Post-acute Care Services Research Articles

Post-acute Ambulatory Care Service Use Among Patients Discharged Home After Stroke or TIA: The Cluster-randomized COMPASS Study.

We examined transitional care management within 90 days and 1 year following discharge home among acute stroke and transient ischemic attack patients from the Comprehensive Post-Acute Stroke Services (COMPASS) Study, a cluster-randomized pragmatic trial of early supported discharge conducted in 41 hospitals (40 hospital units) in North Carolina, United States. Data for 2262 of the total 6024 (37.6%; 1069 intervention and 1193 usual care) COMPASS patients were linked with the Centers for Medicare and Medicaid Services fee-for-service Medicare claims. Time to the first ambulatory care visit was examined using Cox proportional hazard models adjusted for patient characteristics not included in the randomization protocol. Only 6% of the patients [mean (SD) age 74.9 (10.2) years, 52.1% women, 80.3% White)] did not have an ambulatory care visit within 90 days postdischarge. Mean time (SD) to first ambulatory care visit was 12.0 (26.0) and 16.3 (35.1) days in intervention and usual care arms, respectively, with the majority of visits in both study arms to primary care providers. The COMPASS intervention resulted in a 27% greater use of ambulatory care services within 1 year postdischarge, relative to usual care [HR=1.27 (95% CI: 1.14-1.41)]. The use of transitional care billing codes was significantly greater in the intervention arm as compared with usual care [OR=1.87 (95% CI: 1.54-2.27)]. The COMPASS intervention, which was aimed at improving stroke post-acute care, was associated with an increase in the use of ambulatory care services by stroke and transient ischemic attack patients discharged home and an increased use of transitional care billing codes by ambulatory providers.

Prevalence of Urinary Tract Infection and Health Outcomes in Older Adults Undergoing Hip Surgery: A Prospective Study

Urinary tract infections are complications found mostly in older adults undergoing hip surgery. However, little is known about the impact of urinary tract infections on health at after post-hip fracture surgery, particularly in Thailand. This prospective study investigated the prevalence of urinary tract infections and their impact on length of stay, functional ability, re-admission, surgical site infections, and in-hospital mortality. The participants were 120 older adults undergoing hip surgery at four tertiary care hospitals in Bangkok, Thailand. Instruments for collection the data were the Demographic Data Questionnaire, Health Outcome Data Record Form—length of hospital stays, surgical site infections, re-admission, and in-hospital mortality, and the Hip Disability and Osteoarthritis Outcome Score. Data were analyzed using descriptive statistics and Firth’s logistic regression. Results demonstrated that the prevalence of urinary tract infections was 28.32%. Significantly, older adults who developed urinary tract infections had a 2.88-fold increased the risk of impaired functional ability four weeks after surgery and a 3.21-fold increased the risk of re-admission to the hospital compared to those without urinary tract infections. Findings suggest that nurses should continually evaluate urinary tract infections and related factors from admission to post-discharge, as urinary tract infections profoundly affect health outcomes. Strict compliance with guidelines or strengthening post-acute care services to prevent urinary tract infections and its consequences is recommended to promote and restore health, especially functional ability in older adults undergoing hip surgery.

Suicide Risk in Post-COVID-19 Syndrome.

Post-acute sequelae of COVID-19 include several neuropsychiatric disorders. Little is known about the relationship between post-COVID-19 syndrome and suicidality. The aim of the study was to investigate the risk of suicide in subjects with persistent post-COVID-19 syndrome. One-thousand five-hundred eighty-eight subjects were assessed in the Post-Acute Care Service at the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS of Rome. Assessment included: (a) sociodemographic characteristics; (b) symptoms during and after COVID-19; (c) psychopathological evaluation. Participants were divided in those with (SUI) or without (NON SUI) suicide risk according to the Mini International Neuropsychiatric Interview. Additionally, subjects with SUI were split into those with high (HIGH SUI) and low (LOW SUI) suicide risk. Between-group comparisons were made with t-tests for continuous variables and χ2 tests for categorical variables. SUI showed greater percentages of physical complaints during and after COVID-19, greater percentages of psychiatric history and presence of psychiatric history in relatives, greater percentages of subjects previously undergoing psychopharmacotherapy, and greater levels of anxiety, mixed depressive symptoms, general psychopathology than NON SUI. HIGH SUI showed greater number of symptoms during and after COVID-19 and higher levels of mixed depressive symptoms than LOW SUI. Percentages of subjects undergoing psychotherapy was higher in LOW SUI than HIGH SUI. Greater levels of physical complaints and psychopathology during post-COVID-syndrome might enhance the risk of committing suicide. Treatment of physical complaints and psychotherapy might reduce suicide risk.

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19.

Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.

Predicting Readmission Risk During an Inpatient Rehabilitation Hospital Stay

<h3>Research Objectives</h3> To develop a readmission risk stratification tool identifying patients from our inpatient rehabilitation facility at highest risk of readmitting back to an acute care hospital. <h3>Design</h3> Retrospective cross sectional cohort of patients utilizing post-acute care services. <h3>Setting</h3> Inpatient rehabilitation hospital with a highly complex patient population. <h3>Participants</h3> Clinical data was extracted for 11,010 patients with admissions from January, 2018 to February, 2022. The most common patient primary diagnoses included Stroke (25.8%), Orthopedic (14.9%), Medically Complex (13.4%), Brain Injury (12.4%), and Nervous System (10.5%). <h3>Interventions</h3> Development of a post-acute readmission risk tool using machine learning methods. <h3>Main Outcome Measures</h3> The primary outcome was readmission to an acute care hospital during an inpatient rehabilitation hospital stay. Multi-variate logistic regression with backward selection was used to identify demographic, clinical and functional factors associated with readmission. Risk scores were calculated using variable estimates from our final model. Predictive factors were ranked and risk groupings were assigned according to the percentile of the patient's total risk score(Low:0-75%, Medium:75-90%, High:90-100%). Model performance was evaluated using the Area under the Receiver Operating Characteristic curve(AUC). Additional supervised machine learning models(Gradient Boosting, Random Forest, and Neural Network) are currently being developed and performance of these models will be compared to the current model. <h3>Results</h3> The factors most highly correlated with patient readmissions included 1)renal failure comorbidity 2)low score on self-care function 3)gastrointestinal bleeding comorbidity 4)pulmonary disorder primary diagnosis. When stratified into low, medium, and high risk groups, the percentages of patients' discharged to an acute care facility were 9.3%, 19.2% and 30.6%, respectively. The AUC was 0.675(95% CI 0.661, 0.690) for the logistic regression model. <h3>Conclusions</h3> Our readmission risk tool identifies risk factors predictive of patient readmissions during post-acute inpatient rehabilitation. Model performance is comparable to established acute care risk tools, however, additional machine learning methods will be used to reveal the model with best performance. Results from these models will drive clinical processes to account for patients' unique readmission risk profiles and related clinical needs at our inpatient rehabilitation hospital. <h3>Author(s) Disclosures</h3> No disclosures.

Predictors of Extreme Hospital Length of Stay After Traumatic Brain Injury

Hospital length of stay (HLOS) after traumatic brain injury (TBI) is an important metric of injury severity, resource utilization, and access to post-acute care services. Risk factors for protracted HLOS after TBI require further characterization. Data regarding adult inpatients admitted to a single U.S. level 1 trauma center with a diagnosis of acute TBI between August 1, 2019, and April 1, 2022, were extracted from the electronic health record. Patients with extreme HLOS (XHLOS, >99th percentile of institutional TBI HLOS) were compared with those without XHLOS. Socioeconomic status (SES), clinical/injury factors, and discharge disposition were analyzed. In 1638 patients, the median HLOS was 3 days (interquartile range [IQR]: 2-8 days). XHLOS threshold was >70 days (N= 18; range: 72-146 days). XHLOS was associated with younger age (XHLOS/non-XHLOS: 50.4/59.6 years; P= 0.042) and greater proportions with severe TBI (55.6%/11.4%; P < 0.001), low SES (72.2%/31.4%; P < 0.001), and Medicaid insurance (77.8%/30.1%; P < 0.001). XHLOS patients were more likely to die in hospital (22.2%/8.1%) and discharge to post-acute facility (77.8%/16.3%; P < 0.001). No XHLOS patients were discharged to home. In XHLOS patients alive at discharge, medical stability was documented at median 39 days (IQR: 28-58 days) and were hospitalized for another 56 days (IQR: 26.5-78.5 days). XHLOS patients were more likely to have severe injuries, low SES, and Medicaid. XHLOS is associated with in-hospital mortality and need for post-acute placement. XHLOS patients often demonstrated medical stability long before placement, underscoring complex relationships between SES, health insurance, and outcome. These findings have important implications for quality improvement and resource utilization at acute care hospitals and await validation from larger trials.

Comparison between the persistence of post COVID-19 symptoms on critical patients requiring invasive mechanical ventilation and non-critical patients.

During follow-up, patients severely affected by coronavirus disease 2019 (COVID-19) requiring invasive mechanical ventilation (IMV), show symptoms of Post-Intensive Care Syndrome (PICS) such as cognitive impairment, psychological disability, and neuromuscular deconditioning. In COVID-19 pandemic, it is a priority to develop multidisciplinary post-acute care services to address the long-term multisystemic impact of COVID-19. Which are the most relevant multisystemic sequelae in severe post-COVID-19 patients? Observational chart review study that included adult patients discharged from a referral hospital for respiratory diseases in Mexico after recovering from severe COVID-19 disease from December 23, 2020, to April 24, 2021. Data were collected from 280 of 612 potentially eligible patients to evaluate persistent symptoms and compare sequelae in patients who required intubation, using a standardized questionnaire of symptoms, in addition to findings reported during the face-to-face health assessment. Univariable and multivariate analyses were performed for the association among the requirement of IMV and the long-term persistence of symptoms. 280 patients were included. The median age was 55 (range, 19 to 86) years, and 152 (54.3%) were men. The mean length of hospital stay was 19 (SD, 14.1) days. During hospitalization 168 (60%) participants received IMV. A large proportion of these patients reported fatigue (38.7%), paresthesia (35.1%), dyspnea (32.7%) and headache (28%); meanwhile only 3 (1.8%) of them were asymptomatic. Patients who required intubation were more likely to have neuropsychiatric (67.3% vs 55.4%; OR, 1.79 [95% CI, 1.08 to 2.97]) and musculoskeletal involvement (38.7% vs. 25.9%; OR, 1.92 [95% CI, 1.12 to 3.27]), adjusted for age,sex and hospitalization time. The proportion of patients requiring intubation was 60%, reporting persistent symptoms in 98% of them. Neuropsychiatric and musculoskeletal symptoms were the most predominant symptoms in these patients, with a significant difference. Post-COVID-19 syndrome is a frequent problem in patients who required IVM. Physicians in ICU and in care of COVID-19 patients should be aware of this syndrome in order to avoid more complications.

Therapists Predict Discharge Destination More Accurately Than the AM-PAC “6 Clicks” at Evaluation and Discharge for Patients With Isolated Coronary Artery Bypass Graft

Background: Clinicians and hospital care coordinators seek effective tools to assist with reducing length of stay, delivering appropriate postacute care services, and reducing readmissions for patients following coronary artery bypass grafting (CABG) surgery. Objective: To evaluate whether the discharge recommendation by the Activity Measure for Post-Acute Care (AM-PAC) “6 Clicks” Inpatient Basic Mobility and Daily Activity Short Forms agreed with therapists' recommendation and actual discharge disposition for patients who underwent isolated CABG. Methods: Physical therapists (PTs) and occupational therapists (OTs) recorded their respective AM-PAC “6 Clicks” score on a cohort of consecutive patients admitted for isolated CABG between March and April 2020. The level of agreement was compared between AM-PAC-projected discharge disposition, therapists' recommendation, and actual discharge disposition. Results: There were 58 patients who received discharge recommendations from PTs and OTs following isolated CABG. Upon PT initial evaluation, the AM-PAC “6 Clicks” Basic Mobility tool recommended postacute placement in all 58 (100%) cases, whereas PTs recommended postacute placement for only 1 (2%). Similarly, the AM-PAC “6 Clicks” Daily Activity tool recommended postacute placement in all 58 (100%) cases, whereas OTs recommended discharge to home for 44 (76%) cases and recommended further assessment of discharge needs on the remaining 14 (24%). At the final session, the AM-PAC “6 Clicks” Basic Mobility tool recommended postacute placement in 56 (98%) cases and PTs recommended discharge to home in all 58 (100%) cases. The AM-PAC “6 Clicks” Daily Activity tool recommended postacute placement for 25 (43%) cases, whereas OTs recommended discharge to home for 55 (95%) cases. Nearly all (56; 97%) patients were discharged to home, with the remaining 2 (3%) discharged to postacute placement. The 30- day readmission rate was 2%. Conclusion: We found the PT/OT recommendations were strongly associated with discharge disposition, but that the AM-PAC “6 Clicks” scores had poor agreement with therapists' recommendations and with actual discharge dispositions for patients with isolated CABG. The utility of this tool should be explored in other cardiac patient populations, such as valve replacements with and without sternotomy, and heart failure, to corroborate the results.

Long-Term Care for Children With Medical Complexity: A Call for Data.

Long-Term Care for Children With Medical Complexity: A Call for Data.

Personal experiences of appropriate access to post-acute care services in acquired brain injury: a scoping review.

People with an acquired brain injury (ABI) experience substantial access inequalities and unmet health needs, with many experiencing insufficient access to appropriate rehabilitation in the community. To deepen our understanding of what appropriate access to post-acute care services is for this population, and to facilitate optimal recovery, there is a need to synthesise research from the service user perspective. A scoping review study was conducted to identify key characteristics of 'appropriate' access to post-acute care services, as defined by the personal experiences of adults with ABI. Electronic scientific databases Medline, PsycINFO, Proquest Central and CINAHL were searched for studies published between 2000 and 2020. The initial search identified 361 articles which, along with articles retrieved from reference list searches, resulted in 52 articles included in the final analysis. Results indicated that a majority of the studies sampled participants with an average of over 1 year post-injury, with some studies sampling participants ranging over 10 years in difference in time post-injury. A thematic synthesis was conducted and results indicated a number of dominant elements which relate to (1) the characteristics of services: provider expertise, interpersonal qualities, partnership and adaptability; (2) characteristics of the health system: navigable system, integrated care, adequacy, and opportunity. These findings provide some insight into what might be considered appropriate. However, rigorous research, focused on personalised access to post-acute care services, is recommended to verify and elaborate on these findings.

Abstract 31: One-year Mortality And Stroke Readmissions After Ischemic Stroke In Critical Access Hospitals

Background: Critical access hospitals (CAHs) provide emergency and inpatient care in rural communities. CAHs have higher 30-day mortality after stroke, but little is known about long-term outcomes. We compared 1-year outcomes after ischemic stroke for patients treated at CAHs versus other hospitals. Methods: We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke in 2015. Patients were followed 1 year for death or stroke recurrence, accounting for competing risks. We balanced characteristics between CAH and non-CAH patients using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year mortality and recurrent stroke weighted by the IPW. Results: There were 4,487 patients discharged with stroke from CAHs and 202,502 from non-CAHs. CAH vs non-CAH patients were older (mean age 82.8y vs 78.6y) and more often women (61.8% vs 53.9%), white (94.3% vs 83.7%), and dual Medicare-Medicaid eligible (21.6% vs 17.1%). Discharge to home (29.6% vs 36.8%) and inpatient rehabilitation (4.2% vs 18.9%) was less common for CAH patients, whereas discharge to an intermediate care/skilled nursing facility was more common (26.7% vs 23.9%). For CAHs and non-CAHs, respectively, 1-year mortality rates were 27.8% (95% CI 26.5-29.0) and 22.2% (22.0-22.4), and 1-year recurrence rates were 4.3% (3.6-4.9) and 4.6% (4.5-4.7) (Figure). In IPW-adjusted analyses, stroke patients treated at CAHs vs non-CAHs had higher risk of 1-year mortality (HR 1.29, 95% CI 1.22-1.37) but not recurrent stroke (0.91, 0.78-1.06). Conclusions: Stroke patients discharged from CAHs vs non-CAHs had greater risk of 1-year mortality but not recurrence. Further work is needed to understand the observed disparity, potentially with a focus on post-acute care services.

High-Quality Nursing Home and Palliative Care-One and the Same.

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries.

ObjectivesTo examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization.MethodsRetrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use.ResultsParticipants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48–3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35–10.25), nursing home care utilization 11.32 (95% CI, 3.88–33.02), hospitalizations 4.12 (95% CI, 2.88–5.90) and emergency room admissions 4.24 (95% CI, 3.04–5.91).DiscussionOur findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.

Traditional Medicare Spending on Inpatient Episodes as Hospitalizations Decline.

To describe Medicare inpatient episode spending trends between 2009 and 2017 as inpatient use declined among traditional Medicare beneficiaries. Inpatient episodes included claims for all traditional Medicare inpatient, outpatient, and Part D services provided during the 30 days prehospitalization, the inpatient stay, and the 90 subsequent days. We describe the mean number of episodes per 1000 beneficiaries, mean episode-related spending per beneficiary, and mean spending per episode for all beneficiaries and for specific populations and types of episodes. Spending measures are reported with and without adjustment for payment rate increases over the study period. The number of inpatient-initiated episodes per 1000 beneficiaries declined by 18.2% between 2009 and 2017 from 326 to 267. After adjusting for payment rate increases, Medicare spending per beneficiary on episode- related care declined by 8.9%, although spending per episode increased by 11.4% over this period. Between 2009 and 2017, all subgroups defined by age, sex, race, or Medicaid status experienced declines in inpatient use accompanied by decreased overall episode-related spending per beneficiary and increased spending per episode. Larger declines in the number of episodes per 1000 beneficiaries were seen among episodes that began with a planned admission (28.8%) or involved no use of post-acute care services (23.9%). When comparing admissions according to medical diagnosis, the largest decline occurred for episodes initiated by a hospitalization for a cardiac or circulatory condition (31.8%). Medicare inpatient episodes per beneficiary decreased, but spending decreases due to declining volume were offset by increased spending per episode.

Factors influencing clinicians' referral or admission decisions for post-acute stroke or traumatic brain injury rehabilitation: A scoping review.

Demand for post-acute stroke and traumatic brain injury (TBI) rehabilitation outweighs resource availability. Every day, clinicians face the challenging task of deciding which patient will benefit or not from rehabilitation. The objectives of this scoping review were to map and compare factors reported by clinicians as influencing referral or admission decisions to post-acute rehabilitation for stroke and TBI patients, to identify most frequently reported factors and those perceived as most influential. We searched four major databases for articles published between 1946 and January 2021. Articles were included if they reported clinicians' perceptions, investigated referral or admission decisions to post-acute rehabilitation, and focused on patients with stroke or TBI. Twenty articles met inclusion criteria. The International Classification of Functioning, Disability and Health framework was used to guide data extraction and summarizing. Patient-related factors most frequently reported by clinicians were age, mental status prior to stroke or TBI, and family support. The two latter were ranked among the most influential by clinicians working with stroke patients, whereas age was ranked of low importance. Organizational factors were reported to influence decisions (particularly the availability of post-acute care services) as well as clinicians' characteristics (eg, knowledge). Moreover, clinicians' prediction of patient outcome ranked among the most important driver of referral or admission decisions by clinicians working with stroke patients. Findings highlight the complex nature of decision-making regarding patient selection for rehabilitation and provide insight on important factors that frontline clinicians need to consider when having to make rapid decisions in high-pressured acute care environments.

Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study.

We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30days post-hospitalisation. Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid. We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study. Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n=785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit. Post-hospitalisation, 12% (n=59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n=13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR=3.24). Having a home care visit or specialty care visit within 30days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR=0.01). Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid. Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.

Back So Soon? A Community Hospital Creates New Ways to Prevent Readmission.

Purpose/Objectives: Readmission prevention is part of the hospital's strategic plan. Why? Reducing hospital readmissions decreases patient suffering. It also reduces the Centers for Medicare &amp; Medicaid Services financial penalty. But how do you do it? The hospital received a 2-year grant/“investment” from the Massachusetts Health Policy Commission to develop and implement creative, innovative ways of reducing readmissions. The goal was to reduce the 30-day readmission rate for two groups by 20%—adult high utilizers (4 or more admissions within a 12-month period) and adult discharges to post-acute care (PAC) services (skilled nursing facilities and home care agencies). Primary Practice Settings: The primary practice settings for the initiative were the hospital, skilled nursing facilities, a short-term rehabilitation hospital, and the patients' homes. The patients were initially selected according to risk criteria determined by the hospital and then followed in the post-acute venue via telephone call and/or visit. Findings/Conclusions: Enrollment consisted of 2,860 patients. The readmission rate for adult high utilizers fell from 40.1% to 24.6% (a 39% reduction). The PAC readmissions for both skilled nursing facilities and home health agencies fell from 12.9% to 12.5%—a small decrease. However, the overall PAC readmission rate for the CHART (Community Hospital Acceleration, Revitalization, and Transformation) program is significantly lower than the state's—the rate for home health agencies is 17.2% and for skilled nursing facilities is 20.0%—making the effort to reduce the readmission rate all the more challenging. The significant reduction in hospital readmissions is attributed to the work of the Readmission Prevention Team, which met daily to discuss patients. Team members shared perceptions on patient education, medication management, communication, and end-of-life care. The team developed innovative practices and protocols, which were then applied to the patients' care. Implications for Readmission Specialists Practice/Case Management:

Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study

BackgroundDespite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use.MethodsWe extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients’ ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a “traveler”. We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived.ResultsAlthough 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding “travelers,” for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities.ConclusionsGeographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries—the “traveler effect”.

Quality Improvement Project to Enhance Knowledge of Hospice Interdisciplinary Team of Post-Acute Care Services

Quality Improvement Project to Enhance Knowledge of Hospice Interdisciplinary Team of Post-Acute Care Services

Use of Post-Acute Care Services and Readmissions After Acute Myocardial Infarction Complicated by Cardiac Arrest and Cardiogenic Shock.

ObjectiveTo evaluate post–acute care utilization and readmissions after cardiac arrest (CA) and cardiogenic shock (CS) complicating acute myocardial infarction (AMI).MethodsWith use of an administrative claims database, AMI patients from January 1, 2010, to May 31, 2018, were stratified into CA+CS, CA only, CS only, and AMI alone. Outcomes included 90-day post–acute care (inpatient rehabilitation or skilled nursing facility) utilization and 1-year emergency department visits and readmissions.ResultsOf 163,071 AMI patients, CA+CS, CA only, and CS only were noted in 3965 (2.4%), 8221 (5.0%), and 6559 (4.0%), respectively. In-hospital mortality was noted in 10,686 (6.6%) patients: CA+CS, 1935 (48.8%); CA only, 2948 (35.9%); CS only, 1578 (24.1%); and AMI alone, 4225 (2.9%) (P<.001). Among survivors, post–acute care services were used in 67,799 (44.5%), with higher use in the CS+CA cohort (1310 [64.6%]; hazard ratio [HR], 1.19; 95% CI, 1.06 to 1.33; P=.003) and CA cohort (2738 [51.9%]; HR, 1.27; 95% CI, 1.20 to 1.35; P<.001) but not in the CS cohort (3048 [61.2%]; HR, 1.03; 95% CI, 0.97 to 1.11; P=.35) compared with the AMI cohort (60,703 [43.3%]). Compared with the AMI cohort (48,990 [35.0%]), patients with CS only (2,085 [41.9%]; HR, 1.16; 95% CI, 1.10 to 1.22; P<.001) but not those with CA+CS (724 [35.7%]; HR, 1.07; 95% CI, 0.98 to 1.17; P=.14) had higher rates of readmissions (P=.03). Readmissions were lower in those with CA (1,590 [30.2%]; HR, 0.94; 95% CI, 0.89 to 0.99). Repeated AMI, coronary artery disease, and heart failure were the most common readmission reasons. There were no differences for emergency department visits.ConclusionCA is associated with increased post–acute care use, whereas CS is associated with increased readmission risk in AMI survivors.