Nursing Home Days Research Articles

Social Determinants of Health and Healthcare Utilization Disparities among Older Adults with and Without Cognitive Impairment.

The purpose of this study was to determine the healthcare utilization patterns in a national sample of older adults across several social determinants of health factors (ethnicity, gender, race, education) with normal and dementia/impaired cognition. We used datasets from the Health and Retirement Study (HRS, 2018) to evaluate healthcare utilization, including metrics such as hospital and nursing home stays, hospice care, and number of visits to the doctor. Logistic models were used to predict healthcare utilization separately in those with normal cognition and dementia. Our final sample comprised 15,607 adults (mean age: 65.2 normal cognition, mean age 71.5 dementia). Hispanics with normal cognition were less likely to stay in a hospital than non-Hispanic respondents (OR: 0.52-0.71, p<0.01). Being female was associated with a higher risk for shorter nursing home days (OR: 1.41, p<0.01) and doctor visits (OR: 1.63-2, p<0.01) in cognitively normal older adults. Being female was associated with a lower risk for hospital stay in those with dementia (OR: 0.50-0.78, p<0.01). Respondents identifying as Black or other races with dementia were less likely to experience nursing home days (OR: 0.42, p<0.04). Black respondents with normal cognition were less likely to experience doctor visits (OR: 0.32-0.37, p<0.01). Those with more than a high school education in both groups were more likely to experience doctors' visits. The study points to the continued disparities in healthcare utilization linked to participants' social determinants of health factors and cognition.

Evaluating the relationship between facility Age-Friendly recognition and subsequent facility-free days in older Veterans.

Thousands of health systems have been recognized as "Age-Friendly" for implementing geriatric care practices aligned with the "4Ms" (What Matters, Medication, Mentation, and Mobility). However, the effect of Age-Friendly recognition on patient outcomes is largely unknown. We sought to identify this effect in the Veterans Health Administration (VHA)-one of the largest Age-Friendly integrated health systems in the United States. There were 50 VA medical centers (VAMCs) recognized as Age-Friendly by December 2021. We used a time-event difference-in-difference analysis to identify the association of a VAMC's recognition as Age-Friendly on the change in facility-free days (days outside the hospital or nursing home) among Veterans treated at that facility. We also evaluated this association in three subgroups: Veterans at particularly high risk of nursing home entry, Veterans who lived within 10 miles of a medical center, and facilities that had reached Level 2 Age-Friendly recognition. We also evaluated individual components of the endpoint in terms of change in hospital and nursing home days separately. We found Age-Friendly recognition was associated with small statistically significant improvements in facility-free days (0.2% on a base of 97% facility-free days on average per year, or an additional 0.73 days per year on a base of 354 days). There were no differences in any subgroup, or any individual component of the endpoint across all groups. At the individual level, an increase of 0.2% in facility-free days is a weak effect. However, sites were early in implementation, and facility-free days may not be a responsive outcome measure. However, across an entire population, small changes in facility-free days may accrue large cost savings. Future evaluations should consider a broader variety of process and outcome measures.

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia.

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

The relationship of age and comorbid conditions to hospital and nursing home days in Medicaid recipients with HIV.

To determine how aging impacts healthcare utilization in persons with HIV (PWH) compared with persons without HIV (PWoH). Matched case-control study. We studied Medicaid recipients in the United States, aged 18-64 years, from 2001 to 2012. We matched each of 270 074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth. We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for female and male individuals, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for female individuals and 0.4 extra days for male individuals. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55 years, this represents an 81% increase in the nursing home DPM for male individuals, and a 110% increase for female individuals, compared PWoH. Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared with PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.

Diversity of sociodemographic backgrounds and healthcare utilization in cognitively impaired older adults

AbstractBackgroundWith increasing life expectancy, cognitive impairments have become an important public health issue worldwide and in the U.S. Socioeconomically‐disadvantaged populations, including racial/ethnic minorities, are more vulnerable as they have higher rates of underlying conditions and cognitive impairments, such as Alzheimer’s disease and related dementia. With progressive impairments in cognition, behavior, and functionality, patients, families, and healthcare systems face challenges associated with healthcare, including increased costs of care for emergency department visits, hospitalizations, and revisit rates. Our purpose was to examine the relationships between sociodemographic variables and healthcare utilization in older adults with cognitive impairment.MethodThe Health and Retirement Study (HRS), Rand data (2014), were used to understand sociodemographic predictors of healthcare utilization (hospital stay days, nursing home days, home care days, and numbers of doctor’s visits). Due to the skewness of the data, we grouped each category for the length of healthcare utilization into never, short, medium, and long. Only those persons with dementia or impaired cognition were included.ResultOf the 3,924 older adults from the HRS sample, 22% had a diagnosis of dementia and 78% had impaired cognition. Ethnicity, education, and age were significantly associated with the length of hospital stay. Hispanics and those with lower education and younger were less likely to use long hospital stays than others. Ethnicity, marital status, gender, and age were predictors of nursing home length of stay. Blacks, Hispanics, men, and married and younger respondents were less likely to stay long in nursing homes. Blacks and younger respondents were less likely to have long home care utilization. Race, ethnicity, rurality, gender, education, and age were predictors of doctor’s visits. Blacks, Hispanics, rural residents, men, those with lower education, and younger had fewer doctor’s visits. Race, ethnicity, and education were consistent predictors across utilization types.ConclusionThis study provides evidence of the need to understand how older adults with cognitive impairments and multiple marginalized identities (i.e., age, gender, race, ethnicity) can access and use healthcare. This study is important to provide the groundwork for further studies to explore the intersectionality of healthcare utilization and socioeconomic status in patients with cognitive impairments.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia

New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care. To evaluate changes in nursing home use among older adults with dementia following MLTC implementation. This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019. Mandatory MLTC enrollment. Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators. This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year). The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Can a Home-Based Collaborative Care Model Reduce Health Services Utilization for Older Medicaid Beneficiaries Living with Depression and Co-occurring Chronic Conditions? A Quasi-experimental Study.

Depression remains a major public health issue for older adults, increasing risk of costly health services utilization. While home-based collaborative care models (CCM) like PEARLS have been shown to effectively treat depression in low-income older adults living with multiple chronic conditions, their economic impact is unclear. We conducted a quasi-experimental study to estimate PEARLS effect on health service utilization among low-income older adults. Our secondary data analysis merged de-identified PEARLS program data (N = 1106), home and community-based services (HCBS) administrative data (N = 16,096), and Medicaid claims and encounters data (N = 164) from 2011 to 2016 in Washington State. We used nearest neighbor propensity matching to create a comparison group of social service recipients similar to PEARLS participants on key determinants of utilization guided by Andersen's Model. Primary outcomes were inpatient hospitalizations, emergency room (ER) visits, and nursing home days; secondary outcomes were long-term supports and services (LTSS), mortality, depression and health. We used an event study difference-in-difference (DID) approach to compare outcomes. Our final dataset included 164 older adults (74% female, 39% people of color, mean PHQ-9 12.2). One-year post-enrollment, PEARLS participants had statistically significant improvements in inpatient hospitalizations (69 fewer hospitalizations per 1000 member months, p = 0.02) and 37 fewer nursing home days (p < 0.01) than comparison group participants; there were no significant improvements in ER visits. PEARLS participants also experienced lower mortality. This study shows the potential value of home-based CCM for participants, organizations and policymakers. Future research is needed to examine potential cost savings.

108. Evaluation of the Impact of Dalbavancin Usage on Clinical Outcomes, Cost-Savings, and Adherence at a Large Safety Net Hospital

BackgroundDalbavancin is a long-acting second-generation lipoglycopeptide antibiotic with potent activity against Gram-positive organisms. Dalbavancin is currently FDA approved for acute bacterial skin and soft tissue infections (ABSSTIs). Growing evidence suggests that patients can be successfully treated with dalbavancin for indications outside of skin and soft tissue infections which include bacteremia and osteomyelitis (OM) with significant cost savings and reduced length of stay. We developed a protocol for the use of dalbavancin in patients who required intravenous antibiotics for serious bacterial infections but did not qualify for outpatient parenteral antibiotic therapy (OPAT). During the COVID-19 pandemic, we expanded the protocol to reduce the amount of clinical contact required for all patients.MethodsIn this retrospective observational study, we reviewed all patients that received at least one dose of dalbavancin in either inpatient or outpatient setting at Parkland Hospital from July 2019 through February 2021. Patient demographics, type of infection, and rationale for dalbavancin were collected at baseline. Clinical response was measured by avoidance of Emergency Department (ED) visits or hospital readmission at 30, 60, and 90 days. In addition, a separate analysis was conducted to estimate hospital, rehabilitation, or nursing home days saved based on their diagnosis and projected length of treatment. ResultsTwenty-eight patients (24 inpatient, 4 outpatient) were included in the study. The majority were uninsured (89%), homeless (64%), or had active intravenous drug use (IDU) (60%). Indications for use included SSTI (42.9%), bacteremia (64.3%), and OM (42.6%). Clinical failure was observed in 4 (14%), 1 (3.5%), and 2 (7.1%) patients at 30, 60, or 90 days (respectively). Nonadherence to medical recommendations, lack of source control, and ongoing IDU increased risk of returning to the hospital. Dalbavancin use saved a total of 381 days of inpatient/rehab/facility stay. Baseline Characteristics of Patients Types of Infections and Microbiology ED Visit or Readmissions at 30, 60, or 90 DaysConclusionDalbavancin showed similar rates of success with improved length of stay and cost savings. The use of long acting lipoglycopeptides are desirable alternatives to traditional OPAT for patients that otherwise would not qualify for OPAT or desire less hospital contact.Disclosures All Authors: No reported disclosures

Time Spent Away from Home in the Year Following High-Risk Cancer Surgery in Older Adults.

To understand where older adults spend time (at home, in the hospital, or in a nursing home) in the year following high-risk cancer surgery. Retrospective cohort study. Medicare beneficiaries using data from Medicare Inpatient claims to ascertain hospital days and the Minimum Data Set to ascertain nursing home days. Beneficiaries who underwent high-risk cancer surgery (cystectomy, pancreaticoduodenectomy, gastrectomy, or esophagectomy) were identified to determine cumulative time spent away from home in the year following surgery. Adjusted percentages of time spent away from home (ie, days in a hospital or nursing home) were modeled for the year following surgery. A total of 37 748 beneficiaries underwent high-risk cancer surgery during the study period, and 28.3% died within 1 year. Overall, beneficiaries spent 13.9 ± 26.2 days in the hospital (over 1.5 ± 2.0 hospital readmissions) and 37.2 ± 50.6 days in the nursing home (over 1.5 ± 1.0 admissions) in the year following surgery. Among beneficiaries who were alive and dead at 1 year, 18.5% and 30.1% of time was spent away from home, respectively. Beneficiaries who were initially discharged to a facility following surgery and died within 1 year spent 44.4% of their final year away from home. Time spent away from home in the hospital and/or nursing home in the year following high-risk cancer surgery is substantial among Medicare beneficiaries. This information is crucial in counseling patients on postoperative expectations and may additionally influence preoperative decision making. J Am Geriatr Soc 68:505-510, 2020.

Constructing a Measure of Private-pay Nursing Home Days.

Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population. To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity. Retrospective descriptive analysis of US NHs in 2007-2009. We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics. Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities. This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

Algorithm for Identifying Nursing Home Days Using Medicare Claims and Minimum Data Set Assessment Data.

No consensus exists about methods of measuring nursing home (NH) length-of-stay for Medicare beneficiaries to identify long-stay and short-stay NH residents. To develop an algorithm measuring NH days of stay to differentiate between residents with long and short stay (≥101 and <101 consecutive days, respectively) and to compare the algorithm with Minimum Data Set (MDS) alone and Medicare claims data. We linked 2006-2009 MDS assessments to Medicare Part A skilled nursing facility (SNF) data. This algorithm determined the daily NH stay evidence by MDS and SNF dates. NH length-of-stay and characteristics were reported in the total, long-stay, and short-stay residents. Long-stay residents identified by the algorithm were compared with the NH evidence from MDS-alone and Medicare parts A and B data. Of 276,844 residents identified by our algorithm, 40.8% were long stay. Long-stay versus short-stay residents tended to be older, male, white, unmarried, low-income subsidy recipients, have multiple comorbidities, and have higher mortality but have fewer hospitalizations and SNF services. Higher proportions of long-stay and short-stay residents identified by the MDS/SNF algorithm were classified in the same group using MDS-only (98.9% and 100%, respectively), compared with the parts A and B data (95.0% and 67.1%, respectively). NH length-of-stay was similar between MDS/SNF and MDS-only long-stay residents (mean±SD: 717±422 vs. 720±441 d), but the lengths were longer compared with the parts A and B data (approximately 474±393 d). Our MDS/SNF algorithm allows the differentiation of long-stay and short-stay residents, resulting in an NH group more precise than using Medicare claims data only.

Abstract 185: Residual Stroke Morbidity and Post-acute Care Cost: the IMS III Economic Data Cohort

Introduction: The IMS III trial included 1-year follow-up with prospectively collected data on resource use after stroke. While the trial showed no difference in 90-day clinical outcomes by treatment group, this cohort provides invaluable information on cost variations associated with post-stroke morbidity. We report the effect of residual stroke morbidity on cost of stroke care after discharge at 12 months post stroke. Methods: Among 470 subjects with moderate to severe stroke for whom economic data were collected (316 randomized to IV t-PA and endovascular therapy, 154 to IV t-PA alone), we estimated cumulative cost post discharge using cost weights derived from a 5% sample of US Medicare patients in 2012 with an admission for acute ischemic stroke with IV t-PA treatment. Cost weights included post-stroke rehabilitation hospital days, emergency care visits, hospital readmissions, medical office visits, rehabilitation therapy visits and nursing home days. Costs were summed at the level of the subject and estimated for the subset defined by NIH Stroke Scale Score (NIHSS) at day 5, and Modified Rankin Score (mRS) and Barthel Index (BI) at 3 months post stroke. Subjects who died during the initial hospital admission or who had no score at day 5 or at 3 months were not included in our analysis. Age-adjusted, log-transformed costs were compared. Results: There was a 6 fold difference in the cost of follow-up care by lowest and highest NIHSS at day 5 (p&lt;.0001). Similarly large differences by outcome category were observed for both the mRS (p&lt;.0001) groups and subjects defined by the BI (p&lt;.0001) at 3 months (see Figure). Conclusion: Residual stroke morbidity has a large effect on the long-term cost of stroke care, with an effect size of over 600%. Interventions that improve the residual morbidity after stroke as early as day 5 may be expected to result in substantial post discharge cost savings.

The high price of obesity in nursing homes.

This article provides a commentary on the costs of obese nursing home patients. We conducted a comprehensive literature search, which found 46 relevant articles on obesity in older adults and effects on nursing home facilities. This review indicated obesity is increasing globally for all age groups and older adults are facing increased challenges with chronic diseases associated with obesity more than ever before. With medical advances comes greater life expectancy, but obese adults often experience more disabilities, which require nursing home care. In the United States, the prevalence of obesity in adults aged 60 years and older increased from 9.9 million (23.6%) to 22.2 million (37.0%) in 2010. Obese older adults are twice as likely to be admitted to a nursing home. Many obese adults have comorbidities such as Type 2 diabetes; patients with diabetes incurred 1 in every 4 nursing home days. Besides the costs of early entrance into nursing facilities, caring for obese residents is different than caring for nonobese residents. Obese residents have more care needs for additional equipment, supplies, and staff costs. Unlike emergency rooms and hospitals, nursing homes do not have federal requirements that require them to serve all patients. Currently, some nursing homes are not prepared to deal with very obese patients. This is a public health concern because there are more obese people than ever in history before and the future appears to have even a heavier generation moving forward. Policymakers need to become aware of this serious gap in nursing home care.

Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings

BackgroundThe optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings.MethodsEighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). Participants: 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. Outcome measures: Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson’s χ2, ANCOVA, Regression and Kaplan-Meier analyses.ResultsOverall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455–4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066–16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR.ConclusionsAt 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model.Trial registrationClinicaltrials.gov ID NCT01457300

Body Mass Index and the Impact of a Health Promotion Intervention on Health Services Use and Expenditures

To examine the effect of body mass index (BMI) on the impact of a health promotion intervention on health services use and expenditures among Medicare beneficiaries with disabilities. We analyzed data from 452 Medicare beneficiaries who participated in a Medicare demonstration. The intervention included the following components: patient education, health promotion coaching, medication management, and physician care management. We performed the analysis by using generalized linear models (GLM) to examine the impact of BMI and the intervention on total health care expenditures. The intervention was cost neutral over the 2-year study period. Participants in the intervention group used less home health aide services (p = .03) and had fewer nursing home days (p = .05). The intervention appeared to have smaller effects on expenditures as BMI level increased. The findings suggest that a health promotion intervention may achieve better beneficiary outcomes without an increase in resource use in this Medicare population.

The cost-effectiveness of a new disease management model for frail elderly living in homes for the elderly, design of a cluster randomized controlled clinical trial.

BackgroundThe objective of this article is to describe the design of a study to evaluate the clinical and economic effects of a Disease Management model on functional health, quality of care and quality of life of persons living in homes for the elderly.MethodsThis study concerns a cluster randomized controlled clinical trial among five intervention homes and five usual care homes in the North-West of the Netherlands with a total of over 500 residents. All persons who are not terminally ill, are able to be interviewed and sign informed consent are included. For cognitively impaired persons family proxies will be approached to provide outcome information. The Disease Management Model consists of several elements: (1) Trained staff carries out a multidimensional assessment of the patients functional health and care needs with the interRAI Long Term Care Facilities instrument (LTCF). Computerization of the LTCF produces immediate identification of problem areas and thereby guides individualized care planning. (2) The assessment outcomes are discussed in a Multidisciplinary Meeting (MM) with the nurse, primary care physician, nursing home physician and Psychotherapist and if necessary other members of the care team. The MM presents individualized care plans to manage or treat modifiable disabilities and risk factors. (3) Consultation by an nursing home physician and psychotherapist is offered to the frailest residents at risk for nursing home admission (according to the interRAI LTCF). Outcome measures are Quality of Care indicators (LTCF based), Quality Adjusted Life Years (Euroqol), Functional health (SF12, COOP-WONCA), Disability (GARS), Patients care satisfaction (QUOTE), hospital and nursing home days and mortality, health care utilization and costs.DiscussionThis design is unique because no earlier studies were performed to evaluate the effects and costs of this Disease Management Model for disabled persons in homes for the elderly on functional health and quality of care.Trail registration numberISRCTN11076857

S2-05-02: A randomized trial of a coordinated care management intervention to improve quality and outcomes of dementia care

patients received collaborative care led by an advanced practice nurse who worked with the primary care physician, the patient’s caregiver, and the dementia specialists to provide guideline-level care. Therapies focused on non-pharmacologic management of behavioral disturbances. Treatment protocols were supervised by clinicians with expertise in dementia care and followed standard of care for pharmacotherapy. Usual care patients received a formal diagnosis and education program and referral to community services. We combined clinical trial data from 100 low-income older adults with AD with longitudinal data from an electronic medical record to compare three-year outcomes for mortality and health services use among the experimental groups. Results: The average patient age was 77 and the mean MMSE score among this cohort was 17.5 at baseline. Patients suffered from a high burden of comorbid conditions and less than 20% had a spouse-caregiver. Only 55% of the caregiver’s lived with the patient. Although patients in the intervention group (n 55) had significantly better NPI scores at 18 months compared with controls (n-45), we found no difference in 3-year mortality rates (20% v 29%), hospitalization rates (40% v 47%), mean LOS (5.4 v 7), emergency department utilization rate (82% v 78%), Medicaid nursing home rates (9% v. 18%) or mean total Medicaid nursing home days (39 v. 51). Conclusions: Care for older adults with Alzheimer’s disease is fragmented across multiple providers and site of care. These patients are high utilizers of acute care services. Collaborative care based in primary care can improve quality of care and behavioral disturbances and hold promise for decreasing utilization. However, these interventions will need to be broadened in scope, impact, and reach in order to promote implementation.

S2-05-01: Beyond primary care: Improving the impact and reach of collaborative care models for Alzheimer's disease

Most older adults with Alzheimer's disease are cared for by primary care physicians. Recent collaborative care models demonstrate the capacity to improve the process and outcomes of care in primary care. However, these models still suffer from limited impact and reach. We recently reported the results of a controlled clinical trial that tested the effectiveness of collaborative care for older adults with Alzheimer's disease. All enrolled patients met diagnostic criteria for AD. Intervention patients received collaborative care led by an advanced practice nurse who worked with the primary care physician, the patient's caregiver, and the dementia specialists to provide guideline-level care. Therapies focused on non-pharmacologic management of behavioral disturbances. Treatment protocols were supervised by clinicians with expertise in dementia care and followed standard of care for pharmacotherapy. Usual care patients received a formal diagnosis and education program and referral to community services. We combined clinical trial data from 100 low-income older adults with AD with longitudinal data from an electronic medical record to compare three-year outcomes for mortality and health services use among the experimental groups. The average patient age was 77 and the mean MMSE score among this cohort was 17.5 at baseline. Patients suffered from a high burden of comorbid conditions and less than 20% had a spouse-caregiver. Only 55% of the caregiver's lived with the patient. Although patients in the intervention group (n=55) had significantly better NPI scores at 18 months compared with controls (n-45), we found no difference in 3-year mortality rates (20% v 29%), hospitalization rates (40% v 47%), mean LOS (5.4 v 7), emergency department utilization rate (82% v 78%), Medicaid nursing home rates (9% v. 18%) or mean total Medicaid nursing home days (39 v. 51). Care for older adults with Alzheimer's disease is fragmented across multiple providers and site of care. These patients are high utilizers of acute care services. Collaborative care based in primary care can improve quality of care and behavioral disturbances and hold promise for decreasing utilization. However, these interventions will need to be broadened in scope, impact, and reach in order to promote implementation.

Providing All‐Inclusive Care for Frail Elderly Veterans: Evaluation of Three Models of Care

Frail elderly veterans aged 55 and older who met state nursing home admission criteria were enrolled in one of three models of all-inclusive long-term care (AIC) at three Veterans Affairs (VA) medical centers (n=386). The models included: VA as sole care provider, VA-community partnership with a Program of All-inclusive Care for the Elderly (PACE), and VA as care manager with care provided by PACE. Healthcare use was monitored for 6 months before and 6 to 36 months after enrollment using VA, DataPACE, and Medicare files. Hospital and outpatient care did not differ before and after AIC enrollment. Only 53% of VA sole-provider patients used adult day health care (ADHC), whereas all other patients used ADHC. Nursing home days increased, but permanent institutionalization was low. Thirty percent of participants died; of those still enrolled in AIC, 92% remained in the community. VA successfully implemented three variations of AIC and was able to keep frail elderly veterans in the community. Further research on providing variations of AIC in general is warranted.

Kenosha County Falls Prevention Study: A Randomized, Controlled Trial of an Intermediate‐Intensity, Community‐Based Multifactorial Falls Intervention

To decrease the rate of falls in high-risk community-dwelling older adults. Randomized, controlled trial. Community-based. Three hundred forty-nine adults aged 65 and older with two falls in the previous year or one fall in the previous 2 years with injury or balance problems. Subjects received two in-home visits from a trained nurse or physical therapist who assessed falls risk factors using an algorithm. The intervention consisted of recommendations to the subject and their primary physician, referrals to physical therapy and other providers, 11 monthly telephone calls, and a balance exercise plan. Control subjects received a home safety assessment. The primary outcome was rate of falls per year in the community. Secondary outcomes included all-cause hospitalizations and nursing home admissions per year. There was no difference in rate of falls between the intervention and control groups (rate ratio (RR)=0.81, P=.27). Nursing home days were fewer in the intervention group (10.3 vs 20.5 days, P=.04). Intervention subjects with a Mini-Mental State Examination (MMSE) score of 27 or less had a lower rate of falls (RR=0.55; P=.05) and, if they lived with someone, had fewer hospitalizations (RR=0.44, P=.05), nursing home admissions (RR=0.15, P=.003), and nursing home days (7.5 vs 58.2, P=.008). This multifactorial intervention did not decrease falls in at-risk community-living adults but did decrease nursing home utilization. There was evidence of efficacy in the subgroup who had an MMSE score of 27 or less and lived with a caregiver, but validation is required.