Long-term Care Admission Research Articles

Validation of the Passive Surveillance Stroke Severity score in three Canadian provinces

ObjectiveAdjusting for stroke severity is critical in stroke outcomes research. The Passive Surveillance Stroke SeVerity (PaSSV) score is an administrative data-based measure of stroke severity, initially derived in Ontario, Canada using data between 2002-2013. We assessed its geographical and temporal external validity in British Columbia (BC), Nova Scotia (NS), and Ontario, Canada. MethodsIn each province, we identified adult in-patients with ischemic stroke or intracerebral hemorrhage and admitted from an emergency department between 2014-2019 and calculated their PaSSV score using linked administrative data. We used Cox proportional hazards models to evaluate the association between the PaSSV score and the hazard of death over 30 days and the cause-specific hazard of admission to long-term care over 365 days. We assessed the models’ discriminative values using Uno’s c-statistic, comparing models with versus without PaSSV. ResultsWe included 86,142 patients (n=18,387 in BC, n=65,082 in Ontario, n=2,673 in NS). The mean and median PaSSV were similar across provinces. Higher PaSSV score, reflecting lower stroke severity, was associated with a lower mortality (hazard ratio and 95% confidence intervals 0.70 [0.68-0.71] in BC, 0.69 [0.68-0.69] in Ontario, 0.72 [0.68-0.75] in NS) and long-term care admission (0.77 [0.76-0.79] in BC, 0.84 [0.83-0.85] in Ontario, 0.86 [0.79-0.93] in NS). Including PaSSV in the multivariable models improved model fit according to the c-statistics. ConclusionWe showed that PaSSV has geographical and temporal validity. It is a useful tool for risk-adjustment in multi-jurisdiction stroke outcomes research, and a valuable addition to be included in the national algorithm inventory.

Long-term morbidity and mortality of patients who survived past 30 days from bloodstream infection: A population-based retrospective cohort study

For bloodstream infections (BSI), treatment and research have focused on short term mortality. The objective of this study was to describe the 1-year mortality and morbidity in survivors of bloodstream infection when compared to patients with negative blood cultures. We conducted a population-based retrospective cohort study using Ontario administrative databases. Patients were included if they had a blood culture taken from January 1, 2014, to December 31, 2021, and survived past 30 days from blood culture collection. They were followed for the subsequent year. Outcomes were compared among patients with BSI and those without BSI, including all-cause mortality, stroke, myocardial infarction (MI), congestive heart failure (CHF) exacerbation, new start dialysis and admission to a long-term care (LTC) facility. Prognostic factors were balanced using overlap weighting of propensity scores, and a survival or competing risk model was used to describe time-to-event. Of 981,341 patients undergoing blood culture testing, 99,080 (10.1%) patients had a BSI and 882,261 (89.9%) patients did not. Outcomes were all more common among those with BSI as compared to those without BSI, including all-cause mortality (16,764 [16.9%] vs. 84,480 [9.6%]), stroke (1016 [1.0%] vs. 4680 [0.5%]), MI (1043 [1.1%] vs. 4547 [0.5%]), CHF exacerbation (2643 [2.7%] vs. 13,200 [1.5%]), new start dialysis (1703 [1.7%] vs. 2749 [0.3%]), and LTC admission (4231 [4.3%] vs. 13,016 [1.5%]). BSI had an adjusted hazard ratio of 1.10 (95% CI 1.08-1.12, P<0.0001) for mortality, subdistribution hazard ratio (sHR) of 1.27 (95% CI 1.19-1.37, P<0.0001) for stroke, sHR of 1.18 (95% CI 1.10-1.26, P<0.0001) for MI, sHR of 1.05 (95% CI 1.01-1.10, P=0.0176) for CHF exacerbation, sHR of 3.42 (95% CI 3.21-3.64, P<0.0001) for new start dialysis and sHR of 1.87 (95% CI 1.80-1.94, P<0.0001) for LTC admission. BSI survivors have substantial long-term mortality and morbidity including stroke, MI, new start dialysis and functional decline leading to LTC admission.

Dementia Care Partner Preparedness and Desire to Seek Long-Term Care at Hospital Discharge: Mediating Roles of Care Receiver Clinical Factors

ABSTRACT Objectives The purpose of this study was to explore the mediating roles of care receiver clinical factors on the relationship between care partner preparedness and care partner desire to seek long-term care admission for persons living with dementia at hospital discharge. Methods This study analyzed data from the Family centered Function-focused Care (Fam-FFC), which included 424 care receiver and care partner dyads. A multiple mediation model examined the indirect effects of care partner preparedness on the desire to seek long-term care through care receiver clinical factors (behavioral and psychological symptoms of dementia [BPSD], comorbidities, delirium severity, physical function, and cognition). Results Delirium severity and physical function partially mediated the relationship between care partner preparedness and care partner desire to seek long-term care admission (B = -.011; 95% CI = -.019, −.003, and B = -.013; 95% CI = -.027, −.001, respectively). Conclusions Interventions should enhance care partner preparedness and address delirium severity and physical function in hospitalized persons with dementia to prevent unwanted nursing home placement at hospital discharge. Clinical Implications Integrating care partner preparedness and care receiver clinical factors (delirium severity and physical function) into discharge planning may minimize care partner desire to seek long-term care.

Analysis of Medicare Patients Treated with Pimavanserin versus Other Atypical Antipsychotics: A Cost-Offset Model Evaluating Skilled Nursing Facility Stays and Long-Term Care Admissions in Parkinson's Disease Psychosis.

Patients with Parkinson's disease psychosis (PDP) treated with pimavanserin (PIM) versus other atypical antipsychotics (AAPs) including quetiapine (QUE) may have health-care cost savings due to fewer skilled nursing facility-stays (SNF-stays) and long-term care admissions (LTCA). A decision analytic model was developed using the 2019 Medicare Patient Driven Payment Model (PDPM) to estimate SNF-stays and LTCA associated per-patient- per-year (PPPY) facility and rehabilitation costs among patients that initiated PIM vs QUE or vs other-AAPs (i.e, quetiapine, risperidone, olanzapine, aripiprazole). Model inputs were derived for: (i) annual SNF-stay and LTCA rates from an analysis of Medicare beneficiaries with PDP, and (ii) annual mean rehabilitation and resident care-stay costs from PDPM case-mix adjusted value-based payment rates for 5 rehabilitation components (ie, physical-therapy, occupational-therapy, nursing, speech-language pathology, non-therapy ancillary), and an additional variable-per-diem for room/board services. PPPY costs were estimated from (i) SNF-stay and (ii) LTCA rates multiplied by annual mean costs of stay in 2022 USD. Probabilistic sensitivity analysis (PSA) was performed using 1000 Monte Carlo simulations. Overall SNF-stay rates of 20.2%, 31.4%, and 31.7%, and LTCA rates of 23.2%, 33.8%, 34.6% were observed for PIM, QUE, and other-AAPs, respectively. Based on annual mean costs, PPPY SNF-stay rehabilitation and resident related costs for PIM ($41,808) vs QUE ($65,172) or vs other-AAPs ($65,664), resulted in $23,364 and $23,856 PPPY cost savings, respectively. Similarly, PPPY LTCA rehabilitation and resident related costs for PIM ($47,957) vs QUE ($70,091) or vs other-AAPs ($71,566) resulted in $22,134 and $23,609 PPPY cost-savings for PIM, respectively. PSA suggested PIM would provide cost-savings vs QUE or other-AAPs in >99% of iterations. In this analysis, PIM demonstrated nearly 36% and 32% lower PPPY SNF-stays and LTCA costs, respectively, vs QUE or other-AAPs. Research examining additional cost-offsets (i.e., fewer falls/fractures) associated with SNF-stay or LTCA may be needed.

Determining the impact of specialized care on health outcomes and health care utilization in Parkinsonism

BackgroundAlthough care of Parkinsonism (PKM) is assumed to be optimally provided by movement disorder neurologists within an interdisciplinary clinic model, there is a paucity of published data to support this. ObjectivesTo investigate the impact of movement disorder neurologist care of individuals with Parkinsonism (PKM). MethodsA retrospective exposure design was adopted using administrative data. Incident PKM individuals were identified in billing claims. A nine-year exposure period to movement disorder neurologist, general neurologist and non-neurologist care was calculated based on the billing codes. Regression models were used to test the association of provider exposure on time to death and long-term care (LTC) admission. Linear models were used to test varying provider exposure and hospital admissions, hospital days and emergency department visits. Results1914 incident individuals were identified. There was no difference in PKM mortality, emergency visits, hospital admissions, or hospital days between providers, however exposure to general neurology and non-neurology care was associated with a significantly higher risk of admission to LTC compared to movement disorder neurologist care (HR 1.43; 95% CI 1.09–1.87 for general neurology (p-value = 0.0089); HR 1.61; 95% CI 1.25–2.05 for non-neurology (p-value = 0.0002), respectively. ConclusionMovement disorder neurologist care is associated with a lower risk of admission to LTC over general neurologist care in individuals with PKM.

1977 Multimorbidity patterns and aged residential care admissions in Aotearoa New Zealand

Abstract Introduction Multimorbidity is complex and impacts patients' quality of life, health outcomes, and health care utilisation. This project aims to identify multimorbidity patterns and their impact on long-term care admissions in community-dwelling older adults. Methods Multimorbidity was ascertained using primary care data Tū Ora COMPASS Health. Adults aged 65+ (55+ for Māori and Pasifika) were included in the analysis. Aged residential care (ARC) admission was determined from interRAI. Twelve conditions ascertained were hypertension, ischaemia, congestive heart failure, stroke, diabetes, cancer, chronic obstructive pulmonary disease, depression, hypothyroid, osteoporosis, dementia, and neurological diseases. Latent class analyses were completed to identify multimorbidity patterns by ethnicity, i.e., Māori, Pasifika, and non-Māori/non-Pasifika (nMP). For the latter group, analyses were also completed by age groups (&amp;lt;80 years and ≥80 years. Cox-regression models were used to examine the association between multimorbidity patterns and 5-year ARC admission. Results The sample comprises 45,178 older adults: nMP (88%), Māori (8%), and 1,755 Pasifika (4%). The average age for Māori and Pasifika was 65.1, respectively, and nMP was 74.1. We identified three multimorbidity patterns for Māori and Pasifika, and four for nMP (&amp;lt;80 and ≥80). All twelve conditions clustered differently in these samples. Eleven-per-cent Māori were in a 'complex-cluster', and they had a three times higher risk of ARC admission than 'healthier-cluster' [aHR(95%CI): 2.96 (1.81-4.36)]. We did not observe an association between condition clusters and ARC admission risk in the Pasifika sample. In the nM/nP&amp;lt;80y sample, those in 'complex-cluster' (4%) had a 5.5 times higher risk of ARC admission (5.48, 4.68-6.41) than in the 'healthier-cluster'; a similar association was observed in nM/nP≥80y in 'complex-cluster' (8%) when compared to 'healthier-cluster' (4.08, 3.67-4.53). Conclusions Complex clusters were associated with an increased risk of five-year ARC admission. Multimorbidity patterns are helpful for a more strategic approach to managing multimorbidity better in primary care settings.

The social process of involuntary separation and the search for connection.

Placing a loved one in care does not relieve informal caregivers' physical and emotional stresses. This study identified the unique psycho-social-spiritual processes of involuntary separation among spouses following long-term care admission. Participants were 17 spouse-caregivers (12 women and 5 men) with a mean age of 84years who had been involuntarily separated for an average of 20months. The basic psycho-social-spiritual process of spouse-caregiver involuntary separation was connecting in disconnection, which had three distinct stages: (1) Initial coping, (2) Adjusting to the new situation, and (3) Moving forward. Movement through the three stages was influenced by individuals' capacity and willingness to reach out for connection and by the abilities of others to extend accurate empathy and practical help. The implications of this study highlight spouse-caregivers' needs for connection and support not only during the crisis of separation, but in the months and years that follow.

ASSOCIATION OF BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA WITH ADVERSE OUTCOMES POSTHOSPITALIZATION

Abstract In hospitalized persons with dementia, behavioral and psychological symptoms of dementia (BPSD), also known as behavioral symptoms of distress, are associated with increased morbidity, long-term care admissions, and reduced care partner well-being. The Fam-FFC study provided the opportunity to examine the association between BPSD severity and adverse, post-acute outcomes (falls, emergency department transfers, hospital admissions). Logistic regression analysis examined the association of behavioral symptoms (Neuropsychiatric Inventory Questionnaire, NPI) and odds of having a fall, emergency department transfer, and hospital admission, controlling for the intervention, and caregiver and patient characteristics. NPI scores decreased from admission (M = 7.81, SD = 6.12), to discharge (M = 6.4, SD = 5.93), to two months (M = 5.38, SD = 5.91), to six-month follow-up (M = 5.08, SD = 5.94). Higher admission NPI scores were associated with greater odds of experiencing at least one fall (OR = 1.067, p = 0.042) by discharge. Higher discharge NPI scores were associated with higher odds of ED transfer (OR = 1.062, p = 0.006) and at least one hospitalization (OR = 1.06, p = 0.008) after two months. Higher NPI scores at 2-month follow-up were associated with increased odds of ED transfer (OR = 1.062, p = 0.004), experiencing at least one injury (OR = 1.055, p = 0.031), falls (OR = 1.056, p = 0.012), and hospitalizations (OR = 1.065, p = 0.004) at six months. Results underscore the importance of providing interventions to reduce BPSD as a potentially modifiable risk factor to reduce adverse outcomes.

Canadian Association of Radiologists Thoracic Imaging Referral Guideline.

The Canadian Association of Radiologists (CAR) Thoracic Expert Panel consists of radiologists, respirologists, emergency and family physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 24 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 48 recommendation statements across the 24 scenarios. This guideline presents the methods of development and the referral recommendations for screening/asymptomatic individuals, non-specific chest pain, hospital admission for non-thoracic conditions, long-term care admission, routine pre-operative imaging, post-interventional chest procedure, upper respiratory tract infection, acute exacerbation of asthma, acute exacerbation of chronic obstructive pulmonary disease, suspect pneumonia, pneumonia follow-up, immunosuppressed patient with respiratory symptoms/febrile neutropenia, chronic cough, suspected pneumothorax (non-traumatic), clinically suspected pleural effusion, hemoptysis, chronic dyspnea of non-cardiovascular origin, suspected interstitial lung disease, incidental lung nodule, suspected mediastinal lesion, suspected mediastinal lymphadenopathy, and elevated diaphragm on chest radiograph.

Risk of long-term care admissions among Medicare beneficiaries treated with pimavanserin or quetiapine for Parkinson's disease psychosis in USA: a retrospective administrative claims database analysis.

Aim: Risk of long-term care (LTC) admission (LTCA) associated with atypical antipsychotic (AAP) use among patients with Parkinson's disease psychosis (PDP) is a major concern. However, no comparative studies have examined the differences in risk of LTC admissions between pimavanserin (PIM), the only FDA-approved AAP for PDP, and other off-label AAPs including quetiapine (QUE). Objective: To examine all-cause LTCA rates and risk among PDP patients treated with AAPs such as QUE or PIM. Methods: Analysis of Parts A, Band D claims (100% Medicare sample; 2013-2019) of Medicare beneficiaries with PDP that initiate ≥12-month continuous PIM or QUE monotherapy from 1 January 2014 to31 December 2018 (i.e., index date) without any AAP use in the 12-month pre-index period was conducted. Outcome assessments among 1:1 propensity score-matched (31 variables - age, sex, race, region and 27 Elixhauser comorbidities) beneficiaries on PIM versus QUE included risk of all-cause skilled nursing facility stays (SNF-stays), LTC-stays, and overall LTCA (i.e., SNF-stays or LTC-stays). All-cause LTCA rates and LTCA risk were compared using logistic regression and cox proportional hazards models, respectively, controlling for demographics, comorbidities and co-existing-dementia or insomnia. Results: Of the matched sample (n=842 for each group) from total sample (n=9652), overall all-cause LTCA and SNF-stay rates were 23.2 and 20.2% for PIM versus 33.8 and 31.4% for QUE, respectively (p<0.05, for each). Hazard ratio (95% CI) for risk of SNF-stay and overall LTCA was 0.78 (0.61, 0.98) and 0.80 (0.66, 0.97), respectively, for PIM versus QUE beneficiaries (p<0.05, for each). Conclusion: The 20% lower risk of LTCA (i.e., greater delay) with PIM versus QUE in this analysis may suggest that PIM should be started early for the treatment of PDP.

Oral anticoagulant therapy and risk of admission to long-term care in patients with atrial fibrillation: a nationwide cohort study

Abstract Background The impact of oral anticoagulants (OACs) on outcomes in patients with atrial fibrillation (AF) has been a focus of extensive research in the past decades, but there is a complete paucity of information about their effect on the need of long-term care (LTC) in this aging and multimorbid patient group. Purpose To assess the hypothesis that OAC therapy is associated with lower need of LTC in patients with AF. Methods The registry-based FinACAF cohort study covers all patients with incident AF from all levels of care in Finland from 2007 to 2018, as well as all their OAC purchases, LTC admissions, and information on previous home care acuity. Incidence rate ratios (IRRs) for admission to any type of LTC were estimated with Poisson regression using Lexis-type data structure based on three time scales: follow-up time from AF diagnosis, calendar year, and age. OAC use was treated as a time-varying variable from first OAC purchase onwards. Results We identified 188 752 patients (49.0% female; mean age 71.4 years; mean follow-up 3.6 years) with incident AF without prior LTC, of whom 143 534 (76.0%) initiated OAC therapy and 11 775 (6.2%) were admitted to LTC. OAC therapy was associated with a lower rate of LTC admission (adjusted IRR with 95% CI: 0.79 (0.76-0.82)). The association was most evident among patients over 70 years (Kaplan-Meier curve of survival without LTC in Figure). Warfarin and direct oral anticoagulants (DOACs) were both associated with lower need of LTC. Furthermore, when compared to warfarin, DOACs were associated with a lower LTC admission rate (adjusted IRR with 95% CI: 0.69 (0.61-0.79)). No significant disparities were observed between different DOACs. High age and previous need of home care, as well as dementia, psychiatric disorders, and ischemic stroke were the strongest factors associated with the need of LTC. Conclusions In this nationwide cohort of patients with incident AF, OAC therapy, particularly with DOACs, was associated with a substantially lower risk of admission to LTC.Survival without LTC. Age over 70 years.

Oral Anticoagulant Therapy and Risk of Admission to Long-Term Care in patients With Atrial Fibrillation: A Nationwide Cohort Study.

The impact of oral anticoagulants (OACs) on the need of long-term care (LTC) in the aging and multimorbid population of patients with atrial fibrillation (AF) is unknown. We conducted a nationwide cohort study to evaluate the effect of OACs on the need of LTC. Retrospective nationwide cohort study. The registry-based FinACAF cohort study covers all patients with incident AF from all levels of care in Finland from 2007 to 2018, as well as all their OAC purchases, LTC admissions, and information on previous home care acuity. Incidence rate ratios (IRRs) of LTC admission were calculated using Poisson regression models with a Lexis-type data structure based on 3 time scales: follow-up time from AF diagnosis, calendar year, and age. We identified 188,752 patients (49.0% female; mean age 71.4years; mean follow-up 3.6years) with incident AF without prior LTC, of whom 143,534 (76.0 %) initiated OAC therapy and 11,775 (6.2 %) were admitted to LTC. OAC therapy was associated with lower rates of LTC admission (adjusted IRR 0.79, 95% CI 0.76-0.82). When compared to warfarin, direct oral anticoagulants (DOACs) were associated with lower LTC admission rate (adjusted IRR 0.69, 95% CI 0.61-0.79). No significant disparities were observed between different DOACs. OAC therapy, particularly with DOACs, is associated with a substantially lower risk of admission to LTC in patients with AF. Increasing guideline-based OAC coverage among patients with AF may prevent the need of LTC, lengthen survival at home, and potentially decrease health care costs.

Primary health care service utilisation before and after entry into long-term care in Australia

ObjectivesTo examine utilisation of primary health care services (subsidised by the Australian Government, Medicare Benefits Schedule, MBS) before and after entry into long-term care (LTC) in Australia. MethodsA retrospective cohort study of older people (aged ≥65 years) who entered LTC in Australia between 2012 and 2016 using the Historical Cohort of the Registry of Senior Australians. MBS-subsidised general attendances (general practitioner (GP), medical and nurse practitioners), health assessment and management plans, allied health, mental health services and selected specialist attendances accessed in 91-day periods 12 months before and after LTC entry were examined. Adjusted relative changes in utilisation 0–3 months before and after LTC entry were estimated using risk ratios (RR) calculated using Generalised Estimating Equation Poisson models. Results235,217 residents were included in the study with a median age of 84 years (interquartile range 79–89) and 61.1% female. In the first 3 months following LTC entry, GP / medical practitioner attendances increased from 86.6% to 95.6% (aRR 1.10 95%CI 1.10–1.11), GP / medical practitioner urgent after hours (from 12.3% to 21.1%; aRR 1.72, 95%CI 1.70–1.74) and after-hours attendances (from 18.5% to 33.8%; aRR 1.83, 95%CI 1.81–1.84) increased almost two-fold. Pain, palliative and geriatric specialist medicine attendances were low in the 3 months prior (<3%) and decreased further following LTC admission. ConclusionThere is an opportunity to improve the utilisation of primary health care services following LTC entry to ensure that residents’ increasingly complex care needs are adequately met.

338 Profile of older adults post hip fracture: a pre and post-Covid comparison

Abstract Background The Irish Government implemented public health measures during the COVID-19 pandemic, including self-isolation among older citizens. Within our rehabilitation centre, the multidisciplinary team remarked on what they perceived to be negative health repercussions from ‘cocooning’, particularly those admitted following hip fracture. We sought to compare patient cohorts in 2019 and 2022. Methods Data was examined from the Irish Hip Fracture Database online portal specific to our Model 3 hospital for 2019 and 2022. Subset analysis was performed on hip fracture patients admitted to an off-site rehabilitation centre using that hospital’s electronic patient database. Results 245 hip fractures were recorded in 2019 and 380 in 2022. In 2019 37% were aged between 80–89, 12% were over 90. In 2022 45% were aged between 80–89, 14% were over 90. ASA grade pre-operatively; in 2019, 33% were classed as normal or with mild systemic disease, 61% were in the severe systemic disease category. The same categories in 2022 were 41% and 55% respectively. Discharge destination for patients in 2019 and 2022 respectively were as follows: discharged directly home 27% vs 25%, discharged to offsite rehabilitation 32% vs. 38%, new Long-Term Care (LTC) admission 2% vs 3%. Our rehabilitation unit received 26 patients in 2019 and 39 in 2022. The average timed up and go (TUG) on admission in 2019 vs 2022 was 38.7 and 53.7 seconds respectively. Conclusion There was a 55% increase in the number of patients presenting with hip fracture post Covid. Despite similar age and co-morbidity profiles patients average TUG was 39% slower post Covid. Less patients were discharged directly home in 2022, more patients required a period of rehabilitation and the number of new admissions to LTC increased. This small study supports our hypothesis surrounding the detrimental effects of cocooning on older patients.

Emergency Department Bridge Model and Health Services Use Among Patients With Opioid Use Disorder

Little is known about the effectiveness of bridge clinics as transitional care programs for people with opioid use disorder in emergency departments (EDs). We assessed the effect of bridge clinic referral on health services use among patients with opioid use disorder identified in the ED. We used data for individuals aged 18 years and over with active opioid use disorder and no history of medication for opioid use disorder who were administered medication for opioid use disorder while in the ED between January 2013 and August 2022. Bridge clinic referrals started in January 2021. Eligible patients after this date comprised the intervention group. The usual care group included eligible patients before bridge clinic implementation, who were a 1:1 propensity score matched to intervention patients. We estimated risk differences and 95% confidence limits for linkage to long-term care, ED use, and inpatient admission within 120 days of the index ED visit. Our study population comprised 928 observations after matching. Patients referred to the bridge clinic had a higher risk of linkage to long-term care (risk differences=25%; 95% confidence limits: 20%, 30%), higher risk of ED use (risk differences=7.5%, 95% confidence limits: 1.6%, 13%), and lower risk of inpatient admission (risk differences= -1.9%, 95% confidence limits: -5.9%, 2.1%). Inpatient admission increased among patients with serious mental illness but decreased among patients without serious mental illness. Our overall results suggest that bridge clinic referral increases linkage to long-term care. Nevertheless, qualitatively different effects on inpatient admission between patients with and without serious mental illness warrant consideration of unmet needs among patients with serious mental illness.

Inter-provincial variation in older home care clients and their pathways: a population-based retrospective cohort study in Canada

BackgroundIn Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death).MethodsA retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance.ResultsNS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community – either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period.ConclusionsBy following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients.

To compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients. A retrospective cohort study based on the Resident Assessment Instrument-Home Care (RAI-HC) assessments and electronic medical records. The study sample included all regular home care clients aged ≥65years (n= 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants). Health care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use. Compared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08-1.48), home visits (1.23; 1.01-1.49), phone contacts (1.38; 1.13-1.68), and consultations without a patient attending a practice (1.22; 1.04-1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses' median work hours per week were 4.3 (Q1-Q3 1.5-7.7) among opioid users and 2.8 (1.0-6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use. Long-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients' needs. The exact reasons for opioid users' greater health care utilization should be examined in future.

Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults’ transitions into long-term care

BackgroundEstablishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum.MethodsWe performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process.ResultsThe findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care.ConclusionsWe emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.

External validation of the hospital frailty risk score among hospitalised home care clients in Canada: a retrospective cohort study.

The Hospital Frailty Risk Score (HFRS) is scored using ICD-10 diagnostic codes in administrative hospital records. Home care clients in Canada are routinely assessed with Resident Assessment Instrument-Home Care (RAI-HC) which can calculate the Clinical Frailty Scale (CFS) and the Frailty Index (FI). Measure the correlation between the HFRS, CFS and FI and compare prognostic utility for frailty-related outcomes. Retrospective cohort study. Alberta, British Columbia and Ontario, Canada. Home care clients aged 65+ admitted to hospital within 180days (median 65days) of a RAI-HC assessment (n = 167,316). Correlation between the HFRS, CFS and FI was measured using the Spearman correlation coefficient. Prognostic utility of each measure was assessed by comparing measures of association, discrimination and calibration for mortality (30days), prolonged hospital stay (10+ days), unplanned hospital readmission (30 days) and long-term care admission (1 year). The HFRS was weakly correlated with the FI (ρ 0.21) and CFS (ρ 0.28). Unlike the FI and CFS, the HFRS was unable to discriminate for 30-day mortality (area under the receiver operator characteristic curve (AUC) 0.506; confidence interval (CI) 0.502-0.511). It was the only measure that could discriminate for prolonged hospital stay (AUC 0.666; CI 0.661-0.673). The HFRS operated like the FI and CFI when predicting unplanned readmission (AUC 0.530 CI 0.526-0.536) and long-term care admission (AUC 0.600; CI 0.593-0.606). The HFRS identifies a different subset of older adult home care clients as frail than the CFS and FI. It has prognostic utility for several frailty-related outcomes in this population, except short-term mortality.

Older persons living with dementia and their use of acute care services over 2 years in Alberta

To characterize transitions to acute and residential care and identify variables associated with specific transitions among community-based persons living with dementia (PLWD). Retrospective cohort study using primary care electronic medical record data linked with health administrative data. Alberta. Adults aged 65 years or older living in the community who had been diagnosed with dementia and who saw a Canadian Primary Care Sentinel Surveillance Network contributor between January 1, 2013, and February 28, 2015. All emergency department visits, hospitalizations, residential care (supportive living and long-term care) admissions, and deaths within a 2-year follow-up period. In total, 576 PLWD were identified who had a mean (SD) age of 80.4 (7.7) years; 55% were female. In 2 years, 423 (73.4%) had at least 1 transition and, of these, 111 (26.2%) had 6 or more. Emergency department visits, including multiple visits, were common (71.4% had ≥1, 12.1% had ≥4). Of those hospitalized (43.8%), nearly all were admitted from the emergency department; the average (SD) length of stay was 23.6 (35.8) days, and 32.9% had at least 1 alternate level of care day. In total, 19.3% entered residential care, most admitted from hospital. Those admitted to hospital and those admitted to residential care were older and had greater historical health system use, including home care. One-quarter of the sample did not have any transitions (or die) during follow-up; they were typically younger and had limited historical health system use. Older PLWD experienced frequent, and frequently compound, transitions that have implications for them, their family members, and the health system. There was also a large proportion without transitions suggesting that appropriate supports enable PLWD to do well in their own communities. The identification of PLWD who are at risk of or who make frequent transitions may allow for more proactive implementation of community-based supports and smoother transitions to residential care.