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Medical Care Research and Review : MCRR Aug 2020Due to high magnitude and variation in spending on post-acute care, accountable care organizations (ACOs) are focusing on transforming management of hospital discharge...
Due to high magnitude and variation in spending on post-acute care, accountable care organizations (ACOs) are focusing on transforming management of hospital discharge through relationships with preferred skilled nursing facilities (SNFs). Using a mixed-methods design, we examined survey data from 366 respondents to the National Survey of ACOs along with 16 semi-structured interviews with ACOs who performed well on cost and quality measures. Survey data revealed that over half of ACOs had no formal relationship with SNFs; however, the majority of ACO interviewees had formed preferred SNF networks. Common elements of networks included a comprehensive focus on care transitions beginning at hospital admission, embedded ACO staff across settings, solutions to support information sharing, and jointly established care protocols. Misaligned incentives, unclear regulations, and a lack of integrated health records remained challenges, yet preferred networks are beginning to transform the ACO post-acute care landscape.
Topics: Accountable Care Organizations; Cross-Sectional Studies; Humans; Interviews as Topic; Patient Discharge; Patient Transfer; Skilled Nursing Facilities; Subacute Care; Surveys and Questionnaires; United States
PubMed: 29966498
DOI: 10.1177/1077558718781117 -
Journal of the American Medical... Nov 2022The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates using standardized patient functional data across post-acute settings. This study...
OBJECTIVE
The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates using standardized patient functional data across post-acute settings. This study characterized similarities and differences in clinician-observed scores of self-care and transfer items for the standardized section GG functional domain and the functional independent measure (FIM) at inpatient rehabilitation facilities.
DESIGN
We conducted secondary analyses of 2017 Uniform Data System for Medical Rehabilitation national data. Patients were assessed by clinicians on both section GG and FIM at admission and discharge. We identified 7 self-care items and 6 transfer items in section GG conceptually equivalent with FIM. Clinician-assessed scores for each pair of items were examined using score distributions, Bland-Altman plot, correlation (Pearson coefficients), and agreement (kappa and weighted kappa) analyses.
SETTING AND PARTICIPANTS
In all, 408,491 patients were admitted to Uniform Data System for Medical Rehabilitation-affiliated inpatient rehabilitation facilities with one of the following impairments: stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility.
MEASURES
Section GG and FIM.
RESULTS
Patients were scored as more functionally independent in section GG compared with FIM, but change score distributions and score orders within impairment groups were similar. Total scores in section GG had strong positive correlations (self-care: r = 0.87 and 0.95; transfer: r = 0.82 and 0.90 at admission and discharge, respectively) with total FIM scores. Weak to moderate ranking agreements with total FIM scores were observed (self-care: kappa = 0.49 and 0.60; transfers: kappa = 0.43 and 0.52 at admission and discharge, respectively). Lower agreements were observed for less able patients at admission and for higher ability patients of their change scores.
CONCLUSIONS AND IMPLICATIONS
Overall, response patterns were similar in section GG and FIM across impairments. However, variations exist in score distributions and ranking agreement. Future research should examine the use of GG codes to maintain effective care, outcomes, and unbiased reimbursement across post-acute settings.
Topics: Humans; Aged; United States; Inpatients; Medicare; Stroke Rehabilitation; Stroke; Patient Discharge; Rehabilitation Centers; Length of Stay; Retrospective Studies; Recovery of Function; Treatment Outcome
PubMed: 35288084
DOI: 10.1016/j.jamda.2022.02.003 -
Journal of the American Geriatrics... Jun 2020
Topics: Betacoronavirus; COVID-19; Coronavirus Infections; Humans; Nursing Homes; Pandemics; Pneumonia, Viral; SARS-CoV-2; Subacute Care
PubMed: 32315075
DOI: 10.1111/jgs.16499 -
BMC Medicine Jul 2023Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities...
BACKGROUND
Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture.
METHODS
This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates.
RESULTS
Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates.
CONCLUSIONS
In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.
Topics: Humans; Female; Aged; United States; Aged, 80 and over; Male; Medicare; Retrospective Studies; Subacute Care; Hospitalization; Patient Discharge; Patient Readmission; Hip Fractures
PubMed: 37400841
DOI: 10.1186/s12916-023-02958-9 -
The Journals of Gerontology. Series A,... Sep 2018This study examines effects of mobility and multimorbidity on hospitalization and inpatient and postacute care (PAC) facility days among older men.
BACKGROUND
This study examines effects of mobility and multimorbidity on hospitalization and inpatient and postacute care (PAC) facility days among older men.
METHODS
Prospective study of 1,701 men (mean age 79.3 years) participating in Osteoporotic Fractures in Men (MrOS) Study Year 7 (Y7) examination (2007-2008) linked with their Medicare claims. At Y7, mobility ascertained by usual gait speed and categorized as poor, intermediate, or good. Multimorbidity quantified by applying Elixhauser algorithm to inpatient and outpatient claims and categorized as none, mild-moderate, or high. Hospitalizations and PAC facility stays ascertained during 12 months following Y7.
RESULTS
Reduced mobility and greater multimorbidity burden were independently associated with a higher risk of inpatient and PAC facility utilization, after accounting for each other and traditional indicators. Adjusted mean total facility days per year were 1.13 (95% confidence interval [CI] = 0.74-1.40) among men with good mobility increasing to 2.43 (95% CI = 1.17-3.84) among men with poor mobility, and 0.67 (95% CI = 0.38-0.91) among men without multimorbidity increasing to 2.70 (95% CI = 1.58-3.77) among men with high multimorbidity. Men with poor mobility and high multimorbidity had a ninefold increase in mean total facility days per year (5.50, 95% CI = 2.78-10.87) compared with men with good mobility without multimorbidity (0.59, 95% CI = 0.37-0.95).
CONCLUSIONS
Among older men, mobility limitations and multimorbidity were independent predictors of higher inpatient and PAC utilization after considering each other and conventional predictors. Marked combined effects of reduced mobility and multimorbidity burden may be important to consider in clinical decision-making and planning health care delivery strategies for the growing aged population.
Topics: Aged; Aged, 80 and over; Aging; Algorithms; Cohort Studies; Hospitalization; Humans; Independent Living; Inpatients; Length of Stay; Male; Medicare; Mobility Limitation; Multimorbidity; Patient Acceptance of Health Care; Prospective Studies; Risk Factors; Subacute Care; United States
PubMed: 28645202
DOI: 10.1093/gerona/glx128 -
Annals of Geriatric Medicine and... May 2024This study aimed to survey knowledge and perceptions of social prescribing (SP) amongst health and community care workers.
OBJECTIVES
This study aimed to survey knowledge and perceptions of social prescribing (SP) amongst health and community care workers.
STUDY DESIGN
Cross sectional online survey conducted in November 2023.
METHODS
The survey on basic demographics, awareness, knowledge, and practices of SP was completed by 123 health and community care workers.
RESULTS
The mean age of respondents was 39.0 years. Nearly two-thirds had heard of SP. A lower proportion of acute hospital doctors (55.6%) and nurses (56.8%) had heard of SP compared with primary and subacute care doctors (75.0%). The majority agreed that SP is beneficial for patients' mental health and reducing healthcare utilisation. Primary care physicians, community nurses and active ageing centres were the top three professionals selected as most responsible for SP by survey respondents. The most commonly cited barriers to SP were seniors' reluctance (63.4%), lacking knowledge on how to refer (59.3%), lack of time (44.7%) and cost to seniors (44.7%).
CONCLUSION
Overall, health and community care workers demonstrated positive attitudes toward SP and were keen to refer patients for SP. However, additional efforts are needed to improve knowledge about how to refer for and provide training on SP.
PubMed: 38724449
DOI: 10.4235/agmr.24.0062 -
Journal of Aging and Health Dec 2020To investigate the association between functional status and post-acute care (PAC) transition(s). Secondary analysis of 2013-2014 Medicare data for individuals aged...
To investigate the association between functional status and post-acute care (PAC) transition(s). Secondary analysis of 2013-2014 Medicare data for individuals aged ≥66 years with stroke, lower extremity joint replacements, and hip/femur fracture discharged to one of three PAC settings (inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies). Functional scores were co-calibrated into a 0-100 scale across settings. Multilevel logistic regression was used to test the partition of variance (%) and the probability of PAC transition attributed to the functional score in the initial PAC setting. Patients discharged to inpatient rehabilitation facilities with higher function were less likely to use additional PAC. Function level in an inpatient rehabilitation facility explained more of the variance in PAC transitions than function level while in a skilled nursing facility. The function level affected PAC transitions more for those discharged to an inpatient rehabilitation facility than to a skilled nursing facility.
Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement; Female; Functional Status; Hip Fractures; Humans; Male; Medicare; Patient Transfer; Self Care; Stroke Rehabilitation; Subacute Care; United States
PubMed: 32501126
DOI: 10.1177/0898264320925259 -
Facts, Views & Vision in ObGyn 2010The objective of this systematic literature review is to review current scientific knowledge on the definition of and the indications for maternal/obstetric intensive... (Review)
Review
OBJECTIVE
The objective of this systematic literature review is to review current scientific knowledge on the definition of and the indications for maternal/obstetric intensive care (MIC).
METHODS
We conducted a extensive search in OVID MEDLINE, EMBASE, COCHRANE, CINHAL and CEBAM using the keywords: maternal/obstetric intensive care, subacute care, intermediate care, postacute care, critical care, sub intensive care, progressive patient care, postnatal care, perinatal care, obstetrical nursing, neonatology, pregnancy, maternal mortality/morbidity and pregnancy complication. A total of 180 articles and one guideline were identified and supplemented by a hand search. After title, abstract and full text evaluation, the articles and guideline were subjected to critical appraisal.
RESULTS
Out of 180 potentially relevant articles, we identified 44 eligible articles of which 14 relevant MIC-articles of relatively good quality were selected. The concept 'maternal intensive care' was not found elsewhere, "high-dependency care" and "obstetrical intermediate care" appeared to be best comparable to what is understood as a MIC-service in Belgium. This thorough literature search resulted in a limited amount of scientific literature, with most studies retrospective observational tertiary centre based. No clear definition and admission criteria for maternal intensive care were found.
CONCLUSION
This systematic literature review revealed that 1) there is no standard definition of maternal intensive care and 2) that admission criteria to a MIC unit differ widely. Further research is needed to create an evidence-based triage system to help clinicians attribute women to the appropriate level of care and thus stimulate an efficient utilization of maternal/obstetric intensive care services.
PubMed: 25013706
DOI: No ID Found -
BMJ Open Dec 2022Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent...
Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol.
INTRODUCTION
Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.
OBJECTIVES
Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC.
METHODS AND ANALYSIS
A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.
ETHICS AND DISSEMINATION
This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.
Topics: Humans; Retrospective Studies; Emergency Service, Hospital; Emergency Treatment; Canada; Randomized Controlled Trials as Topic
PubMed: 36526315
DOI: 10.1136/bmjopen-2022-068488 -
Health Care Management Review 2020Postacute care has been identified as a primary area for cost containment. The continued shift of payment structures from volume to value has often put hospitals at the...
ISSUE/TREND
Postacute care has been identified as a primary area for cost containment. The continued shift of payment structures from volume to value has often put hospitals at the forefront of addressing postacute care cost containment. However, hospitals continue to struggle with models to manage patients in postacute care institutions, such as skilled nursing facilities or in home health agencies. Recent research has identified postacute care network development as one mechanism to improve outcomes for patients sent to postacute care providers. Many hospitals, though, have not utilized this strategy for fear of not adhering to Centers for Medicare & Medicaid Services requirements that patients are given choice when discharged to postacute care.
MANAGERIAL APPROACH
A hospital's approach to postacute care integration will be dictated by environmental uncertainty and the level of embeddedness hospitals have with potential postacute care partners. Hospitals, though, must also consider how and when to extend shared savings to postacute care partners, which will be based on the complexity of the risk-sharing calculation, the ability to maintain network flexibility, and the potential benefits of preserving competition and innovation among the network members. For hospital leaders, postacute care network development should include a robust and transparent data management process, start with an embedded network that maintains network design flexibility, and include a care management approach that includes patient-level coordination.
CONCLUSION
The design of care management models could benefit from elevating the role of postacute care providers in the current array of risk-based payment models, and these providers should consider developing deeper relationships with select postacute care providers to achieve cost containment.
Topics: Aged; Cost Control; Home Care Services; Hospitals; Humans; Medicare; Patient Discharge; Quality of Health Care; Risk Sharing, Financial; Skilled Nursing Facilities; Subacute Care; United States
PubMed: 30045098
DOI: 10.1097/HMR.0000000000000204