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ABSTRACT: To evaluate Hospital at Home (HaH), a substitute for inpatient care, from the perspectives of participating providers.
Multivariate general estimating equations regression analyses of a patient-specific survey of providers delivering HaH care in a prospective, nonrandomized clinical trial.
Eleven physicians and 26 nurses employed in 3 Medicare-Advantage plans and 1 Veterans Administration medical center.
Problems with care; benefits; problem-free index.
Case response rates were 95% and 82% for physicians and nurses, respectively. The overall problem-free index was high (mean 4.4, median 5, scale 1-5). "Major" problems were cited for 14 of 84 patients (17%), most relating to logistic issues without adverse patient outcomes. Positive effects included quicker patient functional recovery, greater opportunities for patient teaching, and increased communication with family caregivers. In multivariate analysis, the problem-free index was lower for nurses compared with physicians in one site; for patients with cellulitis; and for patients with a higher acuity (APACHE II) score. HaH physicians and nurses differed in their judgments of hours of continuous nursing required by patients.
The health care provider evaluation of substitutive HaH care was positive, providing support for the viability of this innovative model of care. Without provider support, no new model of care will survive. These findings also provide insight into areas to attend to in implementation. Organizations considering adoption of the HaH should monitor provider views to promote quality improvement in HaH.
Medical care 10/2009; 47(9):979-85. · 3.24 Impact Factor
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Charlene C Quinn,
Ann L Gruber-Baldini,
Cynthia L Port,
Conrad May,
Bruce Stuart,
J Richard Hebel,
Sheryl Zimmerman, Lynda Burton,
Ilene H Zuckerman,
Cheryl Fahlman,
Jay Magaziner
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ABSTRACT: To study the role of nursing home (NH) admission and dementia status on the provision of five procedures related to diabetes mellitus.
Retrospective cohort study using data from a large prospective study in which an expert panel determined the prevalence of dementia.
Fifty-nine Maryland NHs.
Three hundred ninety-nine new admission NH patients with diabetes mellitus.
Medicare administrative claims records matched to the NH medical record data were used to measure procedures related to diabetes mellitus received in the year before NH admission and up to a year after admission (and before discharge). Procedures included glycosylated hemoglobin, fasting blood glucose, dilated eye examination, lipid profile, and serum creatinine.
For all but dilated eye examinations, higher rates of procedures related to diabetes mellitus were seen in the year after NH admission than in the year before. Residents without dementia received more procedures than those with dementia, although this was somewhat attenuated after controlling for demographic, health, and healthcare utilization variables. Persons without dementia experience greater increases in procedure rates after admission than those with dementia.
The structured environment of care provided by the NH may positively affect monitoring procedures provided to elderly persons with diabetes mellitus, especially those without dementia. Medical decisions related to the risks and benefits of intensive treatment for diabetes mellitus to patients of varying frailty and expected longevity may lead to lower rates of procedures for residents with dementia.
Journal of the American Geriatrics Society 09/2009; 57(9):1628-33. · 3.74 Impact Factor
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ABSTRACT: To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care.
Survey questionnaire of participants in a prospective nonrandomized clinical trial.
Three Medicare managed care health systems and a Veterans Affairs Medical Center.
Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital.
Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital.
Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores.
Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs -0.60, P=.10, range -12.0 to 7.0; IADL 0.74 vs -0.70, P=.007, range -5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04).
HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.
Journal of the American Geriatrics Society 01/2009; 57(2):273-8. · 3.74 Impact Factor
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Bruce Leff, Lynda Burton,
Scott L Mader,
Bruce Naughton,
Jeffrey Burl,
Debbie Koehn,
Rebecca Clark,
William B Greenough,
Susan Guido,
Donald Steinwachs,
John R Burton
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ABSTRACT: To compare differences in the stress experienced by family members of patients cared for in a physician-led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care.
Survey questionnaire completed as a component of a prospective, nonrandomized clinical trial of a substitutive HaH care model.
Three Medicare managed care health systems and a Veterans Affairs Medical Center.
Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis.
Treatment in a substitutive HaH model.
Fifteen-question survey questionnaire asking family members whether they experienced a potentially stressful situation and, if so, whether stress was associated with the situation while the patient received care.
The mean and median number of experiences, of a possible 15, that caused stress for family members of HaH patients was significantly lower than for family members of acute care hospital patients (mean +/- standard deviation 1.7 +/- 1.8 vs 4.3 +/- 3.1, P<.001; median 1 vs 4, P<.001). HaH care was associated with lower odds of developing mean levels of family member stress (adjusted odds ratio=0.12, 95% confidence interval=0.05-0.30).
HaH is associated with lower levels of family member stress than traditional acute hospital care and does not appear to shift the burden of care from hospital staff to family members.
Journal of the American Geriatrics Society 01/2008; 56(1):117-23. · 3.74 Impact Factor
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ABSTRACT: To determine rates of depression by dementia status in a statewide sample of nursing home admissions, and associations with medical comorbidity and physical functioning.
Trained interviewers obtained information from nursing home residents, staff, significant others, and medical records.
A total of 22.3% were classified depressed in the nondemented status and 23.6% in the demented status. Depression status was significantly associated with more physical dependencies regardless of dementia status. In the nondemented, there was also a significant positive association with number of comorbidities. One interaction, dementia with comorbidity at the highest levels of comorbidity, was significant in looking at association with depression.
There is significant depressive symptomatology in nursing home admissions, which is also associated with difficulty in physical function and with the number of medical comorbidities in the nondemented. Application of the two measures used in this study represents a strategy to assess depression in all nursing home residents.
American Journal of Geriatric Psychiatry 06/2007; 15(5):438-42. · 3.64 Impact Factor
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ABSTRACT: To examine differences in satisfaction with acute care between patients who received treatment in a physician-led substitutive Hospital at Home program and those who received usual acute hospital care.
Survey questionnaire of participants in prospective, nonrandomized clinical trial.
Three Medicare-managed care health systems and a Department of Veterans Affairs Medical Center.
Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in Hospital at Home and 130 in the acute care hospital.
Treatment in a Hospital at Home model of care that substitutes for treatment in an acute care hospital.
A 40-question survey measuring nine domains of care for patients and a 37-question survey measuring eight domains of care for family members.
A higher proportion of patients were satisfied with treatment in Hospital at Home than with the acute care hospital in eight of nine domains, and this difference was statistically different in four domains. Hospital at Home patients were more likely than acute hospital patients to be satisfied with their physician (adjusted odds ratio (AOR) = 3.84, 95% confidence interval (CI) = 1.32-11.19), comfort and convenience of care (AOR = 6.52, 95% CI = 1.97-21.56), admission processes (AOR = 5.90, 95% CI = 2.21-5.76), and the overall care experience (AOR = 2.98, 95% CI = 1.08-8.21). Family members of patients treated in Hospital at Home were also more likely to be satisfied with multiple domains of care.
Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.
Journal of the American Geriatrics Society 10/2006; 54(9):1355-63. · 3.74 Impact Factor
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Jay Magaziner,
Sheryl Zimmerman,
Ann L Gruber-Baldini,
Carol van Doorn,
J Richard Hebel,
Pearl German, Lynda Burton,
George Taler,
Conrad May,
Charlene C Quinn,
Cynthia L Port,
Mona Baumgarten
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ABSTRACT: To evaluate the association between dementia and mortality, adverse health events, and discharge disposition of newly admitted nursing home residents. It was hypothesized that residents with dementia would die at a higher rate and develop more adverse health events (e.g., infections, fevers, pressure ulcers, falls) than residents without dementia because of communication and self-care difficulties.
An expert clinician panel diagnosed an admission cohort from a stratified random sample of 59 Maryland nursing homes, between 1992 and 1995. The cohort was followed for up to 2 years or until discharge.
Fifty-nine Maryland nursing homes.
Two thousand one hundred fifty-three newly admitted residents aged 65 and older not having resided in a nursing home for 8 or more days in the previous year.
Mortality, infection, fever, pressure ulcers, fractures, and discharge home.
Residents with dementia had significantly lower overall rates of infection (relative risk (RR)=0.77, 95% confidence interval (CI)=0.70-0.85) and mortality (RR=0.61, 95% CI=0.53-0.71) than those without dementia, whereas rates of fever, pressure ulcers, and fractures were similar for the two groups. These results persisted when rates were adjusted for demographic characteristics, comorbid conditions, and functional status. During the first 90 days of the nursing home stay, residents with dementia had significantly lower rates of mortality if not admitted for rehabilitative care under a Medicare qualifying stay (RR=0.25, 95% CI=0.14-0.45), were less often discharged home (RR=0.33, 95% CI=0.28-0.38), and tended to have lower fever rates (RR=0.78, 95% CI=0.63-0.96) than residents without dementia.
Newly admitted nursing home residents with dementia have a profile of health events that is distinct from that of residents without dementia, indicating that the two groups have different long-term care needs. Results suggest that further investigation of whether residents with dementia can be well managed in alternative residential settings would be valuable.
Journal of the American Geriatrics Society 12/2005; 53(11):1858-66. · 3.74 Impact Factor
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Bruce Leff, Lynda Burton,
Scott L Mader,
Bruce Naughton,
Jeffrey Burl,
Sharon K Inouye,
William B Greenough,
Susan Guido,
Christopher Langston,
Kevin D Frick,
Donald Steinwachs,
John R Burton
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ABSTRACT: Acutely ill older persons often experience adverse events when cared for in the acute care hospital.
To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home.
Prospective quasi-experiment.
3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center.
455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis.
Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital.
Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care.
Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001).
Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences.
The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.
Annals of internal medicine 12/2005; 143(11):798-808. · 16.73 Impact Factor
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ABSTRACT: Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings.
An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups.
Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS.
Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.
The Gerontologist 09/2005; 45(4):505-15. · 2.48 Impact Factor
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ABSTRACT: To compare outcomes of infection in nursing home residents with and without early hospital transfer.
Observational cohort study.
Fifty-nine nursing homes in Maryland.
Two thousand one hundred fifty-three individuals admitted to nursing homes between 1992 and 1995.
Incident infection was recorded when a new infectious diagnosis was documented in the medical record or nonprophylactic antibiotic therapy was prescribed. Early hospital transfer was defined as transfer to the emergency department or admission to the hospital within 3 days of infection onset. Infection, resident, and facility characteristics were entered into a multivariate model to create a propensity score for early hospital transfer. Association between early hospital transfer and outcomes of infection, namely pressure ulcers and death between Days 4 and 34 after infection onset, were examined, controlling for propensity score.
Four thousand nine hundred ninety infections occurred in 1,301 residents. Genitourinary (28%), skin (19%), upper respiratory (13%), and lower respiratory (12%) were the most common types. Three hundred seventy-five episodes in which residents survived 3 days (7.6%) resulted in early hospital transfer. In multivariate regression, individuals with early hospital transfer had higher mortality (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.04-1.99) and, in 1-month survivors, a greater occurrence of pressure ulcers (OR 1.61, 95% CI=1.17-2.20) than those without, after adjusting for propensity score.
Using observational data and propensity score methods, outcomes were worse in nursing home residents transferred to the hospital within 3 days of infection onset than in those who remained in the nursing home.
Journal of the American Geriatrics Society 05/2005; 53(4):590-6. · 3.74 Impact Factor
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ABSTRACT: The involvement of family and friends in nursing home care represents an important resource for an overburdened long-term care system. However, little guidance exists for researchers interested in measuring family involvement.
This methodological report provides an overview of approaches to measuring family involvement in nursing home care and examines agreement between family and staff on the frequency of visits and telephone calls to a resident by family and friends. Agreement is also assessed for subgroups of the sample based on characteristics of the family, staff, facility, and resident.
From a large and representative sample of nursing home residents, 823 pairs of significant others and staff were interviewed. Primary variables were reports of visitation and telephone contact received by the resident in the preceding 2 weeks according to the significant other and staff person.
Significant other reports of visitation and telephone contact were significantly higher than staff reports (p <.001 and p <.01). Agreement (via intraclass correlation) between significant others and staff was moderate for reports of visit and telephone call frequency. With one exception, no significant differences in agreement were found between subgroups defined by characteristics of the family, staff, facility, or resident. For visits, agreement between nurse's aides and significant others was lower than between other staff persons (e.g., LPNs and RNs) and significant others (p <.05).
Due to the complexity of nursing home settings as well as of the social support system of residents, researchers need to carefully consider their approach to the measurement of the involvement of family and friends in the nursing home.
Nursing Research 12/2002; 52(1):52-6. · 1.40 Impact Factor
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ABSTRACT: The Memory and Medical Care Study (MMCS) is a community-based, longitudinal study of elders at risk for dementia. This paper describes the study methods for identifying subjects with dementia or mild cognitive impairment (MCI) and the validation of these methods. The MMCS cohort was established by identifying subjects at risk for dementia in three previous studies of randomly ascertained samples. Neuropsychologic test score criteria were established to identify MMCS subjects with dementia or MCI. These criteria were validated using a fourth community-based sample of at-risk elders in which dementia was identified by a clinical adjudication panel. Of the 498 MMCS subjects, 70% had dementia and 27% had MCI by the MMCS criteria. In the validation sample, the MMCS dementia classification method was in agreement with the clinical adjudication panel for 81% of cases (kappa = 0.62, 95% confidence interval = 0.45-0.78). The methods used in the MMCS are efficient and reasonably valid for establishing a cohort of subjects to investigate how dementia is assessed, diagnosed, and treated in the community.
Dementia has become a major public health concern (Toseland et al., 1999) because it leads to serious physical, functional, and psychologic morbidity for the individual (Burns et al., 1991;Lyketsos and Rabins, 1994), because it shortens life expectancy (Kelman et al., 1994;Kukull et al., 1994), and because caring for people with dementia exacts a heavy toll on the care providers over the course of the illness (Rabins et al., 1982;George and Gwyther, 1986;Drinka et al., 1987). The broader economic impact of dementia is also sizeable. It is estimated that the cost of Alzheimer disease (AD) alone is >80 billion dollars annually, with payments for long-term home care and nursing home care being the largest component of these expenditures (Ernst and Hay, 1994). Given the projected increase in the prevalence of dementia over the next 50 years (Kawas and Brookmeyer, 2001), it is critical to better understand how dementia is assessed, diagnosed, and treated in the community and to determine whether available treatments influence outcomes for those with dementia, their caregivers, and the community at large. The Memory and Medical Care Study (MMCS) is designed to address these issues.
The onset of dementia is often insidious, and its symptoms frequently go unrecognized for years. However, because no treatments are currently available to prevent or cure dementia [with the possible exceptions of vascular dementia (Meyer et al., 1986), neurosyphilis, and HIV/AIDS], debate persists about the value of early identification. For example, the Agency for Health Care Policy and Research (AHCPR) guidelines on early diagnosis of dementia (Costa et al., 1996) found that techniques for early diagnosis have not been well established and that the costs, benefits, and outcomes of early assessments are unknown. However, an extensive clinical literature [e.g., Mace and Rabins (1999), Jarvik (1988)] and fewer efficacy studies suggest that some symptoms of dementia are treatable (Pinkston et al., 1988;Schneider et al., 1990;Lyketsos et al., 2000), but the effectiveness of these treatments in population-based studies has not been demonstrated. This is an important issue because the presence and severity of noncognitive symptoms correlate with an increased likelihood of nursing home placement and greater caregiver distress (Steele et al., 1990;Lopez et al., 1991;Pearson et al., 1993;Kasper and Shore, 1994). Studies have demonstrated that nursing home placement can be delayed by family support (Mittelman et al., 1993), day care (Brodaty and Peters, 1991), or the use of community services (Jette et al., 1995), but these have often been carried out in nonrepresentative samples of subjects ascertained from research centers or service sites [e.g., Gwyther and George (1986), Lawton and Brody (1989)].
The MMCS is an observational, longitudinal study of community-residing people 65 years of age and older who, in three previous population-based studies, were identified as being at high risk for having dementia. The main objectives of the MMCS are to determine whether those meeting criteria for dementia have been assessed and diagnosed by their physicians and whether the care they receive influences outcomes such as the likelihood and timing of nursing home placement, reduction of noncognitive symptoms of dementia, quality of life, and decreases in expenditures for care. As a basis for addressing these prospective research questions, we first examine the validity of our methods for identifying MMCS subjects who have dementia.
This report describes the design and methods of the MMCS and specifies the criteria and procedures for identifying subjects with dementia based on a battery of four brief neuropsychologic tests. This method was chosen because clinical evaluation of a large community sample was economically unfeasible. The validity of our approach for determining dementia status in the MMCS is established using another population-based observational study of at-risk elders in which dementia was identified by a clinical adjudication panel.
Alzheimer Disease and Associated Disorders 12/2002; 17(1):9-18. · 2.81 Impact Factor
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ABSTRACT: Background
Verbal and physical aggression are common behavior problems among nursing home residents with dementia. Depression among nursing home residents is also a common but underdiagnosed disorder.Method
Data collected on 1101 residents with dementia, newly admitted to a sample of 59 nursing homes across Maryland, were analyzed to determine if there was a relationship between depression and physical and verbal aggression.ResultsResidents with dementia who manifested physical or verbal aggression had a higher prevalence of depression than those without such behaviors (p<0.05).Conclusions
Our findings suggest that nursing home residents with aggressive behaviors should be screened for depression and treated. Copyright © 2001 John Wiley & Sons, Ltd.
International Journal of Geriatric Psychiatry 02/2001; 16(2):139 - 146. · 2.42 Impact Factor
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ABSTRACT: This study investigated whether there are race differences in the structure of informal caregiving networks. Data on 3,793 functionally impaired persons age 65 and over from the 1989 National Long-Term Care Survey were analyzed. The size of the total caregiver network and the unpaid network did not differ by race, but the likelihood of there being a non-immediate family member among unpaid caregivers was higher among disabled older blacks. These findings raise questions about whether race differences in nursing home utilization and paid long-term care services, documented in other studies, can be explained by differences in caregiving arrangements.
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ABSTRACT: The Memory and Medical Care Study (MMCS) is a community-based, longitudinal study of elders at risk for dementia. This paper describes the study methods for identifying subjects with dementia or mild cognitive impairment (MCI) and the validation of these methods. The MMCS cohort was established by identifying subjects at risk for dementia in three previous studies of randomly ascertained samples. Neuropsychologic test score criteria were established to identify MMCS subjects with dementia or MCI. These criteria were validated using a fourth community-based sample of at-risk elders in which dementia was identified by a clinical adjudication panel. Of the 498 MMCS subjects, 70% had dementia and 27% had MCI by the MMCS criteria. In the validation sample, the MMCS dementia classification method was in agreement with the clinical adjudication panel for 81% of cases (kappa = 0.62, 95% confidence interval = 0.45-0.78). The methods used in the MMCS are efficient and reasonably valid for establishing a cohort of subjects to investigate how dementia is assessed, diagnosed, and treated in the community.
Alzheimer Disease and Associated Disorders 17(1):9-18. · 2.81 Impact Factor
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ABSTRACT: To evaluate the relationship of nursing home characteristics to Medicare costs overall and by dementia status.
New admissions followed for 2 years. Setting. Random stratified sample of 55 Maryland nursing homes.
Sample of 1257 residents.
Records, interview, and observation.
Medicare costs were lower in facilities that have a better environmental quality, hospice beds, and more food service workers; costs were higher in hospital-based facilities and those that have a higher Medicaid case mix, X-ray, and some specified types of staff. Across all characteristics, costs for residents with dementia were consistently two-thirds the cost of other residents.
In terms of dementia status, resident characteristics drive Medicare costs, as opposed to facility characteristics. Using alternative residential settings for individuals with dementia may increase Medicare costs of nursing home residents and Medicare costs of residents with dementia who are cared for in settings less able to attend to medical needs.
American Journal of Alzheimer s Disease and Other Dementias 23(1):57-65. · 1.45 Impact Factor
