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Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

ABSTRACT: To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization.Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams).Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone.Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306).The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks.Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments.The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants.Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services.

SUBMITTER: Bruce ML

PROVIDER: S-EPMC5118110 | biostudies-literature | 2016 Nov

REPOSITORIES: biostudies-literature

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Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

Bruce Martha L ML Lohman Matthew C MC Greenberg Rebecca L RL Bao Yuhua Y Raue Patrick J PJ

Journal of the American Geriatrics Society 20161014 11

<h4>Objectives</h4>To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization.<h4>Design</h4>Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams).<h4>Setting</h4>Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone.<h4>Participants</h4>Individuals aged 65 and older who screened posit ...[more]

PMID: 27739067

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Project description:ImportanceAmong older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.ObjectiveTo determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care.Design, setting, and participantsThis cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study.InterventionsThe Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week.Main outcomes and measuresDepression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D).ResultsThe 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005).Conclusion and relevanceHome health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression.Trial registrationclinicaltrials.gov Identifier: NCT01979302.

Project description:We sought to determine if discharge home with home health care (HHC) is an independent predictor of increased readmission after pancreatectomy.We examined 30-day readmissions in patients undergoing pancreatectomy using the Healthcare Cost and Utilization Project State Inpatient Database for California from 2009 to 2011. Readmissions were categorized as severe or nonsevere using the Modified Accordion Severity Grading System. Multivariable logistic regression models were used to examine the association of discharge home with HHC and 30-day readmission using discharge home without HHC as the reference group. Propensity score matching was used as an additional analysis to compare the rate of 30-day readmission between patients discharged home with HHC with patients discharged home without HHC.Of 3,573 patients who underwent pancreatectomy, 752 (21.0%) were readmitted within 30 days of discharge. In a multivariable logistic regression model, discharge home with HHC was an independent predictor of increased 30-day readmission (odds ratio = 1.37; 95% CI, 1.11-1.69; p = 0.004). Using propensity score matching, patients who received HHC had a significantly increased rate of 30-day readmission compared with patients discharged home without HHC (24.3% vs 19.8%; p < 0.001). Patients discharged home with HHC had a significantly increased rate of nonsevere readmission compared with those discharged home without HHC, by univariate comparison (19.2% vs 13.9%; p < 0.001), but not severe readmission (6.4% vs 4.7%; p = 0.08). In multivariable logistic regression models, excluding patients discharged to facilities, discharge home with HHC was an independent predictor of increased nonsevere readmissions (odds ratio = 1.41; 95% CI, 1.11-1.79; p = 0.005), but not severe readmissions (odds ratio = 1.31; 95% CI, 0.88-1.93; p = 0.18).Discharge home with HHC after pancreatectomy is an independent predictor of increased 30-day readmission; specifically, these services are associated with increased nonsevere readmissions, but not severe readmissions.

Project description:ImportanceInpatients treated by hospitalist physicians, who often work contiguous days, experience handoffs at the end of a scheduled shift block. Evidence suggests that transitions of patient care, or handoffs, among physician trainees are associated with adverse patient outcomes. However, little is known about the association between handoffs and patient outcomes among attending physicians, even though similar concerns apply.ObjectiveTo examine the association between inpatient handoffs of hospitalist physicians and patient mortality among hospitalized Medicare beneficiaries.Design, setting, and participantsThis cross-sectional study analyzed a random sample of Medicare beneficiaries who were hospitalized with a general medical condition between January 1, 2011, and December 31, 2016, and treated by a hospitalist. The study compared outcomes of patients with low vs high probability of physician handoff based on date of patient admission relative to the admitting hospitalist's last working day in a scheduled block, hypothesizing that otherwise similar patients admitted toward the end of a physician's shift block would be more likely to be handed off to another physician compared with patients admitted earlier in the shift block. Data analysis was performed from July 1, 2018, to January 12, 2021.ExposureHigh vs low probability of physician handoff.Main outcomes and measuresThe main outcome was patient 30-day mortality rate.ResultsA total of 1 074 000 patients (mean [SD] age, 75.9 [13.7] years; 57.4% female; 82.1% White) were studied. Multivariable regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects (a within-hospital analysis, effectively comparing patients treated at the same hospital). Among 597 288 hospitalizations, no overall difference in 30-day mortality was observed between patients admitted in the 2 days prior (days -1 and -2) to the treating hospitalist's last working day (a high handoff probability) compared with days -6 and -7 (a low handoff probability) (adjusted rate, 10.6%; 95% CI, 10.5%-10.7% vs 10.6%; 95% CI, 10.5%-10.7%; adjusted difference, 0.0%; 95% CI, -0.2% to 0.1%). However, in an exploratory analysis, among patients with high illness severity, defined as those in the top quartile of estimated mortality, 30-day mortality was higher for those with high vs low likelihood of physician handoff (adjusted mortality, 27.8%; 95% CI, 27.6%-27.9% vs 26.8%; 95% CI, 26.6%-27.1%; absolute adjusted difference, 1.0%; 95% CI, 0.5%-1.4%).Conclusions and relevanceIn this national analysis of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall.

Project description:ObjectiveTo determine whether black patients have higher odds of readmission than white patients after major surgery, and to ascertain whether these disparities are related to where black patients receive care.BackgroundRacial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in readmissions after a surgical procedure, an area which is becoming a prime focus for clinical leaders and policymakers.MethodsUsing national Medicare data from 2007 to 2010, we examined 30-day readmissions for patients undergoing coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if black patients had higher readmission rates than white patients, and if so, whether this effect was mediated by the hospitals at which patients received care, or by poverty.ResultsBlack patients had higher readmission rates than white patients (14.8% vs 12.8%, odds ratio [OR] 1.19; 95% confidence interval [CI], 1.16-1.22; P < 0.001). Patients undergoing major surgery at minority-serving hospitals also had higher readmission rates (14.3% vs 12.8%, OR 1.14, 95% CI 1.09-1.19; P < 0.001). In multivariate analyses, black patients at minority-serving hospitals had the highest overall odds of readmissions (OR 1.34). White patients at minority-serving hospitals (OR 1.15) and black patients at non-minority-serving hospitals (OR 1.20) also had higher odds of readmission than the reference group of white patients at non-minority-serving hospitals. Racial disparities were mediated in part by poverty.ConclusionsAmong Medicare beneficiaries, black patients were more likely to be readmitted after hospitalization for surgical procedures. Since racial disparities in readmission rates are mediated both by patients' race and the hospital at which care is delivered, efforts at reducing disparities should focus not only on race-based measures but also on improving outcomes of care at minority-serving hospitals.

Dataset Information

Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

Publications

Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

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