August 6, 2019

Kaiser Family Foundation: Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Homes and Other Long-Term Care Facilities—A Potential for Achieving Medicare Savings and Improving the Quality of Care

We find that beneficiaries living in long-term care facilities account for a disproportionate share of Medicare spending, with relatively high rates of hospitalizations, emergency room visits, skilled nursing facility admissions and other Medicare-covered services. The relatively high Medicare spending is incurred not only by long-term care residents who die within […]
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We find that beneficiaries living in long-term care facilities account for a disproportionate share of Medicare spending, with relatively high rates of hospitalizations, emergency room visits, skilled nursing facility admissions and other Medicare-covered services. The relatively high Medicare spending is incurred not only by long-term care residents who die within the year, or those who transition from another setting into a long-term care facility, but also by beneficiaries living in a facility throughout the calendar year. Studies indicate that 30 to 67 percent of hospitalizations among facility residents could be prevented with well-targeted interventions.3 Others have identified factors that contribute to preventable hospitalizations, including liability concerns, limited staff capacity, financial incentives, and physician preferences.4 This analysis illustrates how successful efforts to reduce the rate of preventable hospitalizations could yield savings to Medicare. Such efforts, if carefully implemented, could also help to improve the quality of patient care for Medicare’s oldest and most frail beneficiaries.
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http://www.kff.org/medicare/upload/Presentation-Slides-Jacobson.pdf

August 6, 2019

National Transitions of Care Coalition

National Transitions of Care Coalition (NTOCC). [Web site]. Http://www.ntocc.org/Home.aspx . Updated 2014. Accessed July 29, 2014. The National Transitions of Care Coalition is a 501©(4) organization dedicated to addressing a serious U.S. health care issue: filling the gaps that occur when patients leave one care setting and move to another […]
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National Transitions of Care Coalition (NTOCC). [Web site]. Http://www.ntocc.org/Home.aspx . Updated 2014. Accessed July 29, 2014. The National Transitions of Care Coalition is a 501©(4) organization dedicated to addressing a serious U.S. health care issue: filling the gaps that occur when patients leave one care setting and move to another care setting. These transitions include patients moving from primary care to specialty physicians; moving or transferring patients from the emergency department to intensive care or surgery; and when patients are discharged from the hospital to home, assisted living arrangements, or skilled nursing facilities. The U.S. health care system often fails to meet the needs of patients during these transitions because care is rushed and responsibility is fragmented, with little communication across care settings and multiple providers. Since 2006, NTOCC’s Advisors Council of over 30 organizations has shared a common goal of improving the quality of Transitions of Care. Working in conjunction with 450 Associate Member organizations and over 3,000 individual professional subscribers, NTOCC has developed tools and resources made available to everyone in the health care industry including providers, payers, patients and consumers. NTOCC’s mission is supported by the Partners Council made up of innovative companies leading critical change in health care coordination.
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Http://www.ntocc.org/Home.aspx

August 7, 2019

The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial

J Gen Intern Med, 25;3:235-42 Authors: Boyd, C. M., Reider, L., Frey, K., Scharfstein, D., Leff, B. Wolff, J., Groves, C., Karm, L., Wegener, S., Marsteller, J., Boult, C. BACKGROUND: The quality of health care for older Americans with chronic conditions is suboptimal. OBJECTIVE: To evaluate the effects of “”Guided […]
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J Gen Intern Med, 25;3:235-42 Authors: Boyd, C. M., Reider, L., Frey, K., Scharfstein, D., Leff, B. Wolff, J., Groves, C., Karm, L., Wegener, S., Marsteller, J., Boult, C. BACKGROUND: The quality of health care for older Americans with chronic conditions is suboptimal. OBJECTIVE: To evaluate the effects of ""Guided Care"" on patient-reported quality of chronic illness care. DESIGN: Cluster-randomized controlled trial of Guided Care in 14 primary care teams. PARTICIPANTS: Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC). INTERVENTION: ""Guided Care"" is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2-5 physicians in providing comprehensive chronic care to 50-60 multi-morbid older patients. MEASUREMENTS: Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care. RESULTS: Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30-3.50, p = 0.003). CONCLUSION: Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.
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http://www.springerlink.com/content/1602g85371r24623/

August 7, 2019

Guided care: cost and utilization outcomes in a pilot study

Dis Manag, 11;1:28-36 Authors: Sylvia, M. L., Griswold, M., Dunbar, L., Boyd, C. M., Park, M., Boult, C., Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations. In a 6-month quasi-experimental study, we compared the cost and utilization […]
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Dis Manag, 11;1:28-36 Authors: Sylvia, M. L., Griswold, M., Dunbar, L., Boyd, C. M., Park, M., Boult, C., Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations. In a 6-month quasi-experimental study, we compared the cost and utilization patterns of patients assigned to GC and Usual Care (UC). The setting was a community-based general internal medicine practice. The participants were patients of 4 general internists. They were older, chronically ill, community-dwelling patients, members of a capitated health plan, and identified as high risk. Using the Adjusted Clinical Groups Predictive Model (ACG-PM), we identified those at highest risk of future health care utilization. We selected the 75 highest-risk older patients of 2 internists at a primary care practice to receive GC and the 75 highest-risk older patients of 2 other internists in the same practice to receive UC. Insurance data were used to describe the groups' demographics, chronic conditions, insurance expenditures, and utilization. Among our results, at baseline, the GC (all targeted patients) and UC groups were similar in demographics and prevalence of chronic conditions, but the GC group had a higher mean ACG-PM risk score (0.34 vs. 0.20, p < 0.0001). During the following 6 months, the GC group had lower unadjusted mean insurance expenditures, hospital admissions, hospital days, and emergency department visits (p > 0.05). There were larger differences in insurance expenditures between the GC and UC groups at lower risk levels (at ACG-PM = 0.10, mean difference = $4340; at ACG-PM = 0.6, mean difference = $1304). Thirty-one of the 75 patients assigned to receive GC actually enrolled in the intervention. These results suggest that GC may reduce insurance expenditures for high-risk older adults. If these results are confirmed in larger, randomized studies, GC may help to increase the efficiency of health care for the aging American population.
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http://www.liebertonline.com/doi/abs/10.1089/dis.2008.111723?prevSearch=allfield%253A%2528Guided%2BCare%2529&searchHistoryKey

August 7, 2019

Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report

J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to […]
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J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the ""medical home,"" models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02571.x/abstract

August 7, 2019

Multidisciplinary approach to inpatient medication reconciliation in an academic setting

PURPOSE The effectiveness of a multidisciplinary medication reconciliation process was studied in an inpatient family medicine unit of an academic hospital center. METHODS In phase 1 of this two-phase study, nurses, pharmacists, and physicians used an admission medication reconciliation form to reconcile patients’ home medications on admission. The form was […]
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PURPOSE The effectiveness of a multidisciplinary medication reconciliation process was studied in an inpatient family medicine unit of an academic hospital center. METHODS In phase 1 of this two-phase study, nurses, pharmacists, and physicians used an admission medication reconciliation form to reconcile patients' home medications on admission. The form was then reviewed by the pharmacist on the unit and by the attending physician, who reconciled the discharge medication list. The discharge medication list was compared against the patient's home medications list, inpatient medication profile, and prescriptions documented in the electronic medical record to investigate any medication discrepancies. Pharmacists participating in the study documented and categorized medication discrepancies by the potential severity of the error. In phase 2, family medicine medical residents and staff were instructed to include reconciled admission and discharge medication lists in the hospital summary. RESULTS A total of 102 patients formed the study sample. There was no significant difference between phase 1 and phase 2 patients in mean age, sex, and length of hospital stay. Totals of 432 and 367 admission medications required reconciliation during phase 1 and phase 2, respectively. The mean number of admission medication discrepancies decreased from 0.5 per patient in phase 1 to 0 per patient in phase 2. The mean number of discharge medication discrepancies decreased from 3.3 per patient in phase 1 to 1.8 per patient in phase 2. CONCLUSION The mean number of medication discrepancies occurring during admission and discharge decreased after a multidisciplinary medication reconciliation process was implemented in an inpatient family medicine unit of an academic hospital center.
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http://www.ncbi.nlm.nih.gov/pubmed/17420202?dopt=AbstractPlus

August 7, 2019

The Joint Commission National Patient Safety Goals

During 2009, the National Patient Safety Goals underwent an extensive review process. As a result, The Joint Commission has revised the NPSGs. The changes were made partly in response to concerns from the field about the resources needed to comply with NPSGs that have become more specific and detailed over […]
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During 2009, the National Patient Safety Goals underwent an extensive review process. As a result, The Joint Commission has revised the NPSGs. The changes were made partly in response to concerns from the field about the resources needed to comply with NPSGs that have become more specific and detailed over time. The revisions include clarifying and streamlining certain elements of performance, as well as deleting some requirements and moving others to the standards. The changes to the NPSGs reflect The Joint Commission’s continuing efforts to focus the NPSGs on those topics that are of highest priority to patient safety and quality care. Decreasing the number of NPSGs allows organizations to focus their efforts on the most important issues. Moving a requirement to the standards means that it is no longer necessary to “spotlight” the issue in the NPSGs. The improvements are similar to the Standards Improvement Initiative (SII), which the standards have undergone, and the goal of the improvements is to clarify language and ensure relevancy to the settings in which they apply. 2011 NPSG # 8: Accurately and completely reconcile medications across the continuum of care.
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http://www.jointcommission.org/standards_information/npsgs.aspx

August 7, 2019

TJC Sentinel Event Alert: Using medication reconciliation to prevent errors

The Joint Commission recognizes that many patients may be too ill, injured, young, or disabled to actively participate in the medication reconciliation process. In addition, patients may need the assistance of another person (e.g., family member, significant other, surrogate decision maker) if they are overwhelmed in managing their condition, are […]
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The Joint Commission recognizes that many patients may be too ill, injured, young, or disabled to actively participate in the medication reconciliation process. In addition, patients may need the assistance of another person (e.g., family member, significant other, surrogate decision maker) if they are overwhelmed in managing their condition, are not proficient in speaking or reading English, or face health literacy challenges that might prevent them from understanding medication use directions. Therefore, the following addition should be included in the section titled "Joint Commission requirements and recommendations." Addendum to Sentinel Event Alert #35, Using medication reconciliation to prevent errors (#4) When the patient is unable to actively or fully participate in the medication reconciliation process and has requested assistance from another person(s) (e.g., family member, significant other, surrogate decision maker), involve the authorized person(s) in the medication reconciliation process. This involvement should occur at all interfaces of care, and on admission to and discharge from the facility.
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http://www.jointcommission.org/assets/1/18/SEA_35.PDF

August 7, 2019

Challenges in transitional care between nursing homes and emergency departments

OBJECTIVE To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN Structured focus group interviews. PARTICIPANTS Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING Two NHs, 2 […]
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OBJECTIVE To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN Structured focus group interviews. PARTICIPANTS Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING Two NHs, 2 EDs, and a county-wide EMS system. ANALYSIS Audiotaped discussions were transcribed and analyzed independently by 2 authors. RESULTS Themes included barriers to providing high-quality care, data needed when residents are transported in both directions between EDs and NHs, and possible solutions to improve care. Communication problems were the most frequently cited barrier to providing care. Residents are often transported in both directions without any written documentation; however, even when communication does occur, it is often not in a mode that is useable by the receiving provider. ED personnel need a small amount of organized, written information. When residents are released from the ED, NH personnel need a verbal report from ED nurses as well as written documentation. All groups were optimistic that communication can be improved. Ideas included use of (1) fax machines or audiotape cassette recorders to exchange information, (2) an emergency form in residents’ charts that contains predocumented information with an area to write in the reason for transfer, and (3) brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs. CONCLUSION The transitional care of NH residents is laden with problems but has solutions that deserve additional development and investigation. KEYWORDS: Nursing homes, emergency service, hospital, emergency medical services, patient transfer
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http://www.jamda.com/article/S1525-8610(06)00174-5/abstract

August 7, 2019

Continuity of care: a multidisciplinary review

Patients are increasingly seen by an array of providers in a wide variety of organizations and places, raising concerns about fragmentation of care. Policy reports and charters worldwide urge a concerted effort to enhance continuity, 1 – 3 but efforts to describe the problem or formulate solutions are complicated by […]
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Patients are increasingly seen by an array of providers in a wide variety of organizations and places, raising concerns about fragmentation of care. Policy reports and charters worldwide urge a concerted effort to enhance continuity, 1 – 3 but efforts to describe the problem or formulate solutions are complicated by the lack of consensus on the definition of continuity. To add to the confusion, other terms such as continuum of care, coordination of care, discharge planning, case management, integration of services, and seamless care are often used synonymously. This synthesis was commissioned by three Canadian health services policy and research bodies. The aim was to develop a common understanding of the concept of continuity as a basis for valid and reliable measurement of practice in different settings.
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http://www.bmj.com/content/327/7425/1219.extract