Postdischarge Correlates of Health Literacy Among Medicaid Inpatients.

Health literacy may represent a target for intervention to improve hospital transitions. This study analyzed the association of health literacy with postdischarge utilization among Medicaid patients treated in an integrated health care system. Discharged inpatients covered by Medicaid (N = 112) participated in this observational study set in a single 600-bed hospital in a private, nonprofit, integrated health care system in the southwestern United States. Participants completed surveys within 15 days of discharge, self-reporting demographics, self-care behaviors, and 2 measures of health literacy (REALM-SF [Short Form of the Rapid Estimate of Adult Literacy in Medicine] and Chew [health literacy screen from Chew et al]). Electronic medical records data were incorporated to determine occurrence of 30-day/90-day postdischarge emergency visits and readmission. Half the respondents (54%) scored at the high-school grade equivalent on REALM-SF, while 46% scored adequate health literacy on the Chew. Forty percent (40%) experienced either emergency care or readmission within 90 days post discharge. Patients who were younger, female, or living with children had relatively better health literacy. Health literacy itself was not associated with readmission or postdischarge emergency care, although African American race was. Although Medicaid patients varied considerably on health literacy, this factor was not associated with adverse health care outcomes. Future work should better identify individuals requiring supportive transition services to reduce problems following hospital discharge.

A Model Program of Community-Based Supports for Older Adults at Risk of Nursing Facility Placement.

Transitioning an older adult into a nursing facility is a major life event for older adults (care recipients, CRs) and their family caregivers (CGs). This article describes the implementation of a community living program and presents findings on important health and well-being indicators. One hundred ninety-one participants aged 60 and older not eligible for or currently enrolled in Medicaid and meeting four risk domains (functional, health, cognitive/emotional, informal support system) were enrolled for the 10-month program. Two evidence-based interventions were blended into a comprehensive community-based approach to long-term care that included $750 per month for home care services. Measures were conducted at baseline and 6 and 12 months. Nine (6%) participants did not complete the program because of nursing facility admission. CRs had fewer physician visits (4.1 vs 7.3, P < .001), emergency department visits (0.3 vs 1.4, P < .001), hospital stays (0.4 vs 0.9, P < .001), and total nights in the hospital (0.8 vs 5.1, P < .001) at 12 months than at baseline. Center for Epidemiologic Studies Depression Scale (CES-D) scores also improved significantly (6.8 vs 9.4, P < .001). CGs had improvements in CES-D scores (5.9 vs 3.9, P < .001) and CG burden (14.7 s 12.6, P = .01) from baseline to 12 months. This multicomponent program improved the physical and mental health of CGs and CRs at risk of nursing facility placement. Future studies are needed to compare the overall placement rate to determine the success of diverting nursing facility placement in this population of older adults.

Cost-effectiveness of the chronic disease self-management program: implications for community-based organizations.

Chronic conditions are the leading cause of growing healthcare spending, disability, and death in the U.S. In the wake of national health reform, policy makers and healthcare professionals are becoming increasingly concerned in containing healthcare costs while improving quality of patient care. A basic policy question is whether the Chronic Disease Self-Management Program (CDSMP), a widely distributed evidenced-based self-managed program, can be cost-effective in managing chronic conditions while improving quality of life. Utilizing data from the National Study of CDSMP, the primary objective of the current study is to estimate cost-effectiveness of the CDSMP program among individuals with at least one chronic condition. The second objective is to determine how cost-effectiveness ratios vary by depression status. EuroQol-5D (EQ-5D) was used to measure health-related quality of life (HRQOL) of CDSMP participants, which was then converted to quality-adjusted life years (QALYs) for cost-effectiveness analysis. Participants who completed the CDSMP program experienced higher EQ-5D scores from baseline to 12-month follow-up (increased from 0.736 to 0.755; p < 0.001). The incremental cost-effectiveness ratio (ICER) ranges from $83,285 to $31,285 per QALYs, which can be comparable to the common benchmark of $50,000/QALYs. ICER by baseline depression status indicates that it will cost more per QALYs gained for those diagnosed with depression based on their Patient Health Questionnaire-8 score. However, cautions should be taken while considering this point estimate too literally because the average cost for CDSMP participants was a rough estimate and based on several simplifying assumptions. Identifying cost-effective strategies that can lower the burden of chronic disease among community-dwelling adults is critical for decision makers in allocating limited resources. Policy makers and community organizations can use this information to guide funding decisions and delivery of CDSMP programs for individuals with multiple chronic health conditions.

The association between office-based provider visits and emergency department utilization among Medicaid beneficiaries.

The purpose of our study was to describe the relationship between office-based provider visits and emergency department (ED) utilization by adult Medicaid beneficiaries. Data were extracted from the publicly-available Medical Expenditure Panel Survey, a nationally representative sample of the civilian non-institutionalized population in the United States. The sample included 1,497 respondents who had full year Medicaid coverage in 2009. Study variables included insurance coverage type, usual source of care, chronic illnesses, and beneficiary demographics. Multivariate analyses were conducted to describe associations between individual characteristics and (a) likelihood of any ED utilization, and (b) number of ED visits by those who utilized the ED at least once in the study year. The analysis was adjusted for demographic characteristics and chronic health conditions. A greater number of office-based provider visits was associated with a higher likelihood of ED utilization. Among those with at least one ED visit, a greater number of office-based visits was associated with a higher number of ED visits. A respondent's age, history of hypertension or myocardial infarction, and Hispanic/Latino ethnicity were associated with having one or more ED visits; age and Hispanic/Latino ethnicity were associated with total number of ED visits among those with at least one. In this representative sample of adult Medicaid beneficiaries, there was no evidence that office-based provider visits reduced ED utilization. Office visits were associated with higher ED utilization, as were certain chronic conditions, older age, and Hispanic/Latino ethnicity. Findings do not support efforts to reduce ED utilization by increasing office-based visits alone.

Feasibility of "Standardized Clinician" Methodology for Patient Training on Hospital-to-Home Transitions.

INTRODUCTION: Patient engagement in health care is increasingly recognized as essential for promoting the health of individuals and populations. This study pilot tested the standardized clinician (SC) methodology, a novel adaptation of standardized patient methodology, for teaching patient engagement skills for the complex health care situation of transitioning from a hospital back to home. METHODS: Sixty-seven participants at heightened risk for hospitalization were randomly assigned to either simulation exposure-only or full-intervention group. Both groups participated in simulation scenarios with "standardized clinicians" around tasks related to hospital discharge and follow-up. The full-intervention group was also debriefed after scenario sets and learned about tools for actively participating in hospital-to-home transitions. Measures included changes in observed behaviors at baseline and follow-up and an overall program evaluation. RESULTS: The full-intervention group showed increases in observed tool possession (P = 0.014) and expression of their preferences and values (P = 0.043). The simulation exposure-only group showed improvement in worksheet scores (P = 0.002) and fewer engagement skills (P = 0.021). Both groups showed a decrease in telling an SC about their hospital admission (P < 0.05). Open-ended comments from the program evaluation were largely positive. CONCLUSIONS: Both groups benefited from exposure to the SC intervention. Program evaluation data suggest that simulation training is feasible and may provide a useful methodology for teaching patient skills for active engagement in health care. Future studies are warranted to determine if this methodology can be used to assess overall patient engagement and whether new patient learning transfers to health care encounters.

Retrospective cohort study of medication adherence and risk for 30-day hospital readmission in a Medicare Cost Plan.

PURPOSE: Reducing hospital readmissions requires deploying appropriate interventions to groups at highest risk for readmission. Long-term medication adherence may indicate one's ability to manage recovery and chronic illness after discharge. If so, medication adherence also may be a predictor of hospital readmission. DESIGN: The objective of this study was to test the association of long-term medication adherence with hospital readmission in a cohort of beneficiaries enrolled in a Medicare Cost Plan. METHODOLOGY: The study employed a retrospective cohort design using administrative pharmacy and health care claims for a sample hospitalized in 2009. Medication adherence was measured with the medication possession ratio (MPR) for the 12 months prior to the first hospitalization in 2009. The likelihood of readmission within 30 days from the first hospitalization in 2009 was estimated using the logistic regression model. RESULTS: Long-term medication adherence was not associated with likelihood of 30-day hospital readmission (odds ratio [OR] = 0.82, P = .71). However, older age (OR = 1.07, P = .003) and longer length of hospital stay (OR = 1.2, P < .001) were associated with higher likelihood of 30-day readmission, while having an office visit within 30 days of discharge (OR = 0.38, P = .03) was associated with lower odds of readmission. CONCLUSION: Except for older age, variables associated with likelihood of readmission are difficult for clinical teams to access during a hospital stay to identify those at risk for readmission. Additional work is needed to identify indicators of readmission risk that can be utilized during hospitalization to identify patients needing post-discharge support to help prevent readmission.

Barriers to health care among Bell County residents with health insurance medical aid.

Barriers to high-quality health care are associated with negative consequences, not only for the uninsured but also for persons with adequate health insurance or medical aid. Understanding barriers encountered by community residents can improve the outcomes of community interventions designed to address unmet health care needs. The Bell County Needs Assessment was conducted to understand the needs of residents in Bell County, Texas. The current study examined residents' (n = 1422) self-reported barriers to health care and factors associated with reporting one or more such barriers. The most common barriers reported were issues related to health care access and socioeconomic barriers. Residents reporting use of urgent care, emergency room, and walk-in clinics as a regular source of care were significantly more likely to experience two or more barriers to health care (OR = 2.543). Community health interventions may be improved by focusing on reducing barriers among patients who rely on urgent or emergency services as their usual source of care.

Multisite qualitative study of primary care physicians' and midlevel providers' self-reported practices and perceptions about maintaining cognitive health.

INTRODUCTION: To facilitate national efforts to maintain cognitive health through public health practice, the Healthy Brain Initiative recommended examining diverse groups to identify stakeholder perspectives on cognitive health. In response, the Healthy Aging Research Network (HAN), funded by the Centers for Disease Control and Prevention (CDC), coordinated projects to document the perspectives of older adults, caregivers of people with dementia, and primary care providers (PCPs) on maintaining cognitive health. Our objective was to describe PCPs' perceptions and practices regarding cognitive health. METHODS: HAN researchers conducted 10 focus groups and 3 interviews with physicians (N = 28) and advanced practice providers (N = 21) in Colorado, Texas, and North Carolina from June 2007 to November 2008. Data were transcribed and coded axially. RESULTS: PCPs reported addressing cognitive health with patients only indirectly in the context of physical health or in response to observed functional changes and patient or family requests. Some providers felt evidence on the efficacy of preventive strategies for cognitive health was insufficient, but many reported suggesting activities such as games and social interaction when queried by patients. PCPs identified barriers to talking with patients about cognitive health such as lack of time and patient reactions to recommendations. CONCLUSION: Communicating new evidence on cognitive health and engaging older adults in making lasting lifestyle changes recommended by PCPs and others may be practical ways in which public health practitioners can partner with PCPs to address cognitive health in health care settings.

Self-reported physical and mental health of older adults: the roles of caregiving and resources.

OBJECTIVES: This study examined factors associated with self-reported physical and mental health, focusing on caregiving status and the availability of social supports and financial resources. METHODS: Two bivariate analyses were performed to examine the sociodemographic characteristics as well as perceived health outcomes among caregiving and non-caregiving participants. Two-equation probit models were used to determine independent predictors of self-reported physical and mental health, using data from 1071 community-based adults (≥ 60 years). An additional bivariate analysis was conducted to investigate the characteristics of caregivers who reported better physical health. RESULTS: Approximately 17% (n=183) of respondents reported being caregivers, and those in caregiving roles tended to be ethnic minorities, married, and have telephone communication with family or friends on a daily basis. Better physical and mental health outcomes were common for caregivers and non-caregivers who reported having more resources (e.g., higher income, better preparedness for future financial need, higher satisfaction with transportation and housing, and no limitation of usual daily activities). However, sociodemographic and social support factors were not significantly associated with physical and mental health among caregivers, unlike their non-caregiver counterparts. In the probit model, caregivers were more likely to be physically healthy compared to non-caregivers (Coefficient=0.34; p-value=0.031). Compared with healthy non-caregivers (n=631), healthy caregivers (n=141) tended to be ethnic minorities, married, and have telephone communication with family or friends on a daily basis. CONCLUSIONS: Findings suggest that preparing resources and maintaining strong social support systems may foster health status among older family caregivers.

Correlates of family health history discussions between college students and physicians: does family cancer history make a difference?

Effective communication between young adults and their healthcare providers can contribute to early detection of risk for developing cancer and establishment of lifelong habits for engagement in healthcare and health promotion behaviors. Our objectives were to examine factors influencing family health history discussions between college students and physicians and factors associated with perceptions about who is responsible for initiating such discussions. Data from an internet-based study of 632 college students were analyzed. Approximately 60% of college student participants reported they had discussed their family health history with a physician. The perception that physicians are responsible for initiating family health history discussions was associated with being non-White and less than completely knowledgeable about cancer. Having a discussion with a physician was associated with being female, having a regular physician, perceiving genetics as a risk for developing cancer, and having a family member diagnosed with cancer. Understanding variation among college students' perceptions about their role in initiating health-history-related discussions and characteristics of those who have or have not discussed family health issues with physicians can inform healthcare practice to foster optimal healthcare interactions in early adulthood.

Utilization of screening mammography among middle-aged and older women.

AIMS: This study examines patterns of screening mammogram use, investigating the relationship of screening with demographic, health status, and healthcare factors. METHODS: Data from 1242 women aged ?41 were obtained from a random sample of mailed surveys to community households in an eight-county region in Central Texas in 2010. The dependent variable was the timing of the participants' most recent screening mammography (in the past 12 months, between 1 and 2 years, or >2 years). Predictor variables included demographic, health status, and healthcare access factors. Multinomial logistic regression identified variables associated with screening mammography practices. RESULTS: The majority of women reported having at least one mammogram during their lifetime (93.0%) and having a mammography within the past 2 years (76.2%). Participants who reported not having a routine checkup in the past 12 months (odds ratio [OR] 0.12, p<0.001), having a lapse of insurance in the past 3 years (OR 2.95, p<0.05), and living in a health provider shortage area (OR 1.42, p<0.05) were less likely to be screened within the past 2 years. CONCLUSIONS: Routine healthcare plays a major role in preventive screening, which indicates screening mammography practices can be enhanced by improving participation in routine checkups with medical providers, continuity of insurance coverage, and women's access to healthcare. Interventions to encourage screening mammography may be particularly needed for women who have experienced a lapse in insurance or have not had a checkup in the past year.

Survey respondents planning to have screening colonoscopy report unique barriers.

Tailoring colorectal cancer screening interventions to address the needs of individuals for whom screening is recommended requires accurate identification of the barriers experienced by each targeted group. The primary purpose of this survey study was to test differences in the barriers to undergoing screening colonoscopy reported by men and women. In addition, we were interested in differences in barriers reported by 1) 50-year-olds versus those age 51 to 80 years, 2) persons reporting readiness for colonoscopy versus those not reporting readiness, and 3) persons who had had a primary care encounter in the preceding 12 months versus those who had not. Four thousand members of a health maintenance organization (Scott & White Health Plan) were surveyed. Response rate overall was 30.85%. No differences in barriers to screening colonoscopy were identified for men versus women. We did identify differences in barriers reported by persons reporting readiness versus those not reporting readiness. Findings suggest that interventions to increase rates of screening colonoscopy require addressing different sets of barriers depending on whether persons report readiness to have a colonoscopy within 6 months.

Programmatic influences on outcomes of an evidence-based fall prevention program for older adults: a translational assessment.

Investigating the implementation and dissemination of evidence-based health-promotion programs to reach large numbers of diverse older adults is needed. The purpose of this study is to examine relationships between class size and session attendance and assess differences in intervention outcomes based on these community-based fall prevention program characteristics. Pre-post data were analyzed from 2,056 falls prevention program participants. PROC MIXED for repeated measures and ordinary least squares regressions were employed. Approximately 32% of participants enrolled in recommended class sizes (eight to 12 participants) and 76.4% of enrolled seniors attended more than five of eight sessions. Enrolling in smaller class sizes was associated with higher class attendance (X (2) = 43.43, p < 0.001). Recommended class sizes and those with 13-20 participants reported significant improvements in falls efficacy and physical activity. Perfect attendance was associated with improvements in falls efficacy (t = 2.52, p < 0.05) and activity limitation (t = -2.66, p < 0.01). Findings can inform fall prevention program developers and lay leader deliverers about ideal class sizes relative to maximum intervention benefits and cost efficiency.

Primary care providers' sources and preferences for cognitive health information in the United States.

In most countries, physicians and other health-care providers play key roles in promoting health. Accumulating scientific evidence suggests that providers may soon want to include cognitive health among the areas they promote. Cognitive health is the maintenance of cognitive abilities that enable social connectedness, foster a sense of purpose, promote independent living, allow recovery from illness or injury and promote effective coping with functional deficits. The US Centers for Disease Control and Prevention has established health promotion about cognitive health as a policy priority, with health providers included as one key group to participate in this effort. This study presents results from focus groups and interviews with primary care physicians (n = 28) and midlevel health-care providers (physician assistants and nurse practitioners, n = 21) in three states of the US. Providers were asked about their sources of information on cognitive health and for their ideas on how best to communicate with primary care providers about research on cognitive health. In results, providers cited online sources, popular media and continuing medical education as their most common sources of information about cognitive health. Popular media sources were used both proactively and reactively to respond to patient inquiries. Differences in sources of information were noted for physicians as compared with midlevel providers, and for rural and urban providers. Several potential ways to disseminate information about cognitive health were identified. Effective messaging is likely to require multiple strategies to reach diverse groups of primary care providers, and to include continuing medical education.

Making the Most of Your Healthcare intervention for older adults with multiple chronic illnesses.

OBJECTIVE: This study tested the efficacy of a patient engagement intervention for older adults with multiple chronic illnesses. METHODS: Seventy-nine participants were randomly assigned to receive the intervention (Intervention Group), contacts on a different topic (Safety Group), or Usual Care. The Intervention and Safety Groups attended a 2-h workshop and participated in phone calls; one before and one after a naturally-occurring medical encounter. The Intervention Group discussed patient engagement concepts from publicly distributed content. The Safety Group discussed general safety (e.g., fire safety, identity theft). Self-report measures were gathered by telephone interview at Baseline and 6-months following Baseline. RESULTS: We did not find expected improvements in patient activation and health-related quality of life. However, the Intervention Group was the only group to show a statistically significant improvement in self-efficacy for self-management. CONCLUSION: The intervention shows promise for improving quality of life and/or health, but requires refinement to reach persons not already engaged in their healthcare and to strengthen its effects. PRACTICE IMPLICATIONS: Patient-directed skills training interventions may be a successful way to support clinicians' and others' efforts to encourage older patients to be actively involved in their care.

Acute variation in cognitive function in hemodialysis patients: a cohort study with repeated measures.

BACKGROUND: Although cognitive function in hemodialysis patients is believed to be best 24 hours after the dialysis session, the extent of variation during the dialysis cycle is unknown. STUDY DESIGN: Cohort study with repeated measures. SETTING & PARTICIPANTS: Hemodialysis centers; patients aged 55 years or older. PREDICTOR: Time of assessment related to the dialysis session. Time 1 (T1) occurred approximately 1 hour before the dialysis session; T2, 1 hour into the session; T3, 1 hour after; and T4, the next day. OUTCOMES: Measures of cognitive function using a 45-minute cognitive battery. An average composite score was calculated to measure global cognitive function, equal to the average of subjects' standardized scores on all tests given at each test time. Times were classified as best and worst according to composite scores. MEASUREMENTS: Testing was conducted on average over 2 dialysis sessions to avoid test fatigue. The cognitive battery included tests of verbal fluency, immediate and delayed verbal and visual memory, and executive function, administered at 4 times. RESULTS: In the 28 subjects who completed testing at 3 or 4 testing times, mean age was 66.7 +/- 9.5 years and mean dialysis vintage was 44.7 +/- 33.3 months. Using a general linear model for correlated data, the composite score was significantly lower (poorer) during dialysis (T2) than shortly before the session (T1) or on the next day (T4; P < 0.001 for both). LIMITATIONS: Relatively small sample size, testing delays, results may not be generalizable. CONCLUSION: Global cognitive function varies significantly during the dialysis cycle, being worst during dialysis and best shortly before the session or on the day after. Clinician visits may be most effective at these times.

Structured practice: a memory intervention for persons with dementia.

This study assessed the feasibility of Structured Practice, a memory intervention format for persons with dementia that requires little or no expertise on the part of a trainer. Fourteen residents of assisted-living facilities practiced a 7-digit telephone number and engaged in guided social interaction with a trainer during several sessions. Free and cued recalls were assessed 5 minutes after each session and at least 1 day after each session. Week-long retention was also assessed for those who showed day-long retention on 2 consecutive assessments. Participants were easily engaged with the Structured Practice materials. Half successfully recalled at least part of the number after a day delay. Most recalled at least part of the number after a 5-minute delay. Structured Practice can serve as a format for teaching everyday information and guiding social interaction with persons with dementia.