Nursing Facility Research Articles

Risk of Dementia Diagnosis After Injurious Falls in Older Adults

Emerging evidence suggests that mild cognitive impairment, which is a precursor to Alzheimer disease and related dementias (ADRD), places older adults at increased risk for falls. However, the risk that an older adult develops dementia after experiencing a fall is unknown. To determine the risk of new ADRD diagnosis after a fall in older adults. This retrospective cohort study examined Medicare Fee-for-Service data from 2014 to 2015, with follow-up data available for at least 1 year after the index encounter. Participants included adults aged 66 years and older who experienced a traumatic injury that resulted in an emergency department (ED) or inpatient encounter and did not have a preexisting diagnosis of dementia. Data analysis was performed from August 2023 to July 2024. Experiencing a fall compared with other mechanisms of injury, defined by International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 external cause of injury codes. The hazard of new ADRD diagnosis within 1 year of a fall, assessed by performing a Cox multivariable competing risk model that controlled for potential confounders while accounting for the competing risk of death. The study included 2 453 655 older adult patients who experienced a traumatic injury; 1 522 656 (62.1%) were female; 124 396 (5.1%) were Black and 2 232 102 (91.0%) were White; and the mean (SD) age was 78.1 (8.1) years. The mechanism of injury was a fall in 1 228 847 incidents (50.1%). ADRD was more frequently diagnosed within 1 year of a fall compared with other injury mechanisms (10.6% [129 910 of 1 228 847] vs 6.1% [74 799 of 1 224 808]; P < .001). The unadjusted hazard ratio (HR) of incident dementia diagnosis after a fall was 1.63 (95% CI, 1.61-1.64; P < .001). On multivariable Cox competing risk analysis, falling was independently associated with an increased risk of dementia diagnosis among older adults (HR, 1.21 [95% CI, 1.20-1.21]; P < .001) after controlling for patient demographics, medical comorbidities, and injury characteristics, while accounting for the competing risk of death. Among the subset of older adults without a recent skilled nursing facility admission, the HR was 1.27 (95% CI, 1.26-1.28; P < .001). In this cohort study, new ADRD diagnoses were more common after falls compared with other mechanisms of injury, with 10.6% of older adults being diagnosed with ADRD in the first year after a fall. To improve the early identification of ADRD, this study's findings suggest support for the implementation of cognitive screening in older adults who experience an injurious fall that results in an ED visit or hospital admission.

Can Avatar Robots Assist Older People and Care Professionals? Evaluation of an Intervention Study in Eight Nursing Homes in Tokyo

Abstract Background Securing human resources to meet increasing demand for older people's care is challenging, particularly in Japan, where the pace of ageing is accelerating. Central and local government have been seeking partial solutions in assistive technologies such as robotics. Against such a background, the study was conducted in 8 nursing care homes in Tokyo, where avatar robots were tested to examine whether and how these robot interventions can affect the daily life of older people and care professionals. Methods Four different types of avatar robot (ORIHIME, NEWME, Piyokame and BOCCO) were introduced to and used in eight nursing care facilities, in order to create conversational opportunities over 12 weeks. Before–after studies were conducted, and a variety of data was collected (interpersonal communication, self-care and depressive tendencies using the International Classification of Functioning, Disability and Health (ICF) and InterRAI assessments). System usability scores (SUS) were collected from care professionals, who also performed a time-on-task analysis. Results Study participants who consented to taking part were 136 older adults (88.4±6.6 years old, 18 men and 118 women) and 63 care professionals. Participants with a high degree of dependency accounted for 31 percent. In total, 136 avatar robots were used. There was an overall, yet marginal, improvement for older people. While the SUS scores were poor, the majority (90 percent) responded that such devices would prove useful in the future. The time-on-task analysis indicates that more time can be secured for ‘person-to-person’ care. Conclusion Positive impacts of avatar robots (to increase the level of social interaction and communication) were observed. However, the results are inconclusive, and more needs to be done with regard to technology skills, competence enhancement and data collection methods for this type of research. The study was funded in part by the Tokyo Metropolitan Government.

Reduction of Rehospitalization with Addition of Geriatrics/Transitions of Care Consult Service

Older adults are at high risk of rehospitalization after an acute event and at even higher risk of permanently losing an activity of daily living with each hospitalization. This is especially true in those with encephalopathy, delirium, dementia, falls, and failure to thrive. Although it is widely known that rehospitalization rates are higher in patients who discharge to skilled nursing and long-term care facilities, geriatrics consultations have not been shown to consistently decrease this risk. In this study, we added a novel component specific to transitions of care alongside a traditional geriatrics consultation for patients discharging to a skilled nursing or long-term care facility. Results show evidence of significant rehospitalization reduction for patients with markers of cognitive impairment and frailty.

Skilled Nursing Facility Rehabilitation Intensity and Successful Discharge in Persons with Dementia

ObjectivesSkilled therapies (STs), including audiology, speech-language therapy, occupational therapy, and physical therapy, can address functional deficits in dementia. This study aims to quantify the association between ST and successful discharge after heart failure (HF) hospitalization in persons living with dementia. DesignRetrospective cohort study. Setting and ParticipantsWe included veterans with dementia (VwD) hospitalized for HF in Veterans Affairs (VA) medical centers and then admitted to non-VA skilled nursing facilities (SNFs) from January 2011 to June 2019. MethodsFollow-up continued 120 days after SNF admission. We measured ST hours per week using MDS admission assessments. We defined successful discharge as SNF discharge occurring within 90 days of SNF admission with MDS discharge status not hospital or institutional setting, and 30 days’ survival after discharge without Medicare or VA-paid rehospitalization or reinstitutionalization. We estimated relative risk using multiple variable regression to adjust for measured sources of confounding. ResultsOur final sample included 8255 VwD. The mean (SD) age was 80 (10) years, and 8074 (98%) were male. Successful discharge occurred in 2776 (34%) of the sample. The median (IQR) weekly hours of ST was 10.4 (7.1–12.1). Sextile 1 received less than 5.2 hours per week of ST. The adjusted relative risk (95% CI) for sextiles 2–6 compared with sextile 1 were, respectively, 2.20 (1.85–2.62), 2.48 (2.09–2.94), 2.52 (2.12–2.99), 2.62 (2.21–3.11), and 2.69 (2.27–3.19). DiscussionDuring SNF care after HF hospitalization, 5.3 or more hours of STs per week was associated with a higher rate of successful discharge, in a roughly dose-dependent fashion, up to a 170% increase in the highest sextile of ST hours. Conclusions and ImplicationsHigher ST hours are associated with successful discharge from SNF after HF hospitalization.

Educational spaces: The relation between school infrastructure and learning outcomes

This article examines the relationship between school infrastructure and academic performance in Ecuador. The objective of this research is to identify which types of infrastructure are associated with better student outcomes in elementary schools. The study employs data from the 2019 UNESCO standardized test, ERCE-2019, for Ecuadorian primary schools. The findings indicate a significant positive correlation between various types of school infrastructure and student achievement. Such infrastructure includes art and music installations, on-site nursing facilities, and basic service connections, especially in rural areas. Significant correlations between educational outcomes and large-scale infrastructure investments are either not observed or are inconsistently evidenced. These results challenge the heavy focus on prominent educational infrastructure projects in Ecuador, suggesting an opportunity to reorient educational spending to enhance outcomes cost-effectively. These research findings may apply not only to Ecuador but potentially to the broader Latin American context.

Preventing delirium in post-acute care.

Older adults admitted to post-acute care often are frail with multiple comorbidities, making them particularly vulnerable to developing delirium. The purpose of this quality improvement project was to create, implement, and evaluate an NP-led, evidence-based delirium prevention protocol in a skilled nursing facility (SNF). The incidence of new-onset delirium was assessed pre- and postimplementation; following implementation, no patients were diagnosed with new-onset delirium, and nurses and certified nursing assistants reported changes to their practice. Based on project design, the approximately 42,000 NPs in the US with nursing home or long-term-care facility privileges are optimally positioned to lead SNFs in the prevention of new-onset delirium.

Unplanned hospital readmission after cholecystectomy in adults with cerebral palsy.

Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy. Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates. A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90day readmission rates after laparoscopic cholecystectomy were 11.4% and 18.1%, respectively. Average length of stay (LOS) after laparoscopic cholecystectomy was 7.1days. After open cholecystectomy, 30 and 90day readmission rates were 16.9% and 30.3% with an average LOS of 14.6days. Infection was the most common cause for 30 and 90day readmission. Factors associated with 30day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid diabetes and malnutrition. Factors associated with 90day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid heart failure, renal disease, epilepsy, and malnutrition. Unplanned readmission rates after open and laparoscopic cholecystectomy in adult patients with CP are much higher than previously demonstrated rates in the general population. These patients frequently suffer multiple comorbid conditions that significantly complicate their surgical care. As more and more of these patients live longer into adulthood, further study is warranted to grasp the perioperative risk of simple and complex surgical procedures.

Potential risks of nonoperative management of appendicitis in high-risk patients

IntroductionThe popularity of nonoperative management for acute appendicitis is based on the untested assumption that it offers a lower risk alternative to surgery in patients who are at high risk for morbidity and mortality with appendectomy. We hypothesized that patients who were at a high risk with appendectomy would also be at a high risk for complications following nonoperative management. MethodsThis is a retrospective cohort study of patients with acute, uncomplicated appendicitis in the 2004–2017 National Inpatient Sample. We used a logistic regression model to predict the risk of morbidity or mortality following appendectomy and applied this model to predict the risk of patients managed nonoperatively. High risk was defined as ≥2 standard deviations above the mean predicted risk of morbidity or mortality. We used inverse probability weighting of the propensity score to compare outcomes of nonoperative versus operative management for high-risk patients. ResultsThe sample included 21,242 high-risk patients with a median age of 68 years (interquartile range 57–78), and 31% were managed nonoperatively. Compared to surgery, nonoperative management was associated with a 9% decrease in complications (95% confidence interval [CI] 7%–10%), 2% increase in mortality (95% CI 2%–3%), $10,202 increase in hospital costs (95% CI $9,065–$11,339), 3-day increase in length of stay (95% CI 2–3), and 9% greater likelihood of discharge to skilled nursing facilities (95% CI 8%–10%). ConclusionNonoperative management of acute appendicitis in high-risk patients may reduce morbidity but increase mortality, duration of hospitalization, discharge to skilled facility, and costs. Surgeons should exercise caution when considering nonoperative management in these vulnerable patients.

Mixed-Method Evaluation to Understand Clinician Perspectives of a Program to Implement High-Intensity Resistance Rehabilitation Into Skilled Nursing Facilities

ObjectiveTo assess rehabilitation clinicians’ viewpoints regarding a multicomponent implementation program aimed at promoting high-intensity resistance rehabilitation (HIR), as well as practical implications for its use in skilled nursing facility (SNF) rehabilitation. DesignProspective convergent mixed-method design. SettingEight rural SNFs within the Department of Veterans Affairs. ParticipantsPhysical rehabilitation clinicians (physical and occupational therapists, physical and occupational therapy assistants, recreational therapists, and kinesiotherapists) who engaged with the implementation program (n=38). InterventionsClinicians engaged with the multicomponent implementation program to promote the use of HIR in clinical practice. The program components included clinician training (i.e., virtual didactic modules with synchronous case discussions), provision of resources (e.g., equipment, job aids), and facilitated implementation (e.g., external implementation facilitator support, distributed tips and tricks). Main Outcome MeasuresAcceptability of Intervention Measure, Training Acceptability Rating Scale, study-specific questionnaires, and qualitative focus groups exploring perceived acceptability, feasibility, and effect on work experience. ResultsQuestionnaires revealed high levels of implementation program acceptability and perceived effect, alongside moderate levels of feasibility. Focus group themes supported these findings, explaining high acceptability and effect through differentiation from other trainings and prolonged engagement. Feasibility results were explained qualitatively by facilitatory factors (i.e., team participation, reduced caseloads, training characteristics) and inhibitory factors (i.e., training timing, self-paced scheduling logistics, lack of protected time and space). There was no reported negative effect on clinician work experience. ConclusionsAccording to SNF clinician perspectives, a positive HIR implementation experience may be enhanced through implementation programs that provide prolonged engagement and a self-paced structure with built-in accountability. Leadership and organizational support appear important to protect time and space for clinicians who experience competing priorities to successfully facilitate evidence uptake. Future work can evaluate the applicability across various contexts beyond rural VA SNFs.

Readmissions in Sepsis Survivors: Discharge Setting Risks.

Sepsis is a complex condition with high morbidity and mortality. Prompt treatment can improve survival, but for survivors the risk of deterioration and readmission remains high. Little is known about the association between discharge setting and readmission among sepsis survivors. To examine 30-day hospital readmission rates in adult sepsis survivors by the type of setting to which patients were discharged. The Medical Information Mart for Intensive Care database was used to identify adult sepsis survivors and evaluate 30-day readmission by discharge setting. A χ2 contingency analysis was used with each factor and presence/absence of readmission. The Kruskal-Wallis test was used to compare readmissions across discharge settings. From our sample (N = 7107; mean age 66.5 years; 46.2% women), 23.6% (n = 1674) were readmitted within 30 days and of those readmitted, 30% were readmitted between 1 and 3 times. Discharge setting (P < .001) and age (P = .02) were significantly associated with readmission, but sex, ethnicity, and insurance type were not. High numbers of readmissions were seen in patients discharged to skilled nursing facilities (29.6%), home health care (26.9%), and home (15.0%). Similar high comorbidity burden and acuteness of illness were seen in patients discharged to these settings. Sepsis survivors discharged to skilled nursing facilities, home health care, and home are at high risk for 30-day readmission. The rates of readmission from home health care and home settings were alarming. Often patients are discharged to inappropriate settings, placing them at risk for residual sepsis and readmission. Future research should focus on appropriate timing of hospital discharge and transition to the most appropriate discharge setting.

Skilled Nursing and Home Health Policy: A Primer for the Hospital Clinician

This paper addresses the increasing challenges faced by hospital clinicians in coordinating and recommending postacute care for patients, focusing on issues related to access to the most common postacute services: skilled nursing facilities (SNFs) and home health agencies (HHAs). In coordinating discharges, hospital clinicians have minimal information on care delivery in these settings. This knowledge gap is exacerbated by the disrupted continuum of patient care between acute care hospitals, SNFs, and HHAs. To address these challenges, hospital clinicians must understand how recent federal policies have impacted SNF and HHA care provision. The paper provides an overview of recent Centers for Medicare and Medicaid Services (CMS) policies and programs affecting SNFs and HHAs, including: (1) fee-for-service reimbursement reform (ie, Patient Driven Payment Model [PDPM] and the Patient Driven Groupings Model [PDGM]); (2) bundled payment programs; (3) accountable care organizations; (4) Medicare Advantage plans. Overall, this paper aims to help hospital clinicians stay informed about the evolving landscape of postacute care delivery by providing relevant information on how recent policy changes have impacted patient care.

Geriatric Pharmacotherapy Case Series: Clotting and Gender-Affirming Care.

Background A transfeminine patient is a 79-year-old with past medical history significant for type 2 diabetes mellitus, hypertension, gender dysphoria, chronic kidney disease, dyslipidemia, total left hip replacement, and recent provoked deep venous thromboembolism (DVT). She was seen by a pharmacist in a primary care clinic after her discharge from a skilled nursing facility. The patient was experiencing symptoms of gender dysphoria after discontinuation of her estradiol in setting of her DVT. Assessment Her renal function was calculated to ensure she was on appropriate dosing of her medications. Because her DVT was provoked, providers determined she would require only 3 months of anticoagulation. Her laboratory test results showed a subtherapeutic estradiol level and her estradiol was restarted. Additionally, aspirin was being prescribed for primary prevention of atherosclerotic cardiovascular disease and was discontinued. Outcome She has significant improvement in her gender dysphoria symptoms with resuming her estradiol and now has a therapeutic estradiol level. She is tolerating her direct oral coagulant well and reports good quality of life. Conclusion When reviewing medications for patients it is important to take several factors into account, including dose, appropriate indication, and patient preference. Pharmacists play a key role, through collaboration with providers, in assessing these medication-specific factors. Estradiol was stopped in this patient because of her DVT, but given her DVT was provoked after a recent surgery, it was unlikely that estradiol was the cause of her clot. Weighing the risks and benefits for any patient is important when determining what medications are appropriate to continue. Additionally, calculating renal function appropriately in a gender-non-conforming patients ensures appropriate and safe dosing.

Estimating the Impact of Hospital-Level Variation on the Use of Inpatient Rehabilitation Facilities Versus Skilled Nursing Facilities on Individual Patients With Stroke.

There is substantial hospital-level variation in the use of Inpatient Rehabilitation Facilities (IRFs) versus Skilled Nursing Facilities (SNFs) among patients with stroke, which is poorly understood. Our objective was to quantify the net effect of the admitting hospital on the probability of receiving IRF or SNF care for individual patients with stroke. Using Medicare claims data (2011-2013), a cohort of patients with acute stroke discharged to an IRF or SNF was identified. We generated 2 multivariable logistic regression models. Model 1 predicted IRF admission (versus SNF) using only patient-level factors, whereas model 2 added a hospital random effect term to quantify the hospital effect. The statistical significance and direction of the random effect terms were used to categorize hospitals as being either IRF-favoring, SNF-favoring, or neutral with respect to their discharge patterns. The hospital's impact on individual patient's probability of IRF discharge was estimated by taking the change in individual predicted probabilities (change in individual predicted probability) between the 2 models. Hospital-level effects were categorized as small (<10%), moderate (10%-19%), or large (≥20%) depending on change in individual predicted probability. The cohort included 135 415 patients (average age, 81.5 [SD=8.0] years, 61% female, 91% ischemic stroke) who were discharged from 1816 acute care hospitals to IRFs (n=66 548) or SNFs (n=68 867). Half of hospitals were classified as being either IRF-favoring (n=461, 25.4%) or SNF-favoring (n=485, 26.7%) with the remainder (n=870, 47.9%) considered neutral. Overall, just over half (n=73 428) of patients were treated at hospitals that had moderate or large independent effects on discharge settings. Hospital effects for neutral hospitals were small (ie, change in individual predicted probability <10%) for most patients (72.5%). However, hospital effects were moderate or large for 78.8% and 84.6% of patients treated at IRF- or SNF-favoring hospitals, respectively. For most patients with stroke, the admitting hospital meaningfully changed the type of rehabilitation care that they received.

A Novel Preoperative Risk Score to Identify Patients at High Risk for Nonhome Discharge after Elective Open Abdominal Aortic Aneurysm Repair

Non-home discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its impact on patients. For home-dwelling patients undergoing elective surgery, the need for postoperative NHD can have meaningful implications on quality of life, long-term outcomes, and healthcare spending. Understanding post-surgical NHD risk is essential to preoperative counseling and shared decision making. This is particularly true for the treatment of abdominal aortic aneurysms as the postoperative course can vary between open and endovascular surgery. We aimed to identify independent predictors of NHD following elective open abdominal aortic aneurysm repair (OAR), and to create a clinically useful preoperative risk score. Elective OAR cases were queried from the SVS Vascular Quality Initiative from years 2013-2022. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed. Overall, 8,274 patients were included and 1,502 (18.2%) required NHD. At baseline, patients who required NHD were more likely to be ≥ 80 years old (23.6% vs. 6.5%), female (35.9% vs. 23.1%), not independently ambulatory (14.6% vs. 4.3%), anemic (24.4% vs. 13.9%), have COPD (41.6% vs. 30.7%), ASA class ≥ 4 (41.0% vs. 32.5%), and a supraceliac proximal clamp (9.8% vs. 5.7%; all P<0.05). Multivariable analysis in the development group identified the following independent predictors of NHD: age ≥ 80 years, not independently ambulatory, proximal clamp location, hypogastric artery occlusion, anemia (Hb <12 g/dL), chronic obstructive pulmonary disease, female sex, hypertension, and American Society of Anesthesiologists class ≥ 4. These were then used to create a 14-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-4 points; n=4,966) with an NHD rate of 9.9%, moderate risk (5-6 points; n=2,442) with an NHD rate of 25.5%, and high risk (≥ 7 points; n=886) with an NHD rate of 44.6%. The risk score had good predictive ability with c-statistic=0.73 for model development and c-statistic=0.72 in the validation dataset. This novel risk score can predict NHD following elective OAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Elevated care at home: An alternative to traditional levels of care.

Elevated care at home (ECH) is a novel in-home care model supporting early hospital discharge and providing an alternative to institutional postacute care. This study compares patient characteristics, mortality, and readmission outcomes of hospitalized patients who transitioned to ECH to patients who transitioned to skilled nursing facilities (SNF) and skilled home health services (SHH). A retrospective study of patients between May 2020 and January 2022 transitioned from the hospital to ECH, SNF, or SHH. The analysis compared patient characteristics, 30-day mortality, and readmission stratified by COVID-19 infection status. Outcomes were assessed using logistic regression after propensity score matching. Of 32,132 eligible patients, 6.3% were transitioned to ECH, 39.7% to SNF, and 54.0% to SHH. After matching, all baseline characteristics except for age were balanced between groups. Postmatch and adjusting for age differences, ECH patients experienced lower risk of death compared to SNF (adjusted odds ratio [AOR] 0.61, 95% confidence interval [CI] 0.40, 0.92) and similar risk of hospital readmission compared to SNF patients (AOR 1.08, 95% CI 0.89, 1.31) and SHH patients (AOR 0.96, 95% CI 0.80, 1.16). COVID-19-negative ECH patients compared to matched SNF patients were more likely to readmit (AOR 1.30, 95% CI 1.02, 1.65) with no significant difference in risk of mortality (AOR 0.72, 95% CI 0.44, 1.18). ECH had similar or improved outcomes relative to SNF and SHH. COVID-19-negative ECH patients experienced higher readmissions relative to SNF. ECH supported patients to return home from the hospital and provided an alternative to an institutional postacute setting.

Physical and Cognitive Function Trends in Post-acute Care after Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018

ObjectivesPhysical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018. DesignObservational study using Medicare enrollment, claims, and assessment data from 2013–2018. Setting and Participants1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018. MethodsMedicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013–2018) by estimating multivariable models that controlled for patient- and hospital-level covariates. ResultsMultivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)–21.57% (2018), P < .001], HHA increased (46.72%–72.47%, P < .001), and IRF decreased (9.13%–5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)–14.23 (2018), P < .001] and cognitive impairment (13.25%–12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09–3.94, P < .001) and cognitive impairment (13.95%–16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81–37.78, P < .001) and cognitive dependence increased (39.08%–46.36%, P < .001), indicating greater dependence. Conclusions and ImplicationsFrom 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Testing the Psychometric Properties of the Readiness for Hospital Discharge Scale Among Residents in Skilled Nursing Facilities: A Pilot Study.

Background and Purpose: The Readiness for Hospital Discharge Scale (RHDS) was created to determine the patient's readiness for discharge to home from the hospital. The purpose of this study is to determine the scale's internal consistency and predictive validity in a skilled nursing facility (SNF) setting. Methods: Participants (N = 30) over the age of 65 were conveniently selected from 10 different SNFs in the Midwest to complete the RHDS prior to discharge. Results: Cronbach's alpha for internal consistency was 0.917. Participants with higher RHDS scores, those who were male, respondents with less education, and participants with Medicare Advantage insurance were more likely to be rehospitalized within 30 days of discharge to home. Conclusions: The results indicate that the RHDS has a good internal consistency in the SNF setting.

Investigating the relationship between sagittal spinal curvature and fall incidence and fall risk among elderly nursing home residents.

Poor balance is an underlying cause of falling in the elderly, for which a change in the natural curvature of the spine plays a major role. Little is known about the relationship between spinal curvatures and fall incidence in this population. We primarily aimed to investigate the relationship between sagittal plane spinal curvatures and fall incidence over 1year among nursing facility residents. Secondarily, we aim to determine associations of sagittal plane spinal curvatures with participants' perception of fall risk and balance capability. Participants (100 residents mean age 70.17 ± 6.01years) underwent standing measures of sagittal plane spinal curvatures (flexible ruler technique) and forward displacement of the head relative to the cervical spine. The Tinetti Performance Oriented Mobility Assessment (POMA) and Fall Efficacy Scale assessed participants' perception of balance and fear of falling. Incident falls were self-reported monthly and tracked across 1year. Spearman's correlations and logistic regression evaluated associations between fall incidence and spinal curvature. Predictive performance of spinal curvature and fall risk was determined by the corresponding ROC for defining a cut-off for variables of spinal curvature and fall risk indicators. Predictive performance of spinal curvature and fall risk factors indicated 84% and 77% of participants were correctly classified using models of kyphosis and head angle, respectively. Our study adds new data on spinal curvatures and incident falls among nursing facility residents. Efforts are needed to intervene to counter progression of spinal curvatures and improve fall prevention practices.

Trends in Post-Acute Care use in Medicare Advantage Versus Traditional Medicare: A Retrospective Cohort Analysis

ObjectivesWe sought to describe national trends in hospitalization and post-acute care utilization rates in skilled nursing facilities (SNFs) and home health (HH) for both Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries, reaching up to the COVID-19 pandemic (2015–2019). DesignRetrospective, observational using 100% sample of Medicare Provider Analysis and Review file (MedPAR), the Medicare Beneficiary Summary File, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS). Setting and ParticipantsMedicare beneficiaries aged 66 and older enrolled in MA or TM who were hospitalized and discharged alive. MethodsWe first calculated the proportions of MA and TM beneficiaries who were hospitalized and who used any post-acute care, as well as the total number of days of post-acute care used. We also calculated the size of the post-acute care network used by TM and MA beneficiaries within each hospital in our sample and the measured quality (star ratings) of the post-acute care providers used. ResultsWe found hospitalizations, SNF stays, and HH stays were all decreasing over time in both populations. Although similar proportions of MA and TM beneficiaries received SNF or HH care, MA beneficiaries received fewer days. The largest difference we found was in the number of post-acute care providers used in TM and MA, with MA using far fewer; however, quality ratings were similar among post-acute care providers used in each program. Conclusions and ImplicationsTogether, these results suggest MA beneficiaries have fewer days in post-acute care, receive care from fewer providers of similar measured quality to TM, but have a similar number of days outside the hospital or SNF in the first 100 days after hospital discharge.

Hospitals' strategies to reduce costs and improve quality: survey of hospital leaders.

Hospitals in the US operate under various value-based payment programs, but little is known regarding the strategies they use in this context to improve quality and reduce costs, overall or in voluntary programs including Bundled Payments for Care Improvement Advanced (BPCI-A). A survey was administered to hospital leaders at 588 randomly selected acute care hospitals, with oversampling of BPCI-A participants, from November 2020 to June 2021. Twenty strategies and 20 barriers were queried in 4 domains: inpatient, postacute, outpatient, and community resources for vulnerable patients. Summary statistics were tabulated, andresponses were adjusted for sampling strategy andnonresponse. There were 203 respondents (35%), of which 159 (78%) were BPCI-A participants and 44 (22%) were nonparticipants. On average, respondents reported implementing 89% of queried strategies in the inpatient domain, such as care pathways or predictive analytics; 65% of postacute strategies, such as forming partnerships with skilled nursing facilities; 84% of outpatient strategies, such as scheduling close follow-up to prevent emergency department visits/hospitalizations; and 82% of strategies aimed at high-risk populations, such as building connections with community resources. There were no differences between BPCI-A and non-BPCI-A hospitals in 19 of 20care redesign strategies queried. However, 78.3% of BPCI-A-participating hospitals reported programs aimed at reducing utilization of skilled nursing and inpatient rehabilitation facilities compared with 37.6% of non-BPCI-A hospitals(P < .0001). Hospitals pursue a broad range of efforts to improve quality. BPCI-A hospitals have attempted to reduce use of postacute care, but otherwise the strategies they pursue are similar to other hospitals.