Potentially Avoidable Hospitalizations of Dually Eligible Medicare and Medicaid Beneficiaries from Nursing Facility and Home- and Community-Based Services Waiver Programs
ABSTRACT 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.
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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 · 1.99 Impact Factor
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ABSTRACT: The coordination of Medicare and Medicaid benefits and services for dually eligible enrollees has been a longstanding policy challenge. Several provisions of the Affordable Care Act (ACA) attempt to address this lack of coordination, including the establishment of the Federal Coordinated Health Care Office. This paper reviews the major changes under the ACA directed at care coordination for the dually eligible population and then concludes with a discussion of the continuing legislative and legal challenges in integrating care for the dually eligible.Journal of Aging & Social Policy 04/2012; 24(2):221-32. DOI:10.1080/08959420.2012.659113 · 0.60 Impact Factor
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ABSTRACT: Reducing preventable hospitalizations is fundamental to the "triple aim" of improving care, improving health, and reducing costs. New federal government initiatives that create strong pressure to reduce such hospitalizations are being or will soon be implemented. These initiatives use quality measures to define which hospitalizations are preventable. Reducing hospitalizations could greatly benefit frail and chronically ill adults and older people who receive long-term care (LTC) because they often experience negative effects of hospitalization, including hospital-acquired conditions, morbidity, and loss of functional abilities. Conversely, reducing hospitalizations could mean that some people will not receive hospital care they need, especially if the selected measures do not adequately define hospitalizations that can be prevented without jeopardizing the person's health and safety. An extensive literature search identified 250 measures of preventable hospitalizations, but the measures have not been validated in the LTC population and generally do not account for comorbidity or the capacity of various LTC settings to provide the required care without hospitalization. Additional efforts are needed to develop measures that accurately differentiate preventable from necessary hospitalizations for the LTC population, are transparent and fair to providers, and minimize the potential for gaming and unintended consequences. As the new initiatives take effect, it is critical to monitor their effect and to develop and disseminate training and resources to support the many community- and institution-based healthcare professionals and emergency department staff involved in decisions about hospitalization for this population.Journal of the American Geriatrics Society 11/2012; 60(12). DOI:10.1111/jgs.12002 · 4.22 Impact Factor