Dataset Information

Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities.

ABSTRACT: Individuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied.To describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization.Retrospective study of patients with HF in 35 SNFs enrolled in a randomized controlled trial of HF-disease management versus usual care between July 2014 and May 2016.Validity of MOST forms, care preference documentation, and ED visits/hospitalizations within 60 days of SNF admission.Of 370 patients (mean age 78.6 years, 58% women, 25% systolic HF), 278 (75%) had a MOST form in the SNF chart, of which 96 forms (35%) were invalid. The most common reason for an invalid MOST form was missing date accompanying patient or provider signature. Of 182 valid MOST forms, 47% of patients chose no cardiopulmonary resuscitation ("No CPR"), 58% selected "Full Treatment," 17% chose "Selective Treatment," and 23% chose "Comfort-Focused Treatment." Patients who were older [odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.25, 1.81] and female (OR = 2.33, 95% CI = 1.18, 4.59) had higher odds of choosing "No CPR." Sixty-six of 182 patients (36%) with valid MOST forms had an ED/hospital visit within 60 days of SNF admission; only 3 patients received medical care that was potentially discordant: all 3 chose "Comfort-Focused Treatment" and were hospitalized for more than symptom management.Seventy-five percent of patients with HF admitted to SNFs had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission. Clinicaltrials.gov # NCT01822912.

SUBMITTER: Lum H

PROVIDER: S-EPMC5730449 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities.

Lum Hillary H Obafemi Oluyomi O Dukes Joanna J Nowels Molly M Samon Kristina K Boxer Rebecca S RS

Journal of the American Medical Directors Association 20170706 10

<h4>Background</h4>Individuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied.<h4>Objectives</h4>To describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency depart ...[more]

PMID: 28688730

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Project description:AimHeart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF.Methods and resultsThe study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group.ConclusionsDelirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.

Project description:ImportanceA substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes.ObjectiveTo assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization.Design, setting, and participantsThis retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020.ExposuresDelirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding.Main outcomes and measuresThe difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores.ResultsA total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001).Conclusions and relevanceIn this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.

Project description:Importance:Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Objective:To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Design, Setting, and Participants:This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Exposures:Inpatient rehabilitation received in IRFs vs SNFs. Main Outcomes and Measures:Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Results:Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. Conclusions and Relevance:In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Project description:ImportanceTelemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs.ObjectiveTo describe patterns of telemedicine use in SNFs.Design, setting, and participantsThis cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020.ExposureTelemedicine adoption at SNF after 2020.Main outcomes and measuresNumber and proportion of telemedicine SNF and outpatient visits.ResultsAcross 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%).Conclusions and relevanceIn this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Dataset Information

Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities.

Publications

Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities.

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