Ambulatory Care Sensitive Hospitalizations Research Articles

Association between discontinuity in clinicians and outcomes of nursing home residents.

Little is known about the impact of clinician discontinuity on quality of care for nursing home residents. We examined the association between clinician discontinuity and outcomes of residents with long-term care stays up to 3 years using claims for a national 20% sample of Medicare fee-for-service beneficiaries from 2014 through 2019. We used an event study analysis that accounted for staggered treatment timing. Estimates were adjusted for resident, clinician, and nursing home characteristics. Three sensitivity analyses were conducted. The first excluded small nursing homes, which were in the lowest quartile based on the number of beds. The second attributed residents to clinician practices rather than individual clinicians. The third removed the 3-year long-term care stay restriction. We found that, compared to residents who did not experience a clinician change, those with a clinician change had a 0.7 percentage point higher likelihood of an ambulatory care sensitive hospitalization in a given quarter (a 36.8% relative increase). Clinician discontinuity was not associated with ambulatory care sensitive emergency department visits. Results from our 3 sensitivity analyses were consistent with those from the primary analysis. Policymakers may consider using continuity in clinicians as a marker of nursing home quality.

Description of care pathways for benzodiazepine and sedative hypnotic discontinuation in older adults: protocol of a multicentre qualitative study

Introduction: Benzodiazepines and sedative hypnotics (BSHs) may represent a threat to patient safety, especially among older adults. The project BE-SAFE (Implementing a patient-centred and evidence-based intervention to reduce BEnzodiazepine and sedative-hypnotic use to improve patient SAFEty and quality of care) is a 5-year research project funded through the Horizon Europe Research Programme (Grant agreement n° 101057123). Its goal is to improve patient safety by addressing knowledge and practice gaps related to the reduction of BSHs used for sleep problems in older adults. Within the project, a patient-centred and evidence-based intervention will be developed to reduce the use of BSHs for sleep problems in older adults. This intervention will be tested in a cluster randomized controlled trial in different hospitals of six European countries (Belgium, Greece, Norway, Poland, Spain and Switzerland). Understanding current care pathways and healthcare systems in relation to BSH discontinuation should help tailor the BE-SAFE intervention to target contexts. This understanding should also shed light on the conditions for patient involvement in shared-decision making and interprofessional and interorganisational collaboration. These elements are expected to be key to the success of the intervention.
 
 Objective: To describe care pathways, including interprofessional and interorganisational collaborations, and healthcare systems in relation to BSH discontinuation in the six countries participating in the BE-SAFE trial, from the perspective of healthcare professionals and patients.
 Methods: A qualitative study will be conducted in the hospitals where the trial will take place and in other healthcare settings that are part of the care pathway, such as primary care. This study will follow four phases: 1) exploring healthcare systems, 2) mapping a typical care pathway for BSH discontinuation, including stakeholder analysis with patients, healthcare professionals and managers, 3) characterising healthcare systems in relation to BSH discontinuation, and 4) validation of results with stakeholders. Participants will be healthcare professionals, especially those involved in BSH discontinuation, managers and patients over 65 years of age either taking BSHs for sleep problems or who have undergone BSH discontinuation in the last three months. Data will be collected through self-administered questionnaires, semi-structured interviews and focus groups. The “6 W” multidimensional model of care trajectories (1) and the “Context and Capabilities for Integrating Care” framework (2) will be used to guide data collection and analyses.
 Expected results: We will obtain an in-depth description of care pathways and healthcare systems in relation to BSH discontinuation in each of the six countries participating in the BE-SAFE trial. These results will help to inform intervention development through the creation of logic models and to fit the BE-SAFE intervention to target contexts. By May 2023, we will have an initial version of the description of care pathways in each country.
 1.Vanasse A, Courteau M, Ethier JF. The ‘6W’ multidimensional model of care trajectories for patients with chronic ambulatory care sensitive conditions and hospital readmissions. Public Health. 2018 Apr 1;157:53–61.
 2.Evans JM, Grudniewicz A, Baker GR, Wodchis WP. Organizational context and capabilities for integrating care: A framework for improvement. Int J Integr Care. 2016 Jun 24;16(3):1–14.
 

ASSOCIATION BETWEEN PROVIDER DISCONTINUITY AND QUALITY OF CARE FOR NURSING HOME RESIDENTS

Abstract Discontinuity in outpatient care has been associated with lower quality care in community settings, but little is known about discontinuity of care in nursing homes (NHs). We examined discontinuity in clinician care and care quality for NH residents using Medicare fee-for-service claims for a 20% national sample of beneficiaries (January 1, 2012 to December 31, 2019). For residents with NH stays of ≥2 years, we examined changes in attributed clinicians during the first two years of their stays. Residents were attributed to the physician or advanced practitioner with a plurality of visits provided to them in the NH in a given year. Estimates were adjusted for resident, clinician, and NH characteristics. The determinant of interest reflected whether there was a change in the attributed clinician from the first to the second year. Among 280,831 residents in our sample, 37.6% (105,551) were attributed to a different clinician in their second year. On a quarterly basis, these residents had a 0.2 percentage point [pp] (95%CI, 0.2-0.3; p-value <.001) higher likelihood of an ambulatory care sensitive (ACS) hospitalization, a 0.2 pp (95% CI, 0.1-0.3; p-value <.001) higher likelihood of an ACS emergency department (ED) visit, and $609 (95% CI, $548.4-$669.5; p-value <.001) higher health care costs in their second year compared to residents without a clinician change. Compared to baseline rates, these represent relative increases of 14.2% in ACS hospitalizations, 11.5% in ACS ED visits, and 8% in costs. Discontinuity in care is associated with lower-quality care for NH residents.

High-Performing Teamlets in Primary Care: A Qualitative Comparative Analysis.

In efforts to improve patient care, collaborative approaches to care have been highlighted. The teamlet model is one such approach, in which a primary care clinician works consistently with the same clinical staff member. The purpose of this study is to identify the characteristics of high-performing primary care teamlets, defined as teamlets with low rates of ambulatory care sensitive emergency department (ACSED) visits and ambulatory care sensitive hospital admissions (ACSAs). Twenty-six individual qualitative interviews were performed with physicians and their teamlet staff member across 13 teamlets. Potentially important characteristics related to high-performing primary care teamlets were identified, calibrated, and analyzed using qualitative comparative analysis (QCA). Key characteristics identified by the QCA that were often present in teamlets with low rates of ACSED visits and, to a lesser extent, ACSAs were staff proactiveness in anticipating physician needs and physician-reported trust in their staff member. This study suggests that physician trust in their staff and proactiveness of staff in anticipating physician needs are important in promoting high-performing teamlets in primary care. Additional studies are indicated to further explore the relationship between these characteristics and high-performing teamlets, and to identify other characteristics that may be important.

Integrated Primary Care Model Prevents Hospitalizations for People Living with Dementia

AbstractBackgroundPeople living with dementia (PLWD) have high rates of total and ambulatory care sensitive hospital admissions and emergency department utilization. Ambulatory care sensitive hospital admissions are those that could be avoided by robust outpatient care. The Integrated Memory Care (IMC) is a comprehensive dementia care model where patients and their family caregivers access dementia‐sensitive geriatric primary care.MethodsWe conducted a retrospective observational study of adult patients of IMC, Cognitive Neurology (CN), and Primary Care (PC) clinics aged 65 and older with a diagnosis of dementia in 2019‐2021. We matched patients by age, gender and race and measured the risk of hospitalization using logistic regressions controlling for clinic. Additionally, we conducted a regression adjusted for state of illness (proxied by activities of daily living (ADL)) for the IMC and CN clinics.ResultsOverall 509 patients seen in IMC were matched with 490 CN patients and 509 PC patients. Most patients were female and white and aged 70‐85. IMC patients had higher overall ADL scores than CN indicating more functional dependence. CN [PN] had 10% [2 times] higher odds (Odds Ratio (OR): 1.107; 95% Confidence Interval (CI): 0.87‐1.41; OR: 2.037; 95% CI: 1.440‐2.882), when compared to IMC patients in unadjusted models. After adjusting for ADL scores, CN patients had 66% higher odds (OR: 1.662; 95% CI: 1.260‐2.193) of having a hospital admission during the study period.ConclusionsDementia‐sensitive primary care reduces the rate of total and ambulatory‐sensitive hospitalizations reducing healthcare costs and causing less disruption to care.

Associations between self-reported healthcare disruption due to covid-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England

ObjectivesTo examine whether there is an association between people who experienced disrupted access to healthcare during the covid-19 pandemic and risk of an avoidable hospital admission.DesignObservational analysis using evidence from...

Big Data Analytics to Reduce Preventable Hospitalizations—Using Real-World Data to Predict Ambulatory Care-Sensitive Conditions

The purpose of this study was to develop a prediction model to identify individuals and populations with a high risk of being hospitalized due to an ambulatory care-sensitive condition who might benefit from preventative actions or tailored treatment options to avoid subsequent hospital admission. A rate of 4.8% of all individuals observed had an ambulatory care-sensitive hospitalization in 2019 and 6389.3 hospital cases per 100,000 individuals could be observed. Based on real-world claims data, the predictive performance was compared between a machine learning model (Random Forest) and a statistical logistic regression model. One result was that both models achieve a generally comparable performance with c-values above 0.75, whereas the Random Forest model reached slightly higher c-values. The prediction models developed in this study reached c-values comparable to existing study results of prediction models for (avoidable) hospitalization from the literature. The prediction models were designed in such a way that they can support integrated care or public and population health interventions with little effort with an additional risk assessment tool in the case of availability of claims data. For the regions analyzed, the logistic regression revealed that switching to a higher age class or to a higher level of long-term care and unit from prior hospitalizations (all-cause and due to an ambulatory care-sensitive condition) increases the odds of having an ambulatory care-sensitive hospitalization in the upcoming year. This is also true for patients with prior diagnoses from the diagnosis groups of maternal disorders related to pregnancy, mental disorders due to alcohol/opioids, alcoholic liver disease and certain diseases of the circulatory system. Further model refinement activities and the integration of additional data, such as behavioral, social or environmental data would improve both model performance and the individual risk scores. The implementation of risk scores identifying populations potentially benefitting from public health and population health activities would be the next step to enable an evaluation of whether ambulatory care-sensitive hospitalizations can be prevented.

Competition and quality of care under regulated fees: evidence from Ghana

BackgroundHow competition affects the quality of care is still not well understood empirically because of limited and mixed results. This study examined whether competition leads to higher or lower quality health outcomes in Ghana.MethodsWe used administrative claims data of hypertension patients for 2017 – 2019 (36 months), and an instrumental variable method to examine the effect of competition, measured as an increase in district doctor-to-population ratio on hospital-level ambulatory care sensitive condition hospitalization and in-hospital death rates.ResultsOverall, we found that an increase in doctor density improves the quality of care for hypertension patients in Ghana. That is, when there are more doctors, fewer patients are hospitalized, and the risk of in-hospital deaths decreases. This result is robust to analyses at the individual and district population levels for ambulatory care sensitive hospitalizations rate.ConclusionsOur findings suggest that in the presence of physician-induced demand, competition can lead to improvement in the quality of care, possibly through improved access to healthcare and increased physician time and contact per patient. Future health policies need to consider possible welfare benefits of induced medical services and training more doctors.

Meso-level ambulatory care and ambulatory care sensitive hospitalizations in Germany

Abstract Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany's major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional regional data sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. In doing so, we adjust for a number of known risk factors for hospitalizations among this patient group. We undertook a Shorrocks-Shapley decomposition to investigate the relative contribution of groups of regressors to the pseudo R2. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. The results of the decomposition analysis for groups of variables indicate that ambulatory care characteristics account for 9.8% of the pseudo R2, morbidity of patients (including gender and age groups) for about 85.5%, and system-related factors of health provision for 4.7%. Our study provides some evidence that meso-level factors such as increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Improving heart failure care and guideline-directed medical therapy through proactive remote patient monitoring-home telehealth and pharmacy integration

To address ambulatory care sensitive hospitalisations in heart failure (HF), we implemented a quality improvement initiative to reduce admissions and improve guideline-directed medical therapy (GDMT) prescription, through proactive integration of...

Primary Care Nurse Practitioner Work Environments and Hospitalizations and ED Use Among Chronically Ill Medicare Beneficiaries.

Nurse practitioners (NPs) play a critical role in delivering primary care, particularly to chronically ill elderly. Yet, many NPs practice in poor work environments which may affect patient outcomes. We investigated the relationship between NP work environments in primary care practices and hospitalizations and emergency department (ED) use among chronically ill elderly. We used a cross-sectional design to collect survey data from NPs about their practices. The survey data were merged with Medicare claims data. In total, 979 primary care practices employing NPs and delivering care to chronically ill Medicare beneficiaries (n=452,931) from 6 US states were included. NPs completed the Nurse Practitioner-Primary Care Organizational Climate Questionnaire-a valid and reliable measure for work environment. Data on hospitalizations and ED use was obtained from Medicare claims. We used Cox regression models to estimate risk ratios. After controlling for covariates, we found statistically significant associations between practice-level NP work environment and 3 outcomes: Ambulatory Care Sensitive (ACS) ED visits, all-cause ED visits, and all-cause hospitalizations. With a 1-unit increase in the work environment score, the risk of an ACS-ED visit decreased by 4.4% [risk ratio (RR)=0.956; 99% confidence interval (CI): 0.918-0.995; P=0.004], an ED visit by 3.5% (RR=0.965; 99% CI: 0.933-0.997; P=0.005), and a hospitalization by 4.0% (RR=0.960;99% CI: 0.928-0.993; P=0.002). There was no relationship between NP work environment and ACS hospitalizations. Favorable NP work environments are associated with lower hospital and ED utilization. Practice managers should focus on NP work environments in quality improvement strategies.

Reasons for hospitalization of people with dementia-Ascoping review

Hospitalization represents ahigh burden for people with dementia, which can accelerate the decline of cognitive and motor skills. Behavioral changes and orientation problems may be increased in people with dementia during hospitalization. Some hospitalizations are potentially preventable by improved outpatient care. To provide an up to date overview of the most common reasons for hospitalization of people with dementia or mild cognitive impairment. Asystematic literature search was conducted in the databases PubMed®, CINAHL and PsycINFO® in May 2020 to conduct the scoping review. Studies in German and English published between July 2010 and May 2020 were included. The most common reasons for hospitalization, which were named in the 14included studies, were infectious diseases, especially respiratory infections and urinary tract infections, cardiovascular diseases (in general or specific, e.g. heart failure) and injuries, poisoning, fractures and falls, and gastrointestinal diseases. Most of the most common reasons for hospitalization are ambulatory care-sensitive hospital cases. Strengthening outpatient care for people with dementia may help prevent hospitalizations.

Impact on Health Care Utilization and Costs of a Medicaid Community Health Worker Program in Detroit, 2018-2020: A Randomized Program Evaluation.

Objectives. To compare health care utilization and costs between beneficiaries randomly assigned to usual services versus a community health worker (CHW) program implemented by 3 Medicaid health plans. Methods. From February 2018 to June 2019, beneficiaries residing in Detroit, Michigan's Cody Rouge neighborhood with more than 3 emergency department (ED) visits or at least 1 ambulatory care‒sensitive hospitalization in the previous 12 months were randomized. CHWs reached out to eligible beneficiaries to assess their needs and link them to services. We compared ED and ambulatory care visits, hospitalizations, and related costs over 12 months. Results. In intention-to-treat analyses among 2457 beneficiaries, the 1389 randomized to the CHW program had lower adjusted ratios of ED visits (adjusted rate ratio [ARR] = 0.96; P < .01) and ED visit costs (ARR = 0.96; P < .01), but higher adjusted ratios of ambulatory care costs (ARR = 1.15; P < .01) and no differences in inpatient or total costs compared with the usual-care group. Conclusions. Initial increases in ambulatory care use from effective programs for underserved communities may mitigate savings from decreased acute care use. Longer-term outcomes should be followed to assess potential cost savings from improved health. Trial Registration: ClinicalTrials.gov identifier: NCT03924713. (Am J Public Health. 2022;112(5):766-775. https://doi.org/10.2105/AJPH.2021.306700).

Residential mobility and potentially avoidable hospitalisations in a population-based cohort of New Zealand children

BackgroundResidential moves are common in early childhood and associations have been found between residential mobility and adverse child health and well-being outcomes. Although there are studies on potentially avoidable hospitalisations...

The impact of ambulatory care spending, continuity and processes of care on ambulatory care sensitive hospitalizations

Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany’s major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. We controlled for a wide range of covariates, such as age, sex, and comorbidities. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. Our study provides some evidence that increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Primary care and preventable hospitalizations among Medicare beneficiaries with non-metastatic breast cancer.

Regular primary care may be important to prevent ambulatory care-sensitive hospitalizations among older individuals living with breast cancer. The current study aimed to examine the relationship between preventable hospitalizations and primary care among Medicare beneficiaries diagnosed with breast cancer. We used SEER-Medicare to identify 61,673 patients with incident stage 0-III breast cancer diagnosed between January 1, 2008, and December 31, 2015. Potentially preventable hospitalizations, defined using the Agency for Healthcare Research and Quality, were captured from diagnosis until death, second malignancy, or December 31, 2016. Primary care and non-oncology specialist visits were identified by distinct utilization groups (low utilizers vs. high utilizers). Incidence rate ratios [IRR]) were estimated for preventable hospitalizations. Multivariable Cox regression models estimated the association of primary care with 5-year overall survival. Median age at diagnosis was 74years (range 66-101), median follow-up was 46months (12-60), and 5-year survival was 82%. Over half of patients (59%) received primary care ≥ 1 time per year, and 7.8% had no primary care. Among low utilizers, no primary care was associated with a 55% increase in the rate of preventable hospitalizations (p < 0.001). Primary care was not associated with preventable hospitalizations among high utilizers. Factors associated with hospitalization for both high and low utilizers included higher stage at diagnosis, older age, and having a preventable hospitalization prior to cancer. Not receiving any primary care was associated with higher risk of 5-year mortality for low utilizers (HR 1.66, p < 0.001; HR 1.46, p < 0.001). Among the group with less utilization, not engaging annually with a primary care provider was associated with a significantly increased rate of preventable hospitalizations. Consistent engagement with primary care may provide an opportunity for care coordination and management and should be considered critical in the context of long-term survivorship.

Primary care visits and ambulatory care sensitive diabetes hospitalizations among adult Alabama Medicaid beneficiaries

PurposeTo describe patterns of care use for Alabama Medicaid adult beneficiaries with diabetes and the association between primary care utilization and ambulatory care sensitive (ACS) diabetes hospitalizations. MethodsThis retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19–64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use on the occurrence of an ACS hospitalization. ResultsOne third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (odds ratio comparing 1–2 visits versus none 0.79, 95% confidence interval 0.73–0.85). ConclusionsProgram and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes.

Evidence of the effect of primary care expansion on hospitalizations: Panel analysis of 143 municipalities in the Brazilian Amazon.

BackgroundThe Family Health Strategy (FHS) became consolidated as a primary care model and gatekeeper for the Unified Health System (Sistema Único de Saúde, SUS) in the Brazil and it is considered one of the largest primary health care programmes in the world. Its rapid expansion allowed the SUS to meet the changing health care needs of the population remote localities of Brazilian municipalities.MethodsIn the present study, exploratory data analysis was performed using modelling to provide a general overview of the study and to delineate possible structural characteristics of the cross-sectional time-series data. Panel regression methods were used to assess the association between FHS coverage and ambulatory care-sensitive hospitalizations (ACSH rates) in the municipalities of Pará, in the Brazilian Amazon, from 2008 to 2017.ResultsThe results showed strong evidence for the association between FHS coverage and ACSH rates, including reductions of 22% in preventable hospitalizations and 15% in hospital expenses that were directly linked to the 40% increase in FHS population coverage during the evaluated period. This expansion of primary care has mainly benefitted areas that are difficult to access and populations that were previously deprived of health care in the vast Amazon territory.ConclusionsThe findings of this study show that the increase of the expansion of primary care reduces the preventable hospitalization and the hospital expenses. This reinforces the need for public protection of the health of populations at risk and the positive impacts of primary care in the Brazilian Amazon.

Monitoring the health and healthcare provision for refugees in collective accommodation centres: Results of the population-based survey RESPOND.

To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee health status and healthcare provision. The core elements of the survey consisted of a population-based sampling procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of primary care services, frequent ambulatory care sensitive hospitalisations, i.e. hospitalisations that could potentially have been avoided through primary care (25.3%), as well as subjective deficits in the quality of care, suggest barriers to accessing healthcare services. Almost half of all refugees (45.3%) live in accommodation facilities of poor structural quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling, multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could complement established procedures for conducting health surveys and be extended to other federal states.

Achieving Population Health Impacts Through Health Promotion Programs Offered by Community-based Organizations.

Evidence-based health promotion programs can help older adults manage chronic conditions and address behavioral risk factors, and translating these interventions to population-scale impact depends on reaching people outside of clinical settings. Area Agencies on Aging (AAAs) have emerged as important delivery sites for health promotion programs, but the impacts of their expanded role in delivering these interventions remain unknown. The objective of this study was to test whether evidence-based health promotion programs implemented by AAAs from 2008 to 2016 influenced health care use and spending by older adults and to examine how agencies' organizational capacity for implementation influenced these population-level impacts. We used panel regression models to examine how the expansion of health promotion programs offered by AAAs over the course of 2008-2016 was associated with a change in health care use and spending by older adults in counties served by the AAAs. We examined impact separately for high capacity and low capacity agencies. Across the full sample of AAAs, beginning to offer any health promotion program in the AAA was associated a with 0.94% percentage point reduction in potentially avoidable nursing home use in counties covered by the AAA (95% confidence interval=-1.58, -0.29), equivalent to a 6.5% change. Expanding the breadth of programs offered by the AAA was also associated with a significant reduction in potentially avoidable nursing home use. Stratified analysis showed that reductions in potentially avoidable nursing home use were evident only in places where the AAA had high implementation capacity. Expansion of health promotion programs offered by AAAs was not associated with the change in county-level hospital readmission rates, ambulatory care sensitive hospitalizations, or Medicare spending per beneficiary. AAAs are an example of community-based organizations that can contribute to health care policy goals such as cost containment. Organizational development support may be needed to extend their ability to effect change in more regions of the country.