Skilled Nursing Visits Research Articles

Trends in Risk Factors for Peripartum Depression in Socio-economically Disadvantaged Childbearing Community

Introduction: Perinatal depression is defined as a depressive episode(s) during the pregnancy and/or postpartum period up to one year. Studies have shown that childbearing people in urban settings experience a higher burden of social factors, such as low socioeconomic status, which may influence the likelihood of developing perinatal depression. Of note, episodes of perinatal depression have been shown to negatively impact child development. Our study has identified population trends in Center for Epidemiological Studies Depression Scale (CES-D) scores >10 during perinatal periods alongside significant social risk factors for people served by LSA Family Health Service providing skilled home-based nursing visits to reduce adverse outcomes. Methods: A retrospective chart review of nursing notes from 2009-2017 was conducted for this cross-sectional study. Outcome measures included antepartum (AP) and postpartum (PP) Center for Epidemiological Studies Depression Scale (CES-D) scores, with a score of > 10, suggesting a positive risk for developing depression. Data were grouped and analyzed using Microsoft Excel and SPSS software (SPSS version 23). Data have been presented as yearly population percentages scoring >10 on their CES-D screen. Results: The maternal outreach program (MOP) enrolled 1,183 birthing individuals from 2009-2017. The mean parental age was 27 years. 70% were Latinx (n=829) and 20.88% (n=247) were Black. Spanish was the primary language for 43.62% (n=516) of participants. Among CES-D screens completed in the antepartum period, 4.5% to 24.6% of the population met criteria over the 9-year study period for risk of developing depression. Positive CES-D screens completed postpartum ranging from 11.9% to 27.2% during the study period. Significant risk factors for positive postpartum CES-D screens were postpartum risk assessment score (p=0.03), increased gestational age (p=0.05), low income (p=0.03), teen/inexperienced parents (p=0.003), and low education levels (p=0.04). Conclusion: Trends of positive antepartum and postpartum depression screens in this population have fluctuated over the study period; however, we have identified significant risk factors for positive postpartum screens. Screening for postpartum depression risk factors is important to identify birthing parents who may most benefit from mental health interventions.

National Trends in Post-Acute Care Costs Following Total Hip Arthroplasty from 2010 through 2018.

Post-acute care remains a target for episode-of-care cost reduction following total hip arthroplasty (THA). The introduction of bundled payment models in the United States in 2013 aligned incentives among providers to reduce post-acute care resource utilization. Institution-level studies have shown increased rates of home discharge with substantial cost savings after adoption of bundled payment models; however, national data have yet to be reported. The purpose of this study was to evaluate national trends in post-acute care utilization and costs following primary THA over the last decade. We reviewed the cases of 189,847 patients undergoing primary THA during 2010 through 2018 from the PearlDiver database. Annual trends in patient demographics, discharge disposition, and post-acute care resource utilization were evaluated. Post-acute care reimbursements were standardized to 2020 dollars and included outpatient visits, prescriptions, physical therapy, home health, inpatient rehabilitation, skilled nursing facilities, and any rehospitalizations or emergency department (ED) visits within 90 days of surgery. From 2010 to 2018, the mean episode-of-care costs ($31,562 versus $24,188; p < 0.001) and overall post-acute care costs ($5,903 versus $3,485; p < 0.001) both declined. Post-acute care savings were primarily driven by reduced costs of skilled nursing facilities ($1,533 versus $627; p < 0.001), home health ($1,041 versus $763; p = 0.002), inpatient rehabilitation ($949 versus $552; p < 0.001), ED visits ($508 versus $102; p < 0.001), and rehospitalizations ($367 versus $179; p < 0.001). Post-acute care costs declined by $578 (p = 0.025) during 2010 to 2012, $768 (p = 0.038) during 2013 to 2015, and $884 (p = 0.020) during 2016 to 2018. Over the last decade, the rate of home discharge after THA increased while rehospitalization and ED visit rates declined, resulting in a substantial decrease in total and post-acute care costs. Post-acute care costs declined most rapidly after the introduction of the new Medicare bundled payment programs in 2013 and 2016.

Let There Be PEACE: Improving Continuous Symptom Monitoring in Hospice Patients.

ObjectiveTo ensure that a standardized method of continuous symptom monitoring was available to hospice patients enrolled at our institution.Patients and MethodsThe Palliative/End-of-Life/Assessment/Care Coordination/Evidence-Based Program (PEACE) seeks to enhance the provision of hospice care through symptom control and patient support. We conducted a quality improvement initiative between November 1, 2015, and March 31, 2017, following Define-Measure-Analyze-Improve-Control methodology to improve hospice care at a rural hospice. The gap in our current hospice model was a standardized method of continuous symptom monitoring. We aimed to explore ways in which technology-assisted care coordination could enhance end-of-life and hospice care. We measured continuous symptom assessments through co-developed condition management protocols (CMPs), technology-assisted care pathways (TACPs), nursing visits, length of stay, respite days, and satisfaction survey data from patients, caregivers, and hospice staff. At baseline, no continuous symptom monitoring was being performed. Baseline data for our enrolled population was compared with data from patients who were eligible, but opted out.ResultsWe monitored 50 patients using CMP and TACP. The mean ± SD number of skilled nursing visits per patient in the enrolled population compared with those who were eligible but opted out was 13.7±7.6 vs 14.2±10.5, respectively. In response to the survey question, “Because of the overall program, I felt supported and confident at home,” 74% (37 of 50) of patients and caregivers answered, “always.”ConclusionPEACE enhanced hospice care through symptom control and patient support through CMP and TACP. PEACE is a unique and feasible care platform for hospice patients, with high patient and caregiver satisfaction.

Home Health Agency Factors Associated With Acute Care Hospitalization and Emergency Department Use.

We linked the Medicare Provider Utilization and Payment Data for Home Health and the Home Health Compare data for the year 2016 to identify home healthcare agency (HHA) characteristics associated with acute care hospitalization (ACH) or emergency department (ED) use. The study cohort consisted of 9,800 HHAs. Beta regression was used to examine the association between average age, race/ethnic composition, number of skilled nursing visits, number of therapy visits, percentage of dual eligible patients, HHA ownership, HHA location, Medicare tenure, proportion of patients with a diagnosis of schizophrenia, stroke, diabetes, depression, chronic obstructive pulmonary disease (COPD), heart failure, cancer and Alzheimer disease, and ACH or ED use. After controlling for HHA-level characteristics, variations in HHAs' ACH and unplanned ED visits were found. For-profit HHAs were significantly less likely to have patients with ACH. (Odds ratio = -0.05, p = 0.020), HHAs in the Midwest, South, and West had lower odds of ACH. HHAs that serve more than 50% Black patients had significantly decreased odds (β = -0.16, p < 0.001) of ACH. A 1-unit increase in the proportion of patients with a diagnosis of schizophrenia, COPD, stroke, heart failure, and Alzheimer disease was associated with increased odds of hospitalization. For each unit increase in the number of skilled nursing visits, the odds of ACH increased by 0.02 (p = 0.001). For-profit and nonprofit HHAs had a significant decrease in the odds of unplanned ED visits (p < 0.05). An increase in the proportion of patients with COPD was associated with increased odds of unplanned ED visits (p < 0.001). HHA characteristics are associated with hospitalization and ED use without hospitalization. These characteristics point to variation in quality of care measured by ACH and ED use.

Treatment patterns and burden of behavioral disturbances in patients with dementia in the United States: a claims database analysis

BackgroundAlthough patients with dementia frequently experience neuropsychological symptoms (NPS) such as agitation, which profoundly impacts patients, caregivers, and the healthcare system, few studies have evaluated the associated burden of agitation or agitation-related symptoms in dementia.MethodsThis retrospective analysis of claims data from the Truven Health MarketScan® database (2012–2015) compared clinical characteristics, treatment patterns, healthcare resource utilization, and costs among patients with dementia with behavioral disturbances (BD) versus patients with dementia without BD. Existing BD diagnosis codes 294.11 or 294.21 were used as a means to identify patients with agitation/agitation-related symptoms.ResultsFrom a starting sample of 6.4 million beneficiaries, 103,402 patients with dementia were identified, of whom 16,440 (16%) had BD during an average of 17 months of follow-up. Patients with BD had significantly more medical and psychiatric comorbidities and greater comedication use (i.e., antidementia drugs, antidepressants, and antipsychotics; all values, P < .0001) compared with patients without BD. A significantly greater number of hospitalizations, hospital days, outpatient hospital/clinic visits, number of skilled nursing visits, and number of patients with hospice visit were reported during follow-up in patients with BD compared with patients without BD (all values, P < 0.0001). Costs were also significantly higher among patients with BD versus those patients without BD ($42,284 vs. $32,640, respectively; P < 0.0001).ConclusionsPatients with dementia with BD had a higher prevalence of comorbidities, greater use of comedications, and greater healthcare utilization and costs than patients with dementia without BD.

Payment drivers in Medicare patients undergoing total ankle arthroplasty

Category: Ankle Arthritis Introduction/Purpose: The Comprehensive Care for Joint Replacement model (CJR) provides bundled payments for in-hospital and 90-day post-discharge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help refine patient selection strategies and identify modifiable preoperative patient factors that can be addressed prior to the patient entering the bundle. Methods: This study is part of an IRB-approved single-center observational study of patients undergoing TAA from 1/1/2012 to 12/15/2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model and had Medicare as the insurance payer. Costs related to readmissions, diagnosis, and procedures that had been excluded by CJR were also excluded from this financial analysis. All inpatient and outpatient payments beginning at the index procedure through 90 days postoperatively were identified. Patient medical profile including Charlson-Deyo and Elixhauser comorbidity scores, preoperative comorbidities, and perioperative factors were then completed based on institutional data and chart review. Additionally, post-discharge disposition, readmissions, emergency department (ED) utilization, and outpatient plastic surgery consultation were recorded within the 90-day bundled payment period. Results: Out of 199 patients with Medicare payments in the study timeframe, 137 had consented to the study and were analyzed. Baseline and operative characteristics are given in Table 1. Increased length of stay (LOS) at the initial procedure, increased Charlson-Deyo comorbidity score, cerebrovascular disease, and peripheral vascular disease were significantly associated with higher payments. Discharge to skilled nursing facility (skilled nursing facility), admissions, ED visits, and wound complications were significant drivers of payment. Conclusion: Increased Charlson-Deyo score and vascular disease along with increased LOS were associated with increased payments from Medicare. Discharge to SNF, readmission, ED visits, and wound complications considerably increased payments. This study identifies the relationship between patient profile and increased financial burden, highlighting the potential utility of pre-operative mitigation of modifiable risk factors and stratification of payments based on patient profile. Lastly, reducing rates of SNF placement, readmission, ED visitation, and wound complications are targets for decreasing costs for patients undergoing TAA.

A cost analysis of remote monitoring in a heart failure program

ABSTRACTIn this study, we examine the cost per outcomes of remote monitoring services in home health care. The methodology followed case matched design via retrospective chart reviews. Results of the chi-square test suggest that there were no significant associations between the intervention and hospital readmissions, χ2 = (1, n = 210, p-value = .71, phi = .71). An independent t-test compared group means of the number of skilled nursing visits and agency costs, p-value of .002 and .000, respectively, favoring the standard of care group. Based on this data set, the home care agency lost $153.46 for each hospital readmission in the intervention group. The cost of care complicated the agency’s resources through an increase in nursing visits without offsetting the agency’s investment into technology; the cost did not support remote monitoring as a financially viable option to the standard of care.

Sex and the Septuagenarian … and Beyond

Sex and the Septuagenarian … and Beyond

The impact of home health length of stay and number of skilled nursing visits on hospitalization among Medicare-reimbursed skilled home health beneficiaries.

The implementation of the Home Health Prospective Payment System in 2000 led to a dramatic reduction in home health length of stay and number of skilled nursing visits among Medicare beneficiaries. While policy leaders have focused on the rising costs of home health care, its potential underutilization, and the relationship between service use and patient outcomes including hospitalization rates have not been rigorously examined. A secondary analysis of five Medicare-owned assessment and claims data sets for the year 2009 was conducted among two independently randomly selected samples of Medicare-reimbursed home health recipients (each n = 31,485) to examine the relationship between home health length of stay or number of skilled nursing visits and hospitalization rates within 90 days of discharge from home health. Patients who had a home health length of stay of at least 22 days or received at least four skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits. Additional study is needed to clarify the best way to structure home health services and determine readiness for discharge to reduce hospitalization among this chronically ill population. In the mean time, the findings of this study suggest that home health providers should consider the benefits of at least four SNV and/or a home health LOS of 22 days or longer.

Frontloading and Intensity of Skilled Home Health Visits: A State of the Science

Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home health patients. Upon review of the frontloading evidence, visit intensity emerged as being closely related. This state of the science presents a critique and synthesis of the published empirical evidence related to frontloading and visit intensity. OVID/Medline, PubMed, and Scopus were searched. Seven studies were eligible for inclusion. Further research is required to define frontloading and visit intensity, identify patients most likely to benefit, and to provide a better understanding of how home health agencies can best implement these strategies.

Impact of frontloading of skilled nursing visits on the incidence of 30-day hospital readmission

Hospitalization among older adults receiving skilled home health services continues to be prevalent. Frontloading of skilled nursing visits, defined as providing 60% of the planned skilled nursing visits within the first two weeks of home health episode, is one way home health agencies have attempted to reduce the need for readmission among this chronically ill population. This was a retrospective observational study using data from five Medicare-owned, national assessment and claim databases from 2009. An independent randomized sample of 4500 Medicare-reimbursed home health beneficiaries was included in the analyses. Propensity score analysis was used to reduce known confounding among covariates prior to the application of logistic analysis. Although whether skilled nursing visits were frontloaded or not was not a significant predictor of 30-day hospital readmission (p = 0.977), additional research is needed to refine frontloading and determine the type of patients who are most likely to benefit from it.

Cost Factors in Implementing Telemonitoring Programs in Rural Home Health Agencies

The purpose of this quantitative study was to examine costs and implementation factors associated with development of telemonitoring programs in eight rural home health agencies. although the telemonitoring group (n = 1,513) averaged fewer visits per episode than the control group (n = 1,573), cost analysis data, including labor, travel, and equipment costs, failed to support the hypothesis that decreased utilization of skilled nursing visits alone could offset the costs of the telemonitoring technology. this study indicates that agencies must achieve savings through improved outcome performance to offset telemonitoring expenses.

Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence?

Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence?

Trials and Tribulations: A Small Pilot Telehealth Home Care Program for Medicare Patients

This article describes a home care agency's experience initiating the technology of a telehealth program for a selected view of its home care patients. The goal of the telehealth program was to improve patient outcomes by augmenting patients' regularly scheduled in-home skilled nursing visits with video-conferencing encounters. Patient selection, costs, projected savings, patient satisfaction, and the technical, clinical, and patient problems with the telehealth system are discussed.

A Randomized Intervention to Improve Heart Failure Outcomes in Community-Based Home Health Care

ABSTRACT This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses' support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home health care agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses' teaching and support skills. Outcome measures included home care, physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p < .05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur.

Community health nursing, wound care, and…ethics?

Because of changing demographics and other factors, patients receiving care for wounds, ostomies, or incontinence are being referred in increasing numbers to community health nursing organizations for initial or continued care. As home-based wound care becomes big business, little discussion is being focused on the moral and ethical issues likely to arise in the high-tech home setting. Progressively more complex and expensive home care relies on family members to take on complicated care regimens in the face of decreasing numbers of allowable skilled nursing home visits. A framework and a principle-based theory for reflection on the character and content of moral and ethical conflicts are provided to encourage informed and competent care of patients in the home. Common moral and ethical conflicts for WOC nurses in the United States are presented. These conflicts include issues of wound care supply procurement; use of documentation to maximize care or profit; problems of quality, care consistency, and caregiver consent; and dilemmas of tiered health care options. The advantages of a framework to address ethical conflicts are discussed.

Resource utilization in home health care: results of a prospective study.

Resource utilization in home health care has become an issue of concern due to rising costs and recent initiatives to develop prospective payment systems for home health care. A number of issues remain unresolved for the development of prospective reimbursement in this sector, including the types of variables to be included as payment variables and appropriate measures of resource use. This study supplements previous work on home health case-mix by analyzing the factors affecting one aspect of resource use for skilled nursing visits--visit length--and explores the usefulness of several specially collected variables which are not routinely available in administrative records. A data collection instrument was developed with a focus group of skilled nurses, identifying a range of variables hypothesized to affect visit length. Five categories of variables were studied using multiple regression analysis: provider-related; patient's socio-economic status; patient's clinical status; patient's support services; and visit-specific. The final regression model identifies 9 variables which significantly affect visit time. Five of the 9 are visit-specific variables, a significant finding since these are not routinely collected. Case-mix systems which include visit time as a measure of resource use will need to investigate visit-specific variables, as this study indicates they could have the largest influence on visit time. Two other types of resources used in home health care, supplies and security drivers, were also investigated in less detail.

Wound Healing in the Home Health Area

This article presents a case that epitomizes the complexity of chronic pressure ulcer care in the home health arena. Proper assessment and care of a wound with appropriate therapy can result in cost savings, ease of application, decreased skilled nursing visits and ultimately, wound healing.

Cost function analysis of Medicare policy: Are reimbursement limits for rural home health agencies sufficient?

This paper estimates a hybrid total cost function to determine to what extent an urban/rural differential exists in home health agency expenditures in Wisconsin in 1987–1988. We find that costs are over $16 higher per visit in urban Milwaukee than in rural and small MSA counties, providing no evidence that Medicare reimbursement limits should be raised to reflect ‘ruralness’. However, the cost of providing skilled nursing care exceeds both urban and rural reimbursement limits. Because rural agencies depend more on Medicare clients and provide disproportionately more skilled nursing visits, this might represent the source of any financial difficulty.