Variation in 30-Day Readmission Rates from Inpatient Rehabilitation Facilities to Acute Care Hospitals

ObjectivesTo quantify the rate of readmission from inpatient rehabilitation facilities (IRFs) to acute care hospitals (ACHs) during the first 30 days of rehabilitation stay. To measure variation in 30-day readmission rate across IRFs, and the extent that patient and facility characteristics contribute to this variation.DesignRetrospective analysis of an administrative database.Setting and ParticipantsAdult IRF discharges from 944 US IRFs captured in the Uniform Data System for Medical Rehabilitation database between October 1, 2015 and December 31, 2017.MethodsMultilevel logistic regression was used to calculate adjusted rates of readmission within 30 days of IRF admission and examine variation in IRF readmission rates, using patient and facility-level variables as predictors.ResultsThere were a total of 104,303 ACH readmissions out of a total of 1,102,785 IRFs discharges. The range of 30-day readmission rates to ACHs was 0.0%‒28.9% (mean = 8.7%, standard deviation = 4.4%). The adjusted readmission rate variation narrowed to 2.8%‒17.5% (mean = 8.7%, standard deviation = 1.8%). Twelve patient-level and 3 facility-level factors were significantly associated with 30-day readmission from IRF to ACH. A total of 82.4% of the variance in 30-day readmission rate was attributable to the model predictors.Conclusions and ImplicationsFifteen patient and facility factors were significantly associated with 30-day readmission from IRF to ACH and explained the majority of readmission variance. Most of these factors are nonmodifiable from the IRF perspective. These findings highlight that adjusting for these factors is important when comparing readmission rates between IRFs.     

Conducting Clinical Research in Post-acute and Long-term Nursing Home Care Settings: Regulatory Challenges

Despite multiple initiatives in post-acute and long-term nursing home care settings (NHs) to improve the quality of care while reducing health care costs, research in NHs can prove challenging. Extensive regulation for both research and NHs is designed to protect a highly vulnerable population but can be a deterrent to conducting research. This article outlines regulatory challenges faced by NHs and researchers, such as protecting resident privacy as well as health information and obtaining informed consent. The article provides lessons learned to help form mutually beneficial partnerships between researchers and NHs to conduct studies that grow and advance NH research initiatives and clinical care.     

Rapid Changes in the Provision of Rehabilitation Care in Post-Acute and Long-Term Care Settings During the COVID-19 Pandemic

ObjectivesLittle is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs.DesignQualitative analysis of open-ended survey results.Setting and Participants30 clinical and administrative staff working in post-acute and long-term care.MethodsFrom June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data.ResultsWe identified 4 themes, related to (1) rapid changes in care delivery, (2) negative impact on patients’ motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients’ isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (eg, for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency.Conclusions and ImplicationsSurvey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.     

Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery

ObjectivesTo compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital.DesignWe conducted a retrospective cohort study of Veterans who had orthopedic surgery at the Salt Lake City VA Medical Center (VAMC) between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital.Setting and ParticipantsVeterans not already on chronic opioid therapy who had orthopedic surgery at the Salt Lake City VAMC and were followed by a transitional pain service.Methods448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models.ResultsPatients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P = .009].Conclusions and ImplicationsVeterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.     

Machine-Learning Modeling to Predict Hospital Readmission Following Discharge to Post-Acute Care

ObjectivesPrimary purpose was to generate a model to identify key factors relevant to acute care hospital readmission within 90 days from 3 types of post-acute care (PAC) sites: home with home care services (HC), skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF). Specific aims were to (1) examine demographic characteristics of adults discharged to 3 types of PAC sites and (2) compare 90-day acute hospital readmission rate across PAC sites and risk levels.DesignRetrospective, secondary analysis design was used to examine hospital readmissions within 90 days for persons discharged from hospital to SNF, IRF, or HC.Settings and ParticipantsCohort sample was composed of 2015 assessment data from 3,592,995 Medicare beneficiaries, including 1,536,908 from SNFs, 306,878 from IRFs, and 1,749,209 patients receiving HC services.MeasuresInitial level of analysis created multiple patient profiles based on predictive patient characteristics. Second level of analysis consisted of multiple logistic regressions within each profile to create predictive algorithms for likelihood of readmission within 90 days, based on risk profile and PAC site.ResultsTotal sample 90-day hospital readmission rate was 27.48%. Patients discharged to IRF had the lowest readmission rate (23.34%); those receiving HC services had the highest rate (31.33%). Creation of model risk subgroups, however, revealed alternative outcomes. Patients seem to do best (i.e., lowest readmission rates) when discharged to SNF with one exception, those in the very high risk group. Among all patients in the low-, intermediate-, and high-risk groups, the lowest readmission rates occurred among SNF patients.Conclusions and ImplicationsThe proposed model has potential use to stratify patients’ potential risk for readmission as well as optimal PAC destination. Machine-learning modeling with large data sets is a useful strategy to increase the precision accuracy in predicting outcomes among patients who have nonhome discharges from the hospital.     

Rehabilitation Providers' Prediction of the Likely Success of the SNF-to-Home Transition Differs by Discipline

Objectives

Our article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics.

Trends in Post-Acute Care Utilization During the COVID-19 Pandemic

ObjectiveTo examine the effect of the COVID-19 pandemic on post-acute care utilization and spending.DesignWe used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending.Setting and participantsWe identified and included 975,179 hospital discharges who were aged ≥65 years.MethodsWe summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings.ResultsThe percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased.Conclusions and ImplicationsChanges in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care.     

Effectiveness of Hearing Rehabilitation for Care Home Residents With Dementia: A Systematic Review

ObjectivesTo report the effectiveness of, and barriers and facilitators to, hearing rehabilitation for care home residents with dementia.DesignSystematic review.Setting and ParticipantsCare home residents with dementia and hearing loss.MethodsNo restrictions on publication date or language were set and gray literature was considered. Eligible studies were critically appraised and presented via a narrative review.ResultsSixteen studies, most of low to moderate quality, were identified. Hearing rehabilitation, including hearing devices, communication techniques, and visual aids (eg, flashcards), was reported to improve residents' communication and quality of life and reduce agitation, with improvements in staff knowledge of hearing loss and job satisfaction. Residents' symptoms of dementia presented barriers, for example, losing or not tolerating hearing aids. Low staff prioritization of hearing loss due to time pressures and lack of hearing-related training for staff were further barriers, particularly for residents who required assistance with hearing devices. Adopting a person-centered approach based on residents’ capabilities and preferences and involving family members facilitated hearing device use.Conclusions and ImplicationsResidents with dementia can benefit from hearing rehabilitation. Identifying and implementing efficient, individualized hearing rehabilitation is necessary for those with complex cognitive needs. Increased funding and support for the social care sector is required to address systemic issues that pose barriers to hearing rehabilitation, including time pressures, lack of training for staff and access to audiology services for residents.     

Post-Acute Care in Inpatient Rehabilitation Facilities Between Traditional Medicare and Medicare Advantage Plans Before and During the COVID-19 Pandemic

ObjectivesCompare post-acute care (PAC) utilization and outcomes in inpatient rehabilitation facilities (IRF) between beneficiaries covered by Traditional Medicare (TM) and Medicare Advantage (MA) plans during the COVID-19 pandemic relative to the previous year.DesignThis multiyear cross-sectional study used Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) data to assess PAC delivery from January 2019 to December 2020.Setting and ParticipantsInpatient rehabilitation for stroke, hip fracture, joint replacement, and cardiac and pulmonary conditions among Medicare beneficiaries 65 years or older.MethodsPatient-level multivariate regression models with difference-in-differences approach were used to compare TM and MA plans in length of stay (LOS), payment per episode, functional improvements, and discharge locations.ResultsA total of 271,188 patients were analyzed [women (57.1%), mean (SD) age 77.8 (0.06) years], among whom 138,277 were admitted for stroke, 68,488 hip fracture, 19,020 joint replacement, and 35,334 cardiac and 10,069 pulmonary conditions. Before the pandemic, MA beneficiaries had longer LOS (+0.22 days; 95% CI: 0.15–0.29), lower payment per episode (−$361.05; 95% CI: −573.38 to −148.72), more discharges to home with a home health agency (HHA) (48.9% vs 46.6%), and less to a skilled nursing facility (SNF) (15.7% vs 20.2%) than TM beneficiaries. During the pandemic, both plan types had shorter LOS (−0.68 day; 95% CI: 0.54–0.84), higher payment (+$798; 95% CI: 558–1036), increased discharges to home with an HHA (52.8% vs 46.6%), and decreased discharges to an SNF (14.5% vs 20.2%) than before. Differences between TM and MA beneficiaries in these outcomes became smaller and less significant. All results were adjusted for beneficiary and facility characteristics.Conclusions and ImplicationsAlthough the COVID-19 pandemic affected PAC delivery in IRF in the same directions for both TM and MA plans, the timing, time duration, and magnitude of the impacts were different across measures and admission conditions. Differences between the 2 plan types shrank and performance across all dimensions became more comparable over time.     

Investing in Post-Acute Care Transitions: Electronic Information Exchange Between Hospitals and Long-Term Care Facilities

Background

Electronic health information exchange (HIE) is expected to help improve care transitions from hospitals to long-term care (LTC) facilities. We know little about the prevalence of hospital LTC HIE in the United States and what contextual factors may motivate or constrain this activity.

Home Health Care Post-PPS

California home health data for the years 1982 through 1987 are analyzed to explore the effects of the implementation of the Prospective Payment System in 1983 and the increase in denial rate for Medicare reimbursed home care in late 1985. After 1983 the following declined: average number of patients per agency, average number of visits per patient, number of freestanding agencies and percentage of reimbursement from Medicare. After 1985 there were declines in the number of patients served, total number of visits, average number of visits per aged client, and number of agencies (proprietary and non-profit) submitting annual reports.     

Addressing the Home Care Shortage: Predictors of Willingness to Provide Paid Home Care in New York

ObjectivesTo determine the prevalence and predictors of willingness to consider becoming a paid home care worker.DesignCross-sectional telephone-based survey study.Setting and Participants800 adult residents of New York State participating in the 2020 Empire State Poll, an annual survey conducted in English and Spanish using random-digit dialing.MethodsWillingness to consider working as a paid home care worker was analyzed as the main outcome. Survey questions also involved demographics and unpaid caregiving experience. We used multinomial logistic regression to examine associations between participant characteristics and willingness to be a paid caregiver.ResultsParticipants had a mean age of 47.7 years (95% CI 45.4-50.0). Demographic information included 51.1% female gender, 65.4% White race, 13.4% Black race, 6.4% Asian or Pacific Islander, 14.8% another race, 19.1% Hispanic/Latino ethnicity, and 43.0% household income below $50,000 per year. A weighted 25.4% of participants would consider becoming a paid home care worker. In an adjusted model, willingness to be a paid home care worker was associated with younger age [odds ratio (OR) 0.98, 95% CI 0.96-1.00, P = .032], female gender (OR 2.46, 95% CI 1.35-4.46, P = .003), Black or other race (OR 2.40, 95% CI 1.11-5.17, P = .026, and OR 3.13, 95% CI 1.30-7.54, P = .011, respectively), Hispanic ethnicity (OR 2.26, 95% CI 1.06-4.81, P = .035), household income below $50,000 per year (OR 2.00, 95% CI 1.03-3.88, P = .040), and having provided unpaid family caregiving (OR 2.08, 95% CI 1.15-3.76, P = .016).Conclusions and ImplicationsA quarter of New Yorkers would consider working as a paid home care worker. Willingness to consider this occupation was associated with the demographic characteristics disproportionately represented in the current home care workforce. Improved working conditions and compensation could help attract and retain home care workers, thereby addressing the rising need for home care in the United States.     

老年居家卫生服务模型研究

目的：改善老年人的健康状况、提高其卫生服务可及性。方法：采用了专家研讨会和概念建模的方法。结果：老年卫生服务的目标是实现其健康老龄化和积极老龄化,途径是为他们提供连续的、全方位的、没有灰色带的、能够提高他们独立生活能力的综合性服务。老年居家卫生服务模型主要包括4个微观系统领域：自我管理支持、决策支持、递送系统设计和临床信息系统;服务内容包括初级卫生保健服务和社会服务两部分。结论：居家卫生服务对于提高老年人卫生服务可及性、提高其独立生活能力、改善其健康状况具有很强针对性。     

Direct Admission from the Emergency Department to a Subacute Care Ward: An Alternative to Acute Hospitalization

In recent years, subacute care units (SCUs) have emerged as alternatives to acute hospitalization for selected emergency department (ED) patients who might benefit from a short period of inpatient stay within a less acute setting. We developed a new protocol to directly admit selected older patients from our acute hospital's (AH) ED to the SCU of a partner community hospital, making use of our ED's short-stay ward as a transit area to overcome administrative, financial, and clinical barriers. The new protocol has removed the need for intervening stays of longer than 24 hours at our AH, reduced overall length of stay across both institutions, decreased hospital admissions, and reduced the number of patient hand-offs.     

Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies

COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.     

The Medical Home Transformation in the Veterans Health Administration: An Evaluation of Early Changes in Primary Care Delivery

Objective

To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration (VHA).

Data Sources/Study Setting/Study Design

We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team (PACT) implementation was associated with changes in organizational processes and patient outcomes.

Principal Findings

Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients.

Conclusions

Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery.     

Projecting Long-Term Care Costs for Home and Community-Based Services in China from 2005 to 2050

ObjectivesThe aim of this study was to estimate and project the trend in long-term care (LTC) costs for home and community-based services as a percentage of gross domestic product in China between 2005 and 2050.DesignLongitudinal.Setting and ParticipantsWe used 61,249 observations from 37,702 adults age ≥65 years from waves 2005, 2008, 2011, 2014, and 2018 of the Chinese Longitudinal Healthy Longevity Surveys.MethodsLTC costs for home and community-based services consisted of the monetary value of time spent on LTC and the direct LTC cost. We used the age-sex-residence-specific weights provided by the Chinese Longitudinal Healthy Longevity Surveys to estimate the LTC costs from 2005 to 2018. We used a component-based model to project LTC costs, in which the 2-part model was used to estimate the average LTC costs and the multi-state Markov model approach was used to project the future population by age, sex, and disability state.ResultsThe percentage of older adults with disabilities was projected to increase from 6.1% in 2005 to 7.5% in 2020 and 9.6% in 2050. The total LTC cost for home and community-based services were projected to increase from 0.3% of gross domestic product in 2005 to 0.7% in 2020 and to 6.4% in 2050.Conclusions and ImplicationsPolicymakers in China should take urgent actions to delay the onset of disabilities among older adults, which would curb the increasing LTC costs and maintain the sustainability of the LTC policies.     

Identifying Challenges Associated With the Care Transition Workflow From Hospital to Skilled Home Health Care: Perspectives of Home Health Care Agency Providers

Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions—information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.     

三城市出院病人对社区卫生服务的认知与评价研究

基于北京、上海和南宁3城市4所三甲医院的1095名出院病人的电话问卷调查和访谈,了解出院病人对社区卫生服务的认知和评价,分析医院和社区卫生服务机构双向转诊过程中存在的问题与障碍。