Reducing Rural and Urban Disparities in Potentially Preventable Hospitalizations: Evidence of Hospital-Based Health Information Technology and Enabling Services.

Background: Telehealth and enabling services are promising approaches to address the intersecting challenges of chronic disease burden, a growing aging population, and poor access to care disproportionately affecting rural areas. Using potentially preventable hospitalizations (PPHs) as an indicator for health system efficiency and quality, this study examined the relationship between health information technology and hospital-provided enabling services on PPHs across rural, micropolitan, and metropolitan areas. Methods: We constructed a patient-, hospital-, community-, and state-level data set using the Medicare fee-for-service claims file and the Medicare Master Beneficiary Summary File, and the American Hospital Association Annual Survey. Logistic regressions were applied to examine associations between PPH and telehealth post-discharge, telehealth treatment, and telehealth post-discharge and enabling services. Results: Approximately 50% of rural and micropolitan residents (vs. 36% of urban residents) were treated in hospitals providing neither telehealth post-discharge services nor enabling services, and 7% (vs. 11% of urban residents) were treated in hospitals with both services. Telehealth post-discharge services were associated with significantly lower odds ratio (OR) of having any PPH due to acute (OR = 0.91, p < 0.001) and chronic conditions (OR = 0.94, p < 0.001). The ORs of having any PPH due to acute and chronic conditions were the least among beneficiaries who were treated in hospitals with both telehealth post-discharge and enabling services (OR = 0.56, p < 0.001, for acute conditions, and OR = 0.73, p < 0.001, for chronic conditions). Conclusions: Hospital use of post-discharge telehealth alongside enabling services may help provide timely access to care, improve care coordination, and reduce PPHs for older rural residents.

Accountable Care Hospitals and Preventable Emergency Department Visits for Rural Dementia Patients.

BACKGROUND/OBJECTIVES: This study examined urban/rural differences in the frequency of preventable emergency department (ED) visits among patients with Alzheimer's disease and related dementias (ADRD), with a focus on the variation of accountable care organization (ACO) participation status for hospitals in urban and rural areas. DESIGN: We performed a cross-sectional study using the 2015 State Emergency Department Databases, the American Hospital Association Annual Survey of Hospitals, and the Area Health Resource File. Individual-, county-, and hospital-level characteristics and state fixed effects were used for model specification. SETTING: Patients with ADRD from seven states who visited the ED and had routine discharges. PARTICIPANTS: Our sample consisted of 117,196 patients with ADRD. MEASUREMENTS: The outcome was preventable ED visits classified using the New York University Emergency Department visit algorithm. We performed a multivariable logistic regression to estimate the variation of preventable ED visits by urban and rural areas. RESULTS: Rural patients with ADRD had 1.13 higher adjusted odds (P = .007) of going to the ED for a preventable visit compared with their urban counterparts. In addition, ACO-affiliated hospitals had .91 lower adjusted odds (P = .005) of preventable ED visits for ADRD patients compared with hospitals not affiliated with an ACO. Whole-county Mental Health Care Health Professional Shortage Area (HPSA) (odds ratio = 1.14; P = .002) designation was also an indicator of higher preventable ED rates. CONCLUSION: ACO delivery systems have the potential to decrease rural preventable ED visits among ADRD patients.

Evaluating Telehealth Adoption and Related Barriers Among Hospitals Located in Rural and Urban Areas.

PURPOSE: To assess telehealth adoption among hospitals located in rural and urban areas, and identify barriers related to enhanced telehealth capabilities in the areas of patient engagement and health information exchange (HIE) capacity with external providers and community partners. METHODS: We used the 2018 American Hospital Association (AHA) Annual Survey and IT Supplement Survey. We applied state fixed effects multivariate analyses and Oaxaca decomposition to estimate the variation of outcomes of interest by hospital geographies. FINDINGS: Our research showed substantial differences in telehealth adoption among hospitals located in rural, micropolitan, and metropolitan areas, where adoption rates increase with urbanicity. Rural hospitals were least likely to have telehealth systems with patient engagement capabilities such as the ability to view their health information online and electronically transmit medical information to a third party. They were also the least likely to report that clinical information was available electronically from outside providers. Our model explained 65% of the rural/urban difference in telehealth adoption, 55% of the number of telehealth services adopted, and 43%-49% of the rural/urban difference in telehealth barriers. CONCLUSION: Findings demonstrated significant barriers to telehealth use among hospitals located in rural and urban areas. For rural hospitals, barriers include lack of HIE capacity among health care providers in the community, and lack of patient engagement capability.

Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression.

INTRODUCTION: Accountable care organizations have been successful in improving quality of care, but little is known about who is benefiting from accountable care organizations and through what mechanism. This study examined variation of potentially preventable hospitalizations for chronic conditions with coexisting depression in adults by hospital accountable care organization affiliation and care coordination strategies by race/ethnicity. METHODS: Data files of 11 states from 2015 State Inpatient Databases were used to identify potentially preventable hospitalizations for chronic conditions with coexisting depression by race/ethnicity; the 2015 American Hospital Association's Annual Survey was used to identify hospital accountable care organization affiliation; and American Hospital Association's Survey of Care Systems and Payment (collected from January to August 2016) was used to identify hospital Accountable care organizations affiliation and hospital-based care coordination strategies, such as telephonic outreach, and chronic care management. In 2019, multiple logistic regressions was used to test the probability of potentially preventable hospitalization by accountable care organization affiliation and race/ethnicity. The test was repeated on a subsample analysis of accountable care organization-affiliated hospitals by care coordination strategy. RESULTS: Preventable hospitalizations were significantly lower among accountable care organization-affiliated hospitals than accountable care organization-unaffiliated hospitals. Lower preventable hospitalization rates were observed among white, African American, Native American, and Hispanic patients. Effective care coordination strategies varied by patients' race. Results also showed variation of the adoption of specific care coordination strategies among accountable care organization-affiliated hospitals. Analysis further indicated effective care coordination strategies varied by patients' race. CONCLUSIONS: Accountable care organizations and specifically designed care coordination strategies can potentially improve preventable hospitalization rates and racial disparities among patients with depression. Findings support the integration of mental and physical health services and provide insights for Centers for Medicare and Medicaid Services risk adjustment efforts across race/ethnicity and socioeconomic status.

Overcoming the Dual Stigma of Mental Illness and Aging: Preparing New Nurses to Care for the Mental Health Needs of Older Adults.

OBJECTIVE: Registered nurses are uniquely positioned to fill shortages in the geropsychiatric healthcare workforce. With training, nurses can coordinate both mental and physical healthcare and deliver mental health interventions. Our objective was to determine how nursing educators are preparing students to care for the mental health needs of older adults and to explore the challenges they face in this effort. METHODS: This was a qualitative study using semi-structured, in-depth interviews. Participants were undergraduate psychiatric nursing instructors recruited from schools of nursing in the Northeastern United States. Semistructured interviews focused on challenges and strategies related to preparing nursing students to meet the mental health needs of older patients. RESULTS: Fourteen interviews were conducted. An overarching theme of bias against geropsychiatric care was identified as a challenge for educators. Educators reported that nursing students carry biases against patients with mental illness and older patients. Nursing students indicated negative perceptions of the psychiatric and geriatric nursing specialties. Most nursing students plan to work in nonpsychiatric settings and do not consider mental health a priority for their patients. To overcome these challenges, educators suggested increased exposure and integration. To prepare new nurses to care for the mental health needs of older patients, nursing schools should expose nursing students to older adults in a variety of settings and integrate mental health topics and training throughout the undergraduate nursing curriculum. CONCLUSION: Nursing schools should evaluate their curricula to ensure that mental health content is prioritized and sufficiently integrated with physical health topics. An increased focus on geropsychiatric and integrated mental health content should be supported by nursing programs and state boards of nursing.