Project description:Background/objectivesCare-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services.DesignAnalysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File.SettingAL facilities and Medicare HH agencies in the United States.Participants741,926 Medicare HH admissions of AL residents in 2017.MeasurementsCare-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission.ResultsAmong the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)).ConclusionFor AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Project description:ImportancePrompted by null findings from several care transition trials and practice changes for heart failure in recent years, leaders from a large integrated health care system aimed to reassess the outcomes of its 10-year multicomponent transitional care program for heart failure (HF-TCP).ObjectiveTo examine the association of the individual HF-TCP components and their bundle with the primary outcome of all-cause 30-day inpatient or observation stay readmissions.Design, setting, and participantsThis retrospective cohort study included patients enrolled in the HF-TCP during an inpatient encounter for heart failure at 13 Kaiser Permanente Southern California hospitals from January 1, 2013, to October 31, 2018, who were followed up from discharge until 30 days, readmission, or death. Data were analyzed from May 7, 2019, to May 1, 2020, with additional review from September 2 to October 1, 2020.ExposuresPatients received 1 home health visit or telecare (telephone) visit from a registered nurse within 2 days of hospital discharge, a heart failure care manager call within 7 days, and a clinic visit with a physician or a nurse practitioner within 7 days.Main outcomes and measuresMultivariable proportional hazards regression models were used to estimate the probability of 30-day readmission for those who received the individual or bundled HF-TCP components compared with those who did not.ResultsA total of 26 128 patients were included; 57.0% were male, and the mean (SD) age was 73 (13) years. The 30-day readmission rate was 18.1%. Both exposure to a home health visit within 2 days of discharge (hazard ratio [HR], 1.03; 95% CI, 0.96-1.10) and a 7-day heart failure case manager call (HR, 1.08; 95% CI, 0.99-1.18) compared with no visit or call were not associated with a lower rate of readmission. Completion of a 7-day clinic visit was associated with a lower readmission rate (HR, 0.88; 95% CI, 0.81-0.94) compared with no clinic visit. There were no synergistic effects of all 3 components compared with clinic visit alone (HR, 1.05; 95% CI, 0.87-1.28).Conclusions and relevanceThis study found that HF-TCP as a whole was not associated with a reduction in 30-day readmission rates, although a follow-up clinic visit within 7 days of discharge may be helpful. These findings highlight the importance of continuous quality improvement and refinement of existing clinical programs.

Project description:BackgroundPrimary health care and its strengthening through performance measurement is essential for sustainably working towards universal health coverage. Existing performance frameworks and indicators to measure primary health care capture system functions like governance, financing and resourcing but to a lesser extent the function of services delivery and its heterogeneous nature. Moreover, most frameworks have weak links with routine information systems and national health priorities, especially in the context of high- and middle-income countries. This paper presents the development of a tool that responds to this context with the aim to create primary health care performance intelligence for the 53 countries of the WHO European Region.MethodsThe work builds-off of an existing systematic review on primary care and draws on priorities of current European health policies and available (inter)national information systems. Its development included: (i) reviewing and classifying features of primary care; (ii) constructing a set of tracer conditions; and (iii) mapping existing indicators in the framework resulting from (i). The analysis was validated through a series of reviews: in-person meetings with country-nominated focal points and primary care experts; at-distance expert reviews; and, preliminary testing with country informants.ResultsThe resulting framework applies a performance continuum in the classical approach of structures-processes-outcomes spanning 6 domains - primary care structures, model of primary care, care contact, primary care outputs, health system outcomes, and health outcomes - that are further classified by 26 subdomains and 63 features of primary care. A care continuum was developed using a set of 12 tracer conditions. A total of 139 indicators were mapped to the classification, each with an identified data source to safeguard measurability. Individual indicator passports and a glossary of terms were developed to support the standardization of the findings.ConclusionThe resulting framework and suite of indicators, coined the Primary Health Care Impact, Performance and Capacity Tool (PHC-IMPACT), has the potential to be applied in Europe, closing the gap on existing data collection, analysis and use of performance intelligence for decision-making towards primary health care strengthening.

Project description:ImportanceMedicare adopted transitional care management (TCM) payment codes in 2013 to encourage clinicians to furnish TCM services after beneficiaries were discharged to the community from medical facilities. To bill for the 30-day service, a care team member must communicate with the beneficiary or the caregiver within 2 business days after the discharge and the clinician must provide an office visit within 14 days.ObjectiveTo investigate whether the receipt of TCM services was associated with the subsequent health care costs and mortality of the beneficiaries in the month after the service was provided.Design, setting, and participantsRetrospective cohort analysis of all Medicare fee-for-service claims for the period of January 1, 2013, through December 31, 2015, for 18 756 707 Medicare fee-for-service beneficiaries with discharges eligible for subsequent TCM services. Discharges from a hospital, an inpatient psychiatric facility, a long-term care hospital, a skilled nursing facility, an inpatient rehabilitation facility, or an outpatient facility for an observational stay were included. Data analysis was performed from July 2016 to March 2018.ExposureFurnishing of TCM services for the 30 days following an eligible discharge for Medicare beneficiaries as reflected in Medicare fee-for-service claims.Main outcomes and measuresTotal Medicare (Parts A, B, and D) health care costs and mortality in the 31 to 60 days after discharge, which is 30 days beyond the potential period for which the beneficiary could receive TCM services. Health care costs and mortality were adjusted for beneficiary age, sex, risk score, dual eligibility for Medicare and Medicaid, type of eligible discharge, year of discharge, and whether the eligible discharge to the community included home health care.ResultsOf 18 756 707 eligible Medicare beneficiaries during the study period, 43.9% were male and had a mean (SD) age of 72.5 (13.8) years. Transitional care management services were billed following eligible discharges in 3.1% of cases in 2013, 5.5% in 2014, and 7.0% in 2015. The adjusted total Medicare costs ($3358; 95% CI, $3324-$3392 vs $3033; 95% CI, $3001-$3065; P < .001) and mortality (1.6%; 95% CI, 1.6%-1.6% vs 1.0%; 95% CI, 1.0%-1.1%; P < .001) were higher among those beneficiaries who did not receive TCM services compared with those who did receive TCM services in the 31 to 60 days following an eligible discharge.Conclusions and relevanceDespite the apparent benefits of TCM services for Medicare beneficiaries, the use of this service remains low. An assessment should be made of interventions that can increase the appropriate use of this service.

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Health and health care in transitional Europe.

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Health and health care in transitional Europe.

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