Long-term Nursing Home Placement Research Articles

Patient Outcomes After Delirium Screening and Incident Alzheimer's Disease or Related Dementias in Skilled Nursing Facilities.

The extent to which a positive delirium screening and new diagnosis of Alzheimer's disease or related dementias (ADRD) increases the risk for re-hospitalization, long-term nursing home placement, and death remains unknown. To compare long-term outcomes among newly admitted skilled nursing facility (SNF) patients with delirium, incident ADRD, and both conditions. A retrospective cohort study of Medicare beneficiaries who entered a SNF from hospital with a minimum 14-day stay (n = 100,832) from 2015 to 2016. Return to home, hospital readmission, admission to a long-term care facility, or death. Patients with delirium were as likely to be discharged home as patients diagnosed with ADRD (HR: 0.63, 95% CI: 0.59, 0.67; HR: 0.65, 95% CI: 0.64, 0.67). Patients with both delirium and ADRD were less likely to be discharged home (HR: 0.49, 95% CI: 0.47, 0.52) and showed increased risk of death (HR: 1.30, 95% CI: 1.17, 1.45). Patients with ADRD, regardless of delirium screening status, had increased risk for long-term nursing home care transfer (HR: 1.66, 95% CI: 1.63, 1.70; HR: 1.76, 95% CI: 1.69, 1.82). Patients with delirium and no ADRD showed increased risk of transfer to long-term nursing home care (HR: 1.25, 95% CI: 1.18, 1.33). The rate of deaths was higher among patients who screened positive for delirium without ADRD compared to the no delirium and no ADRD groups (HR: 2.35, 95% CI: 2.11, 2.61). A positive delirium screening increased risk of death and transfer to long-term care in the first 100 days after admission regardless of incident ADRD diagnosis. Patients with delirium and/or ADRD also are less likely to be discharged home. Our study builds on the evidence base that delirium is important to address in older adults as it is associated with negative outcomes.

Overwhelmed: a Dementia Caregiver Vital Sign.

The emotional stress of caring for someone with Alzheimer's disease and related dementias is high and results in adverse effects on caregivers and the persons living with disease. In preliminary work, caregiver reports of regularly feeling "completely overwhelmed" were associated with lack of measurable clinical benefit from a comprehensive dementia care program. To examine the sociodemographic and clinical characteristics of all caregivers who felt overwhelmed at entry into a comprehensive dementia care program, the trajectory of this symptom over 1 year, and its predictive value for 1-year caregiver outcomes. Longitudinal cohort study SETTING: Academic health center PARTICIPANTS: Caregivers of patients enrolled in a comprehensive dementia care program EXPOSURES: Caregiver report of feeling "completely overwhelmed" at baseline MAIN MEASURES: Caregiver report of feeling "completely overwhelmed" at baseline and 1 year, and validated scales of caregiver strain, distress, depressive symptoms, burden, mortality, and long-term nursing home placement KEY RESULTS: Compared to caregivers who were not overwhelmed, overwhelmed caregivers had more distress from behavioral symptoms of the person living with dementia, worse depression scores, and higher composite dementia burden scores at baseline. They also had worse depressive symptoms, strain, and composite burden scores at 1 year, after adjustment for baseline scores. Having an overwhelmed caregiver did not predict long-term nursing home placement or mortality among persons with dementia. A single question about whether a caregiver is overwhelmed might indicate caregivers who have considerable current and future symptom burden and who may benefit from increased support and resources.

Death, long-term nursing home placement, and impoverishment after recurrent myocardial infarction

Study objectiveTo determine whether recurrent myocardial infarction (MI) is associated with increased risk of mortality, long-term nursing home placement, and impoverishment. DesignRetrospective cohort study. SettingUnited States Medicare program. ParticipantsIndividuals age > 65 years with recurrent MI hospitalizations (n = 228,826) between January 1, 2007 and June 30, 2017 and controls with initial but not recurrent MI (n = 915,304). Main outcome measuresDeath, nursing home placement, and impoverishment (Medicaid enrollment or subsidies for low-income and -resource individuals) through December 31, 2017. ResultsIn the recurrent MI and control cohorts, 47% and 41% of individuals were age > 80 years, respectively, and 56% of both cohorts were women. After 1 year, 48% of the recurrent MI cohort and 16% of the control cohort died, 9% and 7% experienced nursing home placement, and 4% and 2% experienced impoverishment. Multivariable-adjusted hazard ratios (95% confidence intervals) comparing the recurrent MI and control cohorts were 2.04 (2.03–2.06) for death, 0.89 (0.88–0.91) for nursing home placement, and 1.32 (1.28–1.36) for impoverishment. ConclusionsOlder US adults with recurrent MI had higher risk of death and impoverishment than controls who had experienced an initial MI. Unadjusted, recurrent MI was associated with higher risk of nursing home placement; however, after adjusting for sociodemographic characteristics and comorbidities, individuals with recurrent MI had slightly lower risk of nursing home placement. Preventing recurrent MI may also reduce the risk of death and impoverishment among older US adults.

Utilization and Cost Effects of the VHA Caring for Older Adults and Caregivers at Home (COACH) Program.

Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (average treatment effect on the treated [ATT] -3%; p = .01). The program increased utilization of emergency services (ATT 6%; p = .01), hospitals (ATT 10%; p < .001), and personal care services (ATT 31%; p < .001). Health care costs were also significantly increased. Improved access to services may have enabled COACH Veterans to stay at home longer. As one of Veterans Health Administration's top priorities to expand caregiver assistance programs, COACH seems to be a promising model for a nationwide implementation.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews.

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP). We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors). Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP. Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

UCLA Partners with GAPNA To Improve Alzheimer’s and Dementia Care

UCLA Partners with GAPNA To Improve Alzheimer’s and Dementia Care

"Now I Write Songs": Growth and Reciprocity After Long-Term Nursing Home Placement.

Nursing home residents have a need for activities that are meaningful, yet mandated scheduled activities remain poorly characterized. In order to understand how scheduled activities provide meaning for nursing home residents, we conducted a study of daily life in a nursing home with a robust activities program. This 2-year, longitudinal ethnographic study embedded an ethnographer into the activities department of a 430-bed, not-for-profit, faith-based nursing home. Forty-three interviews and more than 250 hr of participant-observation were conducted, with a focus on creative arts and religious activities. Thirty-two residents and 15 activities staff were followed more than 12-23 months. Data were coded concurrently, and emerging themes challenged through purposive recruitment until thematic saturation was reached. Scheduled activities in the nursing home offered opportunities for learning and personal growth regardless of functional or cognitive disability. Three major themes emerged. Artistic development included new self-identification as a musician, painter, or sculptor through arts programming. Intellectual and spiritual growth involved the use of activities to support ongoing practice and study. Reciprocity occurred as residents used the arts to remain contributing members of their institutional society, reciprocating with the institution that housed them. Nursing home scheduled activities can facilitate the transformation of identity from resident or patient to the normalized social roles of artist, Torah scholar, and productive member of society.

Men Lacking a Caregiver Have Greater Risk of Long-Term Nursing Home Placement After Stroke.

Social support can prevent or delay long-term nursing home placement (NHP). The purpose of our study was to understand how the availability of a caregiver can affect NHP after ischemic stroke and how this affects different subgroups differently. Nested cohort study. Nationally based REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Stroke survivors aged 65 to 100 (256 men, 304 women). Data were from Medicare claims from January 2003 to December 2013 and REGARDS baseline interviews conducted from January 2003 to October 2007. Caregiver support was measured by asking, "If you had a serious illness or became disabled, do you have someone who would be able to provide care for you on an on-going basis?" Diagnosis of ischemic stroke was derived from inpatient claims. NHP was determined using a validated claims algorithm for stays of 100days and longer. Risk was estimated using Cox regression. Within 5years of stroke, 119 (21.3%) participants had been placed in a nursing home. Risk of NHP was greater in those lacking available caregivers (log-rank P=.006). After adjustment for covariates, lacking an available caregiver increased the risk of NHP after stroke within 1year by 70% (hazard ratio (HR)=1.70, 95% confidence interval (CI)=0.97-2.99) and within 5years by 68% (HR=1.68, 95% CI=1.10-2.58). The effect of caregiver availability on NHP within 5years was limited to men (HR=3.15, 95% CI=1.49-6.67). In men aged 65 and older who have survived an ischemic stroke, the lack of an available caregiver is associated with triple the risk of NHP within 5years.

MEN LACKING A CAREGIVER HAVE GREATER RISK OF LONG-TERM NURSING HOME PLACEMENT AFTER STROKE

Background/Objectives Social support can prevent or delay long-term nursing home placement (NHP). The purpose of our study was to understand how the availability of a caregiver can affect NHP after ischemic stroke and how this affects different subgroups differently. Design Nested cohort study. Setting Nationally based REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants Stroke survivors aged 65 to 100 (256 men, 304 women). Measurements Data were from Medicare claims from January 2003 to December 2013 and REGARDS baseline interviews conducted from January 2003 to October 2007. Caregiver support was measured by asking, “If you had a serious illness or became disabled, do you have someone who would be able to provide care for you on an on-going basis?” Diagnosis of ischemic stroke was derived from inpatient claims. NHP was determined using a validated claims algorithm for stays of 100 days and longer. Risk was estimated using Cox regression. Results Within 5 years of stroke, 119 (21.3%) participants had been placed in a nursing home. Risk of NHP was greater in those lacking available caregivers (log-rank P = .006). After adjustment for covariates, lacking an available caregiver increased the risk of NHP after stroke within 1 year by 70% (hazard ratio (HR) = 1.70, 95% confidence interval (CI) = 0.97–2.99) and within 5 years by 68% (HR = 1.68, 95% CI = 1.10–2.58). The effect of caregiver availability on NHP within 5 years was limited to men (HR = 3.15, 95% CI = 1.49–6.67). Conclusion In men aged 65 and older who have survived an ischemic stroke, the lack of an available caregiver is associated with triple the risk of NHP within 5 years.

Parkinson’s Disease Psychosis—A Symptom Complex Signaling Risk for Increased Disability and Caregiver Burden

Parkinson’s disease psychosis (PDP) occurs frequently in patients with Parkinson’s disease (PD) and involves a spectrum of symptoms, from mild hallucinations to those that are more disruptive, as well as delusions, particularly around spousal infidelity and theft of money or possessions. Risk factors for PDP include dopaminergic (and other) medications, cognitive disorders, sleep disorders, and duration of PD. Emerging evidence suggests that PDP also reflects underlying PD pathology. Routine querying of major PDP symptoms can hasten recognition and allow earlier diagnosis of PDP. Mild hallucinations with retained insight are frequent and may be tolerable by patients and caregivers, but symptoms that can be considered as psychosis will typically increase in frequency and severity. Increasing PDP results in patient distress, increased caregiver burden, and is a leading cause of long-term nursing home placement. PDP has also been associated with an increased risk for morbidity and mortality. Ongoing research into the prevalence, risk factors, phenomenology, pathophysiology, and emerging pharmacotherapy for PDP provides hope for improved diagnosis and management of PDP.

Predictors of long-term nursing home placement under competing risk: evidence from the Health and Retirement Study.

To examine predictors of long-term nursing home placement (LTNHP) while controlling for mortality as a competing risk event. Longitudinal. Health and Retirement Study, 1998-2010. Nationally representative sample of community-living older adults (N = 10,385). Longitudinal data were used with a maximum follow-up of 12 years. First, a traditional Cox proportional hazards model was estimated treating death as an uninformative censoring event. A joint cause-specific hazards model that accounts for the competing risk of mortality in estimating the risk of LTNHP was then estimated. The effect of adjusting for competing risk of mortality is evident for nearly all predictors of LTNHP. Predictors were over- or underestimated in the traditional Cox model, and several predictors changed in the direction of the association, whereas others changed in magnitude. For example, after controlling for mortality, women aged 85 and older had more than twice the risk (hazard ratio = 7.23, 95% confidence interval = 5.18-10.10) of LTNHP than evidenced in the traditional Cox model. Whenever possible, the competing risk of mortality should be recognized and adjusted in developing screening tools and predictive risk models for LTNHP.

Everyone’s Talking About It, But Does It Work? Nursing Home Diversion and Transition

In response to increasing Medicaid expenditures and consumer preferences, states are reforming their long-term care systems to provide more community-based services. One popular reform is renewed efforts to prevent unnecessary long-term nursing home placement (diversion) and to provide nursing home residents an opportunity to return to the community (transition). Nearly 3,800 individuals, 60 years old and older, participated in Ohio's statewide nursing home diversion and transition initiative between March 2010 and May 2011. This research tracked outcomes for consumers and evaluated the implementation of the new program. Nearly 80% of diversion and transition participants who were still living at the time of their 6-month follow-up were residing in the community. An agency-level process analysis revealed innovative intervention strategies, promising practices, and barriers. Process results found that Area Agencies on Aging (AAAs) have become more proactive in working with high-risk individuals, with agencies identifying new at-risk consumers through hospital and nursing home interventions.

The Roles of Senior Management in Improving Hospital Experiences for Frail Older Adults

With the aging of the population, healthcare executives are paying increased attention to fostering safe and high-quality care for older adults who become hospitalized. The Hospital Elder Life Program (HELP) is an evidence-based program that has been shown to be cost-effective in reducing episodes of delirium, functional decline, and long-term nursing home placement for older hospitalized adults. Senior administrators are known to play a role in quality improvement, but little is known about their roles in adopting clinical improvement programs such as HELP. Therefore, we conducted a mixed-methods study of 63 hospitals at different stages of adopting HELP to identify key roles and motivations of senior management to adopt HELP and the perceived impact of HELP on patient and staff outcomes. Our findings can be used by hospital management teams as they identify ways to influence and benefit from efforts to improve clinical quality, safety, and the experiences of older adults treated in their hospitals.

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low‐Income Seniors

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

Community-based care and risk of nursing home placement.

To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a "natural experiment." Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare-TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15-1.79). The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.

Changing patterns of hip fracture care before and after implementation of the prospective payment system

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated. (<i>JAMA</i>1987;258:218-221)

Changing Patterns of Hip Fracture Care Before and After Implementation of the Prospective Payment System

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.