Objectives
To determine the effect of home‐based primary care (HBPC) on Medicare costs and mortality in frail elders.
Design
Case–control concurrent study using Medicare administrative data.
Setting
...HBPC practice in Washington, District of Columbia.
Participants
HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy‐in status (whether Medicaid covers Part B premiums), long‐term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania.
Intervention
HBPC clinical service.
Measurements
Medicare costs, utilization events, mortality.
Results
Mean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2‐year follow‐up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow‐up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06, P = .44) or in average time to death (16.2 vs 16.8 months, P = .30).
Conclusion
HBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls.
Objectives: To compare rates of falling between nursing home residents with and without dementia and to examine dementia as an independent risk factor for falls and fall injuries.
Design: Prospective ...cohort study with 2 years of follow‐up.
Setting: Fifty‐nine randomly selected nursing homes in Maryland, stratified by geographic region and facility size.
Participants: Two thousand fifteen newly admitted residents aged 65 and older.
Measurements: During 2 years after nursing home admission, fall data were collected from nursing home charts and hospital discharge summaries.
Results: The unadjusted fall rate for residents in the nursing home with dementia was 4.05 per year, compared with 2.33 falls per year for residents without dementia (P<.0001). The effect of dementia on the rate of falling persisted when known risk factors were taken into account. Among fall events, those occurring to residents with dementia were no more likely to result in injury than falls of residents without dementia, but, given the markedly higher rates of falling by residents with dementia, their rate of injurious falls was higher than for residents without dementia.
Conclusion: Dementia is an independent risk factor for falling. Although most falls do not result in injury, the fact that residents with dementia fall more often than their counterparts without dementia leaves them with a higher overall risk of sustaining injurious falls over time. Nursing home residents with dementia should be considered important candidates for fall‐prevention and fall‐injury‐prevention strategies.
The National Pressure Ulcer Advisory Panel has updated the definition of a pressure ulcer and the stages of pressure ulcers, based on current research and expert opinion. Black et al address the ...methods that guided the revision and present the updated definition of a pressure ulcer and pressure ulcer stages.
Objectives: To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long‐term care residents.
Design: Retrospective cohort study with ...convenience sampling.
Setting: Ninety‐five long‐term care facilities participating in the National Pressure Ulcer Long‐Term Care Study throughout the United States.
Participants: A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry.
Measurements: Data collected for each resident over a 12‐week period included resident characteristics (e.g., demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs).
Results: Seventy‐one percent of subjects (n=1,081) did not develop a PU during the 12‐week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for >21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses' aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU.
Conclusion: A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long‐term care residents. Research‐based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors.
The Independence at Home (IAH) Demonstration Year 2 results confirmed that the first‐year savings were 10 times as great as those of the pioneer accountable care organizations during their initial 2 ...years. We update projected savings from nationwide conversion of the IAH demonstration, incorporating Year 2 results and improving attribution of IAH‐qualified (IAH‐Q) Medicare beneficiaries to home‐based primary care (HBPC) practices. Applying IAH qualifying criteria to beneficiaries in the Medicare 5% claims file, the effect of expanding HBPC to the 2.4 million IAH‐Q beneficiaries is projected using various growth rates. Total 10‐year system‐wide savings (accounting for IAH implementation but before excluding shared savings) range from $2.6 billion to $27.8 billion, depending on how many beneficiaries receive HBPC on conversion to a Medicare benefit, mix of clinical practice success, and growth rate of IAH practices. Net projected savings to the Centers for Medicare and Medicaid Services (CMS) after routine billing for IAH services and distribution of shared savings ranges from $1.8 billion to $10.9 billion. If aligning IAH with other advanced alternative payment models achieved at least 35% penetration of the eligible population in 10 years, CMS savings would exceed savings with the current IAH design and HBPC growth rate. If the demonstration were simply extended 2 years with a beneficiary cap of 50,000 instead of 15,000 (as currently proposed), CMS would save an additional $46 million. The recent extension of IAH, a promising person‐centered CMS program for managing medically complex and frail elderly adults, offers the chance to evaluate modifications to promote more rapid HBPC growth.
Objectives: To identify resident, wound, and treatment characteristics associated with pressure ulcer (PrU) healing in long‐term care residents.
Design: Retrospective cohort study with convenience ...sampling.
Setting: Ninety‐five long‐term care facilities participating in the National Pressure Ulcer Long‐Term Care Study throughout the United States.
Participants: Eight hundred eighty‐two residents, aged 18 and older, with length of stay of 14 days or longer, who had at least one Stage II to IV PrU.
Measurements: Data collected for each resident over a 12‐week period included resident characteristics, treatment characteristics, and change in PrU area. Data were obtained from medical records, Minimum Data Set, and other records.
Results: Two multiple regression models, one for each stage grouping (Stage II, Stage III and IV), were completed. The area of Stage II PrU was reduced more with moist (F=21.91, P<.001) than with dry (F=13.41, P<.001) dressings. PrUs cleaned with saline or soap showed less decrease in area (F=12.34, P<.001) than PrUs cleaned with other cleansers such as antiseptic, antibiotic, or commercial cleansers. Change in area of Stage III and IV PrUs was related to sufficient enteral feeding (F=5.23, P=.02), enteral feeding without higher acuity levels (F=3.94, P=.048), size of PrU (very large (F=120.89, P=.001) and large (F=27.82, P=.001)), and type of dressing (moist (F=14.70, P<.001) and dry (F=5.88, P=.02)). Stage III and IV PrUs increased in area when debrided (F=5.97, P=.02). The overall models were significant (Stage III and IV, F=20.30, coefficient of determination (R2)=0.06, P<.001; Stage II, F=40.28, R2=0.13, P<.001) but explained little of the variation in change in PrU area.
Conclusion: In this sample of nursing facility residents, use of moist dressings (Stage II, Stage III and IV) and adequate nutritional support (Stage III and IV) are strong predictors of PrU healing.
The Independence at Home (IAH) Demonstration Year 1 results have confirmed earlier studies that showed the ability of home‐based primary care (HBPC) to improve care and lower costs for Medicare's ...frailest beneficiaries. The first‐year report showed IAH savings of 7.7% for all programs and 17% for the nine of 17 programs that surpassed the 5% mandatory savings threshold. Using these results as applied to the Medicare 5% claims file, the effect of expanding HBPC to the 2.2 million Medicare beneficiaries who are similar to IAH demonstration participants was projected. Total savings ranged from $12 billion to $53 billion depending on the speed and extent of dissemination of HBPC among this IAH‐like population. Using a fixed growth rate, as hospitalists experienced in their first decade, 35% coverage would be achieved at the end of 10 years, with total 10‐year savings through IAH reaching $37.5 billion and $17.3 billion accruing to the Centers for Medicare and Medicaid Services as a net reduction in overall expenditures, with $12.6 billion from Medicare Parts A and B savings.
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