Post-acute Care Admission Research Articles

Racial and Ethnic Disparities in Referral Rejection from Postacute Care Facilities among People with Opioid Use Disorder in Massachusetts.

The aim of the study was to examine the association between Black, White, and Hispanic or Latino race and ethnicity and referral rejection from private postacute care facilities among hospitalized individuals with opioid use disorder (OUD). In this retrospective cohort study, we linked electronic postacute care referrals from Boston Medical Center in 2018 to electronic medical record data, which we used to ascertain OUD status and race and ethnicity. Using multivariable logistic regression, we examined the association between Black, White, and Hispanic or Latino race and ethnicity and referral rejection, adjusting for individual-level characteristics including medication for opioid use disorder treatment type and for facility-level factors using facility random effects. We identified 159 hospitalizations from 141 individuals with OUD referred to private postacute medical care, corresponding to 1272 referrals to 244 facilities. Hospitalizations comprised 53 (33%) non-Hispanic Black, 28 (18%) Hispanic or Latino, and 78 (49%) non-Hispanic White individuals. In adjusted analyses, referrals for non-Hispanic Black individuals had significantly higher odds of rejection compared to referrals for non-Hispanic White individuals (adjusted odds ratio 1.83, 95% confidence interval [1.24, 2.69], P = 0.002). There were no significant differences between referrals for Hispanic or Latino individuals and non-Hispanic White individuals (adjusted odds ratio 1.11, 95% confidence interval [0.67, 1.84], P = 0.69). Among people with OUD referred to private postacute care in Massachusetts, non-Hispanic Black individuals were more likely to be rejected compared to non-Hispanic White individuals, demonstrating racism in postacute care admissions. Efforts to address discrimination against people with OUD in postacute care admissions must also address racial equity.

Hospital-Level Care at Home Patients Remain at Home Longer Following Acute Illness: A Literature Review.

Hospital-level care at home (HCaH) is a modern alternative to traditional inpatient hospitalization (TIH) for acutely ill adults which is cost-effective without impacting patient mortality. Additional outcomes comparing HCaH and TIH have been studied including hospital readmission and post-acute care admission. There is convincing evidence that suggests a trend in the reduction of readmissions following acute hospitalization in the home. Additionally, post-acute care admissions have been significantly reduced following HCaH compared to TIH. The concept of a home hospital allows patients to remain home during acute illness and stay at home longer following discharge, thereby avoiding the need for hospital readmission and post-acute care placement. This research is increasingly important to the aging population in the United States that seeks a safe and beneficial alternative to overwhelmed medical facilities.

Candida auris Screening of High-Risk Patients: A Descriptive Comparison of 2 Strategies.

Background: Candida auris infection is associated with high morbidity and mortality. C. auris can persist in the healthcare environment and is associated with outbreaks. We compare screening strategies for C. auris in two high-risk patient populations. Methods: Our center is a tertiary, 865-bed hospital. In the context of known regional outbreaks of C. auris in post-acute care (PAC) facilities, we experienced extended clusters of apparent C. auris acquisition across several hospital units. Hospital acquisition was defined as new C. auris in clinical cultures in patients with no known history of C. auris colonization/infection. We performed point prevalence surveys (PPS) on affected units weekly until all tests were negative for two consecutive weeks. We also initiated admission screening for C. auris for patients admitted from PAC. All screening swabs were collected per CDC’s procedure. Tests were performed either by RT-PCR or Chromagar C. auris media, depending on availability. We compared the overall positivity rates of exposure PPS versus PAC admission screenings using Z-test for two proportions with statistical significance set at p < 0 .05 Results: From 2/2023-12/2023, a total of 533 tests on 367 unique patients were processed during PPS; 512 tests were negative and 21 were positive (3.9% positivity rate). Three additional samples were either unable to be processed or indeterminate. There were 68 patients who had repeat testing weekly for ≥2 weeks. Most remained negative, but 5 tested positive after variable amounts of negative-week intervals: 3 patients at week 2, 1 patient at week 4 and 1 patient at week 5. From 8/2023 to 12/2023, a total of 89 patients admitted from 35 different PAC facilities underwent admission screening for C. auris. Only three patients were positive (3.4%), each from a different facility. The difference in the positivity rates between PPS and PAC was not statistically significant (Z-score 0.25, p = 0.79). Discussion: Our C. auris screening strategies found similar positivity rates for patients admitted to the hospital from PACs compared to targeted PPS in the setting of apparent hospital acquisition events. These strategies may be considered as complementary. Facilities experiencing apparent acquisition events should consider screening high-risk admissions to identify and isolate colonized patients, particularly if standard infection prevention practices are being performed with high fidelity.

FACTORS ASSOCIATED WITH OLDER ADULTS’ READINESS FOR DISCHARGE FROM POST ACUTE CARE TO HOME

Abstract Following acute hospitalization, older adults are often transferred to post-acute care (PAC) for rehabilitation and nursing care. Most PAC admissions are comprised of adults with multimorbidity (>2 chronic diseases). After PAC discharge many patients are rehospitalized within 30 days. The goal of this study was to evaluate factors associated with older adult’s readiness for PAC discharge to home. A prospective one-arm descriptive correlation study was conducted. Older adults (N=19) discharged from PAC to home participated. Subjects were recruited over a 3-month period from a large midwestern facility. Participants completed the Patient Readiness for Hospital Discharge -Short Form (PR RHDS-SF) and Patient Activation Measure (PAM). Medication burden, measured by the medication regimen complexity index (MRCI) calculated from discharge medication record. Participants included 12 females and 5 males, mean age of 73 (SD 8.2)) years. The PT RHDS -SF mean score was 49.3 (SD 16.8). The PAM mean score was 54.7 (SD 7.4). Medication burden was high, mean MRCI was 31.5 (SD 11.6). There was a significant correlation [r (17) .48, p=.04] between total PT RHDS-SF score and patient activation levels. Preparing PAC patients to self-manage their multimorbid conditions may enhance their self-confidence with transition from PAC to home. Evaluating self-management preparedness of older adults prior to PAC discharge is vastly understood. Research is needed to prepare multimorbid older adult patients transitioning from PAC to home focused on perceived readiness and self-management confidence.

Economic and Humanistic Burden Among Medicare-Aged Women With Fragility Fracture in the United States.

Describe patient characteristics, health care resource utilization, costs, and humanistic burden of women with Medicare insurance with incident fragility fracture who were admitted to post-acute-care (PAC). Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) data. Community-dwelling female Medicare beneficiaries with incident fragility fracture January 1, 2017, to October 17, 2019, resulting in PAC admission to a skilled nursing facility (SNF), home-health care, inpatient-rehabilitation facility, or long-term acute-care hospital. Patient demographic/clinical characteristics were measured during 1-year baseline. Resource utilization and costs were measured during baseline, PAC event, and PAC follow-up. Humanistic burden was measured among SNF patients with linked Minimum Data Set assessments. Multivariable regression examined predictors of PAC costs after discharge and changes in functional status during SNF stay. A total of 388,732 patients were included. Compared with baseline, hospitalization rates were 3.5, 2.4, 2.6, and 3.1 times higher and total costs 2.7, 2.0, 2.5, and 3.6 times higher for SNF, home-health, inpatient-rehabilitation, and long-term acute-care, respectively, following PAC discharge. Utilization of dual-energy X-ray absorptiometry (DXA) and osteoporosis medications remained low: 8.5% to 13.7% received DXA during baseline vs 5.2% to 15.6% following PAC; 10.2% to 12.0% received osteoporosis medication during baseline vs 11.4% to 22.3% following PAC. Dual eligibility for Medicaid (ie, low income) was associated with 12% higher costs; Black patients had 14% higher costs. Activities of daily living scores improved 3.5 points during SNF stay, but Black patients had 1.22-point lower improvement than White patients. Pain intensity scores showed small improvement (-0.8 points). Women admitted to PAC with incident fracture had high humanistic burden with little improvement in pain and functional status and significantly higher economic burden after discharge compared with baseline. Disparities in outcomes related to social risk factors were observed, with consistently low utilization of DXA and osteoporosis medications even after fracture. Results indicate a need for improved early diagnosis and aggressive disease management to prevent and treat fragility fractures.

Northeast Postacute Medical Facilities Disproportionately Reject Referrals For Patients With Opioid Use Disorder.

Referrals of hospitalized patients with opioid use disorder (OUD) to postacute medical care facilities are commonly rejected. We linked all electronic referrals from a Boston safety-net hospital in 2018 to clinical data and used multivariable logistic regression to examine the association between OUD diagnosis and rejection from postacute medical care. Hospitalized patients with OUD were referred to more facilities than patients without OUD (8.2 versus 6.6 per hospitalization), were rejected a greater proportion of the time (83.3percent versus 65.5percent), and in adjusted analyses had greater odds of rejection from postacute care (adjusted odds ratio, 2.2). In addition, people with OUD were referred disproportionately to a small subset of facilities with a higher likelihood of acceptance. Our findings document disparities in postacute care admissions for people with OUD. Efforts to ensure equitable access to medically necessary postacute medical care for people with OUD are needed.

59 IMPROVED OUTCOMES WITH DELAYED ADMISSION TO POST-ACUTE CARE: RESULTS OF A NATURAL EXPERIMENT

Abstract Background In Ireland, the national Health Service Executive developed a post-acute care (PAC) scheme in 2016 to provide funds to acute hospitals for beds in nursing homes to allow discharge of patients who would benefit from a period of recovery in a nursing home before returning home when medically fit for discharge with no need for rehabilitation or long-term care (LTC). However, budgetary restrictions introduced from June 2019 resulted in a delay in access to funding. This change in funding was used as a natural experiment of the effectiveness of this scheme in a single large general hospital before and after delays due to funding restrictions. Methods Data regarding PAC admissions for those aged 65 years or more from July to October 2017, when there were no budgetary restrictions, and from July to October 2019, when funding was delayed, were compared. Chi-square tests were used to compare proportions, and the nonparametric Mann–Whitney U test was used to compare continuous data. Results Compared with the 2017 cohort, those in 2019 spent 6 days longer in the acute hospital following a delay in 2019 between being approved clinically as needing PAC and subsequent admission to a facility. However, readmissions to hospital within 90 days of discharge and directly from PAC were significantly higher in 2017, as was discharge from PAC directly to LTC. Conclusion This retrospective study demonstrates restrictive practices regarding discharge to PAC introduced for budgetary reasons caused longer acute bed LOS with reduced LOS in PAC, reduced hospital RAR and reduced admissions to LTC suggesting that a pre-existing liberal selection process may result in poorer identification of appropriate patients for PAC.

Greater Quadriceps Muscle Mass at Post-Acute Care Admission is Associated with Better Swallowing Ability at Discharge among Adults with Stroke

ObjectivesThis study aimed to examine the relationship between muscle mass and intramuscular adipose tissue of the quadriceps at post-acute care admission and recovery of swallowing ability in patients with stroke. DesignProspective study. Setting and ParticipantsThis study was hospital-based and included 62 inpatients with stroke. MethodsThe primary outcome was swallowing ability at discharge. The swallowing ability was assessed using the Food Intake Level Scale (FILS). The FILS change was calculated by subtracting FILS at admission from FILS at discharge. Ultrasound images were acquired at admission using B-mode ultrasound imaging. Muscle mass and intramuscular adipose tissue of the quadriceps were assessed based on muscle thickness and echo intensity, respectively. The mean muscle thickness and echo intensity of the right and left quadriceps were used in the analysis. A multiple regression analysis was performed to identify the factors independently associated with the FILS at discharge and FILS change. The independent variables were the muscle thickness and echo intensity of the quadriceps, FILS at admission, age, sex, body mass index, days from stroke onset, C-reactive protein, updated Charlson comorbidity index, number of medications, unit number of rehabilitation therapy, and Barthel Index score at admission. ResultsMuscle thickness of the quadriceps was significantly and independently associated with FILS at discharge (β = 0.27) and FILS change (β = 0.40). Echo intensity of the quadriceps was not significantly and independently associated with FILS at discharge (β = 0.22) and FILS change (β = 0.31). Conclusions and ImplicationsOur results indicated that greater quadriceps muscle mass at post-acute care admission was associated with better swallowing ability at discharge in patients with stroke. Assessing muscle mass of the quadriceps at admission is important for predicting recovery of swallowing ability and interventions for quadriceps muscle mass may be effective for improving swallowing ability of patients with stroke.

Older Adults with Mental Illness or Dementia Struggle with the Skilled Nursing Facility-to-Home Transition

<h3>Introduction</h3> In 2018, 1.6 million fee-for-service (FFS) Medicare beneficiaries used skilled nursing facilities (SNFs) at least once. Older adult SNF patients with mental illness (MI) and Alzheimer's disease and related dementias (ADRD) comprise groups that are at risk of nursing home long-term care. We examined how the presence of MI and ADRD were associated with discharge from SNF admissions to the community and home time (the number of days alive that were not in a hospital, inpatient rehabilitation facility, or SNF). We hypothesized that older adults with MI and ADRD were less likely to have been discharged to the community and had less home time. We anticipated that these associations would be attenuated, however, after accounting for the behavioral and psychological manifestations of MI and ADRD such as daily functioning, depressive symptoms, and aggressive behaviors. <h3>Methods</h3> Our study examined 46,342 New York State FFS Medicare beneficiaries aged 65 years and older with an index SNF admission in 2014 following a hospitalization of three or more days. Our first outcome was whether an SNF patient was discharged to the community within 100 days of SNF admission (binary: yes/no). Included in the "no" category were older adults who were discharged from the SNF to a hospital or a different SNF, remained in the SNF longer than 100 days, or died. For those discharged to the community, our second outcome was home time (continuous) in the 90 days following SNF discharge. The key independent variable was the presence of a MI or ADRD diagnosis, which we organized into three groupings: 1) MI present and ADRD absent, 2) ADRD present (with and without MI), and 3) both MI and ADRD absent (serving as reference group). We extracted data from the Minimum Data Set, Medicare claims, and other administrative databases. We conducted logistic and zero-inflated negative binomial regressions to analyze the associations between MI/ADRD grouping with our outcomes. <h3>Results</h3> Among SNF post-acute care admissions, 23.0% had MI only, 22.7% had ADRD, and 58.9% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge (MI: odds ratio, OR=0.90, 95% confidence interval, CI: 0.86-0.95; ADRD: OR=0.51, 95% CI: 0.49-0.54). When the manifestations of MI and ADRD were added to the regression models, however, MI was no longer associated with community discharge and ADRD's association was attenuated (MI: OR=0.97, 95% CI: 0.92-1.02; ADRD: OR=0.71, 95% CI: 0.67-0.75). Among those discharged to the community, after adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with 1.26 and 1.41 fewer days in the community (MI: -1.26 days, 95% CI: -1.95, -0.57; ADRD: -1.41 days, 95% CI: -2.21, -0.60). When the manifestations of MI and ADRD were added to the regression models, MI's association with home time persisted, but ADRD was no longer associated (MI: -0.73 days, 95% CI: -1.41, -0.05; ADRD: 0.45 days, 95% CI: -0.27, 1.17). <h3>Conclusions</h3> Among NYS FFS Medicare beneficiaries who received post-acute care SNF services, older adults with MI and ADRD had worse SNF discharge outcomes. These worse outcomes appear to have been at least partially driven by impaired daily functioning, depressive symptoms, and aggressive behaviors that can be consequences of MI or ADRD. Accordingly, psychogeriatric care to optimally manage the symptoms and behaviors associated with MI and ADRD may be necessary to improve community discharge and home time. <h3>Funding</h3> Dr. Simning was supported by the Empire Clinical Research Investigator Program, sponsored by the New York State Department of Health, as well as the National Institute on Aging (grant number K23AG058757). The content is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health.

THE IMPACT OF MEDICARE ADVANTAGE ON SKILLED NURSING FACILITY FINANCIAL PERFORMANCE, STAFFING, AND QUALITY

Since the mid-2000s, skilled nursing facilities (SNFs) face an increasing percentage of post-acute care patients enrolled in Medicare Advantage (MA), yet our understanding the of how this affects SNFs is limited. Managed care may provide better coordination and continuous care that enhances SNF quality, but MA plans can also negotiate lower payments, providing SNFs with fewer financial resources to invest in staffing and quality. We use data from 2011-2015 from Medicare Beneficiary Summary File, Minimum Data Set, Certification and Survey Provider Enhanced Reporting, and Medicare Cost Reports to estimate linear fixed effect panel regressions with instrumental variables. We find that SNFs with greater MA share of post-acute care admissions have worse financial performance, lower nursing staff levels, and worse quality as measured by deficiency scores. Our finding favors the hypothesis that MA creates downward financial pressure and strong MA presence in local markets can potentially to spillover to non-MA residents.

2449. Early Detection of Candida auris is Essential to Control Spread: Four Effective Active Surveillance Strategies

Background C. auris has been identified from > 1600 US patients. Risk factors include high-acuity post-acute care admissions (e.g., long-term acute care hospitals (LTACHs)), hospitalization abroad, and carbapenemase-producing organism (CPO) colonization. Early detection of C. auris is key to controlling spread. We describe four active surveillance strategies that led to early C. auris identification.MethodsBased on known risk factors, state health departments used active C. auris surveillance strategies: (1) species identification of yeast from urine cultures from LTACHs, (2) screening patients with a CPO and hospitalization abroad, (3) LTACH C. auris point prevalence surveys (PPS), or (4) admission screening in acute and long-term care settings.Results(1)A laboratory in Southern California serving 12 LTACHs began species identification for all Candida from urine cultures, which would have otherwise been discarded because they are assumed to be not clinically significant. Within 5 months, testing of 271 Candida urine isolates identified the region’s first C. auris case, prompting contact tracing and identification of additional cases and facilities. (2) When CPOs were identified in patients with recent hospitalizations outside of the United States, the Maryland Department of Health screened patients for C.auris colonization. Of four screened, one, who received care in Kenya, was C. auris colonized. (3) The Indiana State Department of Health implemented monthly PPS at an LTACH that frequently admits patients transferred from a high prevalence area. Of 38 patients screened, two were colonized. (4) The Connecticut Department of Public Health offers C. auris admission screening for patients who received inpatient care in high prevalence areas; of 12 screened, one C. auris colonized patient was found. Infection control assessments and implementation of infection control measures followed each detection.ConclusionEarly detection of C. auris is important but is impacted by infrequent yeast species identification and a reservoir of asymptomatic colonized patients. Healthcare facilities and public health jurisdictions can consider adopting one or more of these strategies based on epidemiology and resource availability.Disclosures All authors: No reported disclosures.

Influence of Cognition on Length of Stay and Rehospitalization in Older Veterans Admitted for Post-Acute Care.

Evaluate the relative contribution of cognitive test performance to post-acute care (PAC) length of stay (LOS) and rehospitalization while controlling for key demographic, medical, and functional outcomes. Retrospective medical record review of 160 older Veterans, including cognitive test performance (Addenbrooke's Cognitive Examination-Revised [ACE-R]), on admission to a Veterans Administration Hospital Community Living Center (CLC) PAC. Individuals with impaired scores on the ACE-R had a longer LOS (10 median days longer; U = 2,547.00, p = .028). Of those rehospitalized, 71.4% (n = 20) screened positive for cognitive impairment. Key medical factors explained the largest amount of variance in CLC-PAC LOS (29.8%), followed by admission ADL (activities of daily living) dependency (4.6%) and ACE-R total score (3.30%). Cognitive screening should be considered on PAC admission, with impairment on ACE-R predicting geriatric rehabilitation outcomes such as risk of increased LOS and rehospitalization.

Identifying Malnutrition in PALTC Communities

Identifying Malnutrition in PALTC Communities

The impact of post-acute care rehabilitation on functional status in stroke patients from different hospital accreditation level

In order to construct a medical transfer system for the stroke, Taiwan Ministry of Health and Welfare implemented a national program of Post-acute Care for Cerebrovascular Diseases (PAC-CVD) in March 2014. Under the intensive in-patient rehabilitation programs and per diem payment, the healthcare utilization was expected to be improved. The purpose of this study was to investigate the impact of intensive post-acute stroke rehabilitation on functional status in different hospital accreditation level. The stroke patients who were admitted to post-acute ward in two hospitals during 2014/03/01 to 2017/8/31 were indicated to the study. The patients was separated to group 1 (a rural regional hospital) and group 2 (a metropolitan district hospital). The modified Rankin Scale (mRS) score, Barthal Index (BI), Instrumental Activities of Daily Living Scale (IADL) and Berg Balance Scale (BBS) were used to evaluate functional status. In total, 740 stroke patients (311 patients in group 1, and 429 patients in group 2) were included. The length of days (LOS) between stroke onset and post-acute care (PAC) ward admission were 11.60 days in group 1, and 21.41 days in group 2. The length of days in PAC ward were 27.02 days in group 1, and 36.85 days in group 2. The percentage of patients referred from other acute hospitals were 23.47% in group 1, and 89.51% in group 2. The severity (MRS grading on PAC admission day) was 3.53 in group 1, and 3.88 in group 2. The functional improvement after rehabilitation training was noted in both groups. Under the intensive post-acute in-patient rehabilitation programs, the stroke patients got functional improvement. No matter the accreditation level of the hospital, the same payment may make more chance for the district hospitals to develop. The healthcare utilization may work efficiently under the medical transfer system.

Is Rapid Recovery Hip and Knee Replacement Possible and Safe in the Octogenarian Patient?

BackgroundRapid recovery programs are now aimed to reduce costs of hip and knee arthroplasties by discharging patients directly home, shortening hospital length of stay (LOS), and reducing readmission rates. Although patients aged 80 years and older are included in the Medicare bundle, little work has been performed to determine if older patients can safely participate in rapid recovery programs. MethodsWe retrospectively reviewed 2482 patients undergoing primary and revision total hip and knee arthroplasties (THA and TKA) who all participated in a multifaceted rapid recovery program. The goals of this program were next day discharge to home without the use of home services or post-acute care admission. We examined the hospital LOS and the percentage of patients discharged home as well as 90-day readmission rates to determine efficacy and safety of this program in the patients aged 80 years and older. ResultsOctogenarians receiving primary THA and TKA were discharged home >90% of the time with LOSs <2 days and low readmission rates. Revision THA and TKA patients aged 80 years and older were discharged home about 70% of the time with significantly longer LOSs than patients aged more than 80 years. The revision THA patients aged more than 80 years had the highest readmission rates. ConclusionPatients aged more than 80 years can successfully and safely participate in rapid recovery programs.

Prolonged acute care and post-acute care admission and recovery of physical function in survivors of acute respiratory failure: a secondary analysis of a randomized controlled trial

BackgroundThe proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate.MethodsWe performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ≥4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score.ResultsOf the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4–29.8) points lower (p < 0.0001) than patients who were discharged to home. However, there was no difference in the rate at which physical function improved from 3 to 6 months for patients who required prolonged admission compared with those who returned home (p = 0.24 for interaction between prolonged admission and time). Adjusted for age, Acute Physiology and Chronic Health Evaluation II score, and sex, both groups had CS-PFP-10 scores that were 8.2 (CI 4.5–12.0) points higher at 6 months than at 3 months (p < 0.0001). For each additional year in patient age, CS-PFP-10 recovered 0.36 points slower (95% CI 0.12–0.61; p = 0.004).ConclusionsPatients who require prolonged admission after acute respiratory failure have significantly lower physical functional performance than patients who return home. However, the rates of physical functional recovery between the two groups do not differ. The majority of survivors do not recover sufficiently to achieve functional independence by 6 months. Older age negatively influences the trajectory of functional recovery.Trial registrationClinicalTrials.gov, NCT01058421. Registered on 26 January 2010.

Delirium During Postacute Nursing Home Admission and Risk for Adverse Outcomes.

To identify the rate of delirium present during admission to postacute care (PAC) in the nursing home setting and to determine whether patients with delirium had higher risk for adverse outcomes. Retrospective cohort study. US Medicare- and Medicaid-certified nursing homes, 2011 to 2014. Individuals admitted to all US nursing homes for PAC, aged ≥65 years, and without prior history of nursing home residence (n = 5,588,702). Minimum Data Set (MDS) 3.0 admission assessments identified delirium based upon Confusion Assessment Method (CAM) items. Robust Poisson regression was used to calculate adjusted relative risks (aRRs) with 95% confidence intervals (CIs) for death following PAC admission, and for 30-day discharge outcomes including re-hospitalization from PAC, discharge home, and functional improvement. Delirium was identified in 4.3% of new postacute nursing home admissions. Mortality within 30 days of PAC admission was observed in 16.3% of patients with delirium and 5.8% of patients without delirium (aRR = 2.27, CI = 2.24-2.30). The rate of 30-day readmission from PAC was 21.3% for patients with delirium compared with 15.1% among patients without delirium (aRR = 1.42, 95% CI = 1.40, 1.43). 26.9% of patients with delirium were discharged home within 30 days of admission compared to 52.5% of patients without delirium (aRR = 0.57, 95% CI = 0.57, 0.58). 48.9% of patients with delirium showed functional improvement at discharge compared to 59.9% of patients without delirium (aRR = 0.83, 95% CI = 0.82, 0.83). Patients with delirium present upon PAC admission were at high risk for mortality and 30-day re-hospitalization and were less likely to have timely discharge to home or to improve in physical function at discharge. Early identification and care planning for individuals with delirium at PAC admission may be essential to improve outcomes.

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

ObjectivesHospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. DesignRetrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003–2009. SettingThe MCBS is a nationally representative survey of beneficiaries matched with claims data. ParticipantsCommunity-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. Intervention/ExposurePotential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. MeasurementsHospital readmission during the PAC stay, return to community residence, and all-cause mortality. ResultsOf 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21–7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39–1.92), and for-profit PAC ownership (1.43, 1.21–1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9% vs 8.6%, P < .001) and 100 days (39.9% vs 14.5%, P < .001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60–2.54; 100 days: OR 3.79, 95% CI 3.13–4.59). ConclusionsHospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis.

BackgroundActivity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care.MethodsWe undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication.ResultsOf 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk = 1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences.ConclusionsTransitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

No adverse impact of depressive symptoms on the effectiveness of postacute care service: A multicenter male-predominant prospective cohort study

BackgroundAlthough the clinical effectiveness of community hospital-based postacute care (PAC) services has been shown, little was known regarding the impact of depression on the clinical outcomes of older patients receiving PAC services in Taiwan. MethodsFrom January 2009 to August 2010, patients aged 65 years and older referred from tertiary medical centers or acute wards of community hospitals to PAC units were invited for study. All patients received the 4-week Comprehensive Geriatric Assessment-based intervention program in the PAC units. The functional assessment was composed of Geriatric Depression Scale–Short Form (GDS), Mini-Mental Status Examination, Barthel Index, Instrumental Activities of Daily Living, and Braden Score. ResultsAmong the 401 participants (mean age, 82.0 years; 95.5% males), 66 (16.5%) patients were depressed at PAC unit admission. Depressed patients had significantly lower Barthel Index (38.1 ± 2.4 vs. 47.6 ± 1.2, p = 0.002) and Braden Score (17.7 ± 0.3 vs. 18.8 ± 0.2, p = 0.004) than nondepressed patients. Improvement was noted on all measures of functional outcome among patients receiving PAC services. Furthermore, GDS was significantly improved in depressed patients (from 6.4 ± 0.2 to 2.8 ± 0.2 in depressed patients vs. from 1.6 ± 0.1 to 0.9 ± 0.1 in nondepressed patients, p < 0.001). ConclusionDepression was common when patients were newly admitted to PAC services, which was highly associated with poorer physical function. Improvement in physical function and depressive symptoms among all patients after PAC service was found, and the presence of depressive symptoms at PAC admission did not predict any adverse outcome of PAC services.