge.Conclusion and ImplicationsHigher CFI is associated with short time at home in Medicare beneficiaries who are discharged to the community after post-acute SNF stay. Our results support the utility of CFI in identifying SNF patients who need additional resources and interventions to prevent health decline and poor quality of life.     

Lost in Transition: Missed Opportunities for the 4 Ms to Support Post-Acute Care Transitions

Thousands of health systems have adopted the 4 Ms framework, a set of evidence-based practices specific to older adults, as part of the Age-Friendly Health Systems (AFHS) initiative. However, implementation efforts have largely been setting-specific and approaches to achieve continuity of the 4 Ms during care transitions are nascent. Transitions from hospitals to skilled nursing facilities (SNFs) are one type of care transition that would greatly benefit from continuity of 4 Ms practices. Drawing from the authors' insights and 5 exploratory interviews at 3 health systems that implemented the 4 Ms in the inpatient setting, we describe a set of current-state challenges when trying to extend specific inpatient 4 Ms practices (eg, deprescribing of high-risk medications) as well as the nuanced understanding of the individual's clinical trajectory developed during an inpatient stay. We also offer concrete opportunities, such as developing 4 Ms–centric discharge summary templates, to address the challenges. With the large investment in AFHS transformation and associated efforts to implement the 4 Ms framework in all care settings used by older adults, it is critical to raise awareness of the specific obstacles to promoting continuity of successful 4 Ms practices during care transitions and work to overcome them. Our insights from hospital-to-SNF transitions offer a starting point.     

A Multilingual Mass Communication Intervention for Seniors and People with Disabilities on Medicaid: A Randomized Controlled Trial

Objectives. To evaluate the following: (1) baseline knowledge, attitudes, and behavioral intentions about Medicaid managed care (MMC) among seniors and people with disabilities (SPD) receiving Medicaid benefits; (2) SPD Medicaid beneficiaries' use of and satisfaction with a user‐designed MMC guidebook; and (3) guidebook effects on changes in MMC knowledge, attitudes, and intended behaviors of SPD beneficiaries. Data Sources/Study Setting. Survey data collected between February and May 2008 from a random sample of SPD receiving Medicaid benefits in three California counties. Study Design. This randomized controlled trial of 319 intervention and 373 control SPD Medicaid beneficiaries used pre‐ and postintervention telephone surveys to compare changes in MMC knowledge, attitudes, and intended behaviors. Data Collection Methods. Baseline and follow‐up telephone interviews were conducted in English, Spanish, Cantonese, and Mandarin. Principal Findings. Seventy‐seven percent of intervention participants reported using the guidebook. Nearly all (97.9 percent) found it somewhat or very useful. Intervention participants showed gains in knowledge, positive attitudes, and intentions to enroll in MMC that are statistically significant compared with control participants. However, knowledge levels remained low even among intervention participants. Conclusions. Findings suggest that the guidebook is an effective way to improve recipients' MMC knowledge, confidence, and behavioral intentions.