Potentially Avoidable Hospitalizations of Dually Eligible Medicare and Medicaid Beneficiaries from Nursing Facility and Home- and Community-Based Services Waiver Programs

Department of Aging, Disability and Long Term Care, RTI International, Waltham, Massachusetts, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.57). 03/2012; 60(5):821-9. DOI: 10.1111/j.1532-5415.2012.03920.x
Source: PubMed


Beneficiaries dually eligible for Medicare and Medicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in this population.
Retrospective study of hospitalizations.
Hospitalizations from nursing facilities (NF) including Medicare and Medicaid-covered stays, and Medicaid Home and Community-Based Services (HCBS) waiver programs.
Dually eligible individuals who received Medicare skilled nursing facility (SNF) or Medicaid NF services or HCBS waiver services in 2005.
Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed without hospitalization.
More than one-third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH. PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH. The total Medicare costs for these hospitalizations were $3 billion, but only $463 million for Medicaid. A sensitivity analysis, assuming that 20%-60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population.
Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life.

1 Follower
18 Reads
  • Source
    • "In order to calculate risk-adjusted quality measures and perform multivariable analyses , we first identified resident characteristics that were potentially associated with these measures based on previous literature (Flacker & Kiely, 2003; Li et al., 2011; Ouslander et al., 2010; Spector et al., 2013; Walsh et al., 2012). They included age, gender, race (non-Hispanic White vs. otherwise), difficulties in the activities of daily living (ADLs), the Cognitive Performance Scale (CPS), do-not-resuscitate order, and the presence or absence of dementia (Alzheimer disease or other types of dementia), stroke, diabetes or other endocrine disease, cardiovascular disease, musculoskeletal disease, cancer, incontinence (frequent or complete bowel or bladder incontinence), antipsychotic drug use, hip fracture in last 180 days, or being at the end stage of life (≤6 months to live). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Several states are currently collecting and publicly reporting nursing home resident and/or family member ratings of experience with care in an attempt to improve person-centered care in nursing homes. Using the 2008 Maryland nursing home family survey reports and other data, this study performed both facility- and resident-level analyses, and estimated the relationships between family ratings of care and several long-term care quality measures (pressure ulcers, overall and potentially avoidable hospitalizations, and mortality) after adjustment for resident characteristics. We found that better family evaluations of overall and specific aspects of care may be associated with reduced rates of risk-adjusted measures at the facility level (range of correlation coefficients: -.01 to -.31). Associations of overall experience ratings tended to persist after further adjustment for common nursing home characteristics such as nurse staffing levels. We conclude that family ratings of nursing home care complement other types of performance measures such as risk-adjusted outcomes. © The Author(s) 2015.
    Medical Care Research and Review 07/2015; DOI:10.1177/1077558715596470 · 2.62 Impact Factor
  • Source
    • "Third, our primary outcome, days at home, is patient-centered, which is rare as a primary outcome in caregiver trials. Yet such a focus is critical to both improving patients' quality of life and supporting the VA in its mission to provide care in the least restrictive setting [10] [11] [12]. Fourth, we remove financial barriers for the financiallyconstrained caregivers to address low recruitment and retention rates that are common in many caregiver trials. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Within the Veterans Health Administration (VHA), the largest integrated health care system in the US, approximately 8.5 million Veteran patients receive informal care. Despite a need for training, half of VHA caregivers report that they have not received training that they deemed necessary. Rigorous study is needed to identify effective ways of providing caregivers with the skills they need. This paper describes the Helping Invested Families Improve Veterans’ Experience Study (HI-FIVES), an ongoing randomized controlled trial that is evaluating a skills training program designed to support caregivers of cognitively and/or functionally impaired, community-dwelling Veterans who have been referred to receive additional formal home care services. This two-arm randomized controlled trial will enroll a total of 240 caregiver-patient dyads. For caregivers in the HI-FIVES group, weekly individual phone training occurs for 3 weeks, followed by 4 weekly group training sessions, and two additional individual phone training calls. Caregivers in usual care receive information about the VA Caregiver Support Services Program services, including a hotline number. The primary outcomes is the number of days a veteran patient spends at home in the 12 months following randomization (e.g. not in the emergency department, inpatient or nursing home setting). Secondary outcomes include patient VHA health care costs, patient and caregiver satisfaction with VHA health care, and caregiver depressive symptoms. Outcomes from HI-FIVES have the potential to improve our knowledge of how to maximize the ability to maintain patients safely at home for caregivers while preventing poor mental health outcomes among caregivers.
    Contemporary Clinical Trials 07/2014; 38(2). DOI:10.1016/j.cct.2014.05.003 · 1.94 Impact Factor
  • Source
    • "The bed-hold policy may inadvertently create incentives to hospitalize residents as the nursing home receives partial per diem payments without providing services when the resident is hospitalized (Gruneir et al., 2007). On the other hand, some studies have not found that bed-hold policies are associated with potentially avoidable hospitalizations (Walsh et al., 2010). "

Show more