Posthospital Care Transitions: Patterns, Complications, and Risk Identification

Coleman, Eric A.; Min, Sung‐Joon; Chomiak, Alyssa; Kramer, Andrew M.

doi:10.1111/j.1475-6773.2004.00298.x

Cited by 367 publications

(306 citation statements)

References 39 publications

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“…We had hypothesized that disability limitations measured as ADL limitations would be significant predictors of readmission for all the cohorts, supported by literature data. [10][11][12][13][14][15][16][17][18][19][39][40][41][42] Although ADL limitations were significant predictors of readmission for pneumonia using the HRS-CMS and ACS-HCUP data sets, this was not demonstrated for the heart failure or acute myocardial infarction cohorts. Cognitive impairment did not predict readmission in any cohort for either data set, perhaps because the diagnosis of dementia is part of the standard CMS risk adjustment already applied.…”

Section: Discussionmentioning

confidence: 99%

“…7 However, an increasing body of literature reveals that patient disability and social determinants of health impact readmission risk and vary across hospital populations, contributing to higher readmission penalties for safety-net hospitals-and generating increasing interest in studying risk adjustment for sociodemographic factors. 1,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] To provide a better understanding of the extent to which the addition of patient disability and social determinants of health would impact the current risk adjustment models used by CMS, the objective of our study was to assess how measures of disability and social determinants of health were associated Electronic supplementary material The online version of this article (doi:10.1007/s11606-016-3869-x) contains supplementary material, which is available to authorized users.…”

Section: T He Centers For Medicare and Medicaid Services (Cms)mentioning

confidence: 99%

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The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study

et al. 2016

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BACKGROUND: Readmission rates after pneumonia, heart failure, and acute myocardial infarction hospitalizations are risk-adjusted for age, gender, and medical comorbidities and used to penalize hospitals. OBJECTIVE: To assess the impact of disability and social d e t e r m i n an t s o f h ea l t h o n c o n d i t i o n-s p e c i f i c readmissions beyond current risk adjustment. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of Medicare patients using 1) linked Health and Retirement Study-Medicare claims data (HRS-CMS) and 2) Healthcare Cost and Utilization Project State Inpatient Databases (Florida, Washington) linked with ZIP Code-level measures from the Census American Community Survey (ACS-HCUP). Multilevel logistic regression models assessed the impact of disability and selected social determinants of health on readmission beyond current risk adjustment. M A I N M E A S U R E S : O u t c o m e s m e a s u r e d w e r e readmissions ≤30 days after hospitalizations for pneumonia, heart failure, or acute myocardial infarction. HRS-CMS models included disability measures (activities of daily living [ADL] limitations, cognitive impairment, nursing home residence, home healthcare use) and social determinants of health (spouse, children, wealth, Medicaid, race). ACS-HCUP model measures were ZIP Codepercentage of residents ≥65 years of age with ADL difficulty, spouse, income, Medicaid, and patient-level and hospital-level race. KEY RESULTS: For pneumonia, ≥3 ADL difficulties (OR 1.61, CI 1.079-2.391) and prior home healthcare needs (OR 1.68, CI 1.204-2.355) increased readmission in HRS-CMS models (N = 1631); ADL difficulties (OR 1.20, CI 1.063-1.352) and 'other' race (OR 1.14, CI 1.001-1.301) increased readmission in ACS-HCUP models (N = 27,297). For heart failure, children (OR 0.66,) and wealth (OR 0.53, CI 0.349-0.787) lowered readmission in HRS-CMS models (N = 2068), while black (OR 1.17, CI 1.056-1.292)

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Section: Discussionmentioning

confidence: 99%

Section: T He Centers For Medicare and Medicaid Services (Cms)mentioning

confidence: 99%

The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study

et al. 2016

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“…This integration could focus on better communication using electronic health records and communications at the time of transfer. 17,18 Integration could also occur through contractual arrangements. Hospitals might acquire post-acute providers or create preferred provider referral networks.…”

Section: Discussionmentioning

confidence: 99%

Post-acute referral patterns for hospitals and implications for bundled payment initiatives

et al. 2014

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a b s t r a c tBackground: Under new bundled payment models, hospitals are financially responsible for post-acute care delivered by providers such as skilled nursing facilities (SNFs) and home health agencies (HHAs). The hope is that hospitals will use post-acute care more prudently and better coordinate care with postacute providers. However, little is known about existing patterns in hospitals' referrals to post-acute providers. Methods: Post-acute provider referrals were identified using SNF and HHA claims within 14 days following hospital discharge. Hospital post-acute care network size and concentration were estimated across hospital types and regions. The 2008 Medicare Provider Analysis and Review claims for acute hospitals and SNFs, and the 100% HHA Standard Analytic Files were used. Results: The mean post-acute care network size for U.S. hospitals included 57.9 providers with 37.5 SNFs and 23.4 HHAs. The majority of these providers (65.7% of SNFs, 60.9% of HHAs) accounted for 1 percent or less of a hospital's referrals and classified as "low-volume". Other post-acute providers we classified as routine. The mean network size for routine providers was greater for larger hospitals, teaching hospitals and in regions with higher per capita post-acute care spending. Conclusions: The average hospital works with over 50 different post-acute providers. Moreover, the size of post-acute care networks varies considerably geographically and by hospital characteristics. These results provide context on the complex task hospitals will face in coordinating care with post-acute providers and cutting costs under new bundled payment models.

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“…Additionally, research has focused more on singular care transitions (Wysocki et al, 2014) and their predictors (Callahan et al, 2012;Luppa et al, 2010) rather than examining the overall patterns of service use for LTC clients over time (Coleman, Min, Chomiak, & Kramer, 2004;Murtaugh & Litke, 2002). This gap in knowledge, coupled with the increasing prevalence of dementia among older persons, provides an important rationale for this work (Alzheimer Society of Canada, 2010;WHO, 2015).…”

Section: Introductionmentioning

confidence: 99%

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

Cloutier¹,

Penning

2016

GERONT

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Purpose of the Study: Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers' experiences? (b) What lessons do our mothers' experiences offer for the care of older women with dementia? Design and Methods: Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives-the stories of our mothers who made the transition from home care into residential (nursing home) care. Results: Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families. Implications: A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeyshealth and service trajectories of older women with dementia. Writing over a decade ago about their mother's experience of nursing home care after a serious stroke, Kane and West (2005) argued that society appears uninterested in making the necessary commitment to care for frail older adults in creative, compassionate, and appropriate ways aligned with goals of quality of care and quality of life. In this special issue called, Aging-It's Personal, we explore this concern by triangulating data from our funded research program with our personal narratives describing our mothers' experiences as clients of the long-term care (LTC) system.As social gerontologists, we have spent much of our careers studying health service provision for vulnerable older adults. As adult children, we have recent personal and family-centered experience related to our mothers' care journeys as women who began their service trajectory in home care and continued on to become clients of residential (nursing home) care until their deaths. In thisThe Gerontologist cite as : Gerontologist, 2017, Vol. 57, No. 1, 68-81 doi:10.1093 Advance Access publication November 16, 2016 article, we employ the metaphor of Janus, the two-faced Roman god of beginnings and transitions, to explore how our personal and professional worlds have intertwined, affecting us indelibly as family members, sparking our research questions, and giving us a greater appreciation for the ways that care is navigated. We consider ...

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Posthospital Care Transitions: Patterns, Complications, and Risk Identification

Cited by 367 publications

References 39 publications

The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study

The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study

Post-acute referral patterns for hospitals and implications for bundled payment initiatives

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

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