Hospital Proximity and Emergency Department Use among Assisted Living Residents.

OBJECTIVES: To examine the relationship between AL communities' distance to the nearest hospital and residents' rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions. DESIGN: Retrospective cohort study, where the main exposure of interest was the distance between each AL and the nearest hospital. SETTING AND PARTICIPANTS: 2018-2019 Medicare claims were used to identify fee-for-service Medicare beneficiaries aged ≥55 years residing in AL communities. METHODS: The primary outcome of interest was ED visit rates, classified into those that resulted in an inpatient hospital admission and those that did not (ie, ED treat-and-release visits). ED treat-and-release visits were further classified, based on the NYU ED Algorithm, as (1) nonemergent; (2) emergent, primary care treatable; (3) emergent, not primary care treatable; and (4) injury-related. Linear regression models adjusting for resident characteristics and hospital referral region fixed effects were used to estimate the relationship between distance to the nearest hospital and AL resident ED use rates. RESULTS: Among 540,944 resident-years from 16,514 AL communities, the median distance to the nearest hospital was 2.5 miles. After adjustment, a doubling of distance to the nearest hospital was associated with 43.5 fewer ED treat-and-release visits per 1000 resident years (95% CI -53.1, -33.7) and no significant difference in the rate of ED visits resulting in an inpatient admission. Among ED treat-and-release visits, a doubling of distance was associated with a 3.0% (95% CI -4.1, -1.9) decline in visits classified as nonemergent, and a 1.6% (95% CI -2.4%, -0.8%) decline in visits classified as emergent, not primary care treatable. CONCLUSIONS AND IMPLICATIONS: Distance to the nearest hospital is an important predictor of ED use rates among AL residents, particularly for visits that are potentially avoidable. AL facilities may rely on nearby EDs to provide nonemergent primary care to residents, potentially placing residents at risk of iatrogenic events and generating wasteful Medicare spending.

Defining the Core Skills and Activities of the Attending Physician in Post-Acute and Long-Term Care.

The American Board of Post-Acute and Long-Term Care Medicine (ABPLM) contracted with a psychometric firm to perform a 3-phase Job Analysis following best practices. Literature was reviewed, a task force of subject matter experts was convened, a survey was developed and sent via Survey Monkey to attending physicians practicing in post-acute and long-term care settings (PALTC). The task force refined a comprehensive list of the tasks, knowledge, and medical knowledge needed in the role of attending physician in PALTC. These items were written as statements and edited until consensus was reached on their accuracy, conciseness, and lack of overlap. Task statements described distinct, identifiable, and specific practice-related activities relevant across multiple care settings. Knowledge statements described previously acquired information considered necessary to effectively perform such tasks. The survey consisted of 260 items, including 21 demographic questions, 115 task statements, 73 knowledge statements, and 72 medical knowledge statements. The survey was disseminated via e-mail invitations to Society for Post-Acute and Long-Term Care (AMDA) members and through an online link available through ABPLM's website. A total of 389 respondents participated. Survey data were analyzed with statistical analysis software SPSS. For each task and knowledge statement, an Overall Task Rating and Knowledge Rating were developed by combining the importance rating weighted at 65% and (for task) the frequency rating or (for knowledge) the cognitive level weighted at 35%. One task statement and 1 medical knowledge statement had a mean importance rating lower than 2.5 and were dropped from further review, resulting in a final count of 114 task, 73 knowledge, and 71 medical knowledge statements (258 total). The results of this Job Analysis highlight the unique and specific nature of medical care provided by attending physicians across a range of PALTC settings. These findings lay a foundation for Focused Practice Designation or Subspecialty in PALTC and changes in practice and policy.

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration.

OBJECTIVE: Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN: Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS: Six NHs in Monroe County, NY. METHODS: A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS: Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS: A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

The Impact of Medicaid Payer Status on Hospitalizations in Nursing Homes.

OBJECTIVES: To examine the association between payer status (Medicaid vs. private-pay) and the risk of hospitalizations among long-term stay nursing home (NH) residents who reside in the same facility. DATA AND STUDY POPULATION: The 2007-2010 National Medicare Claims and the Minimum Data Set were linked. We identified newly admitted NH residents who became long-stayers and then followed them for 180 days. ANALYSES: Three dichotomous outcomes-all-cause, discretionary, and nondiscretionary hospitalizations during the follow-up period-were defined. Linear probability model with facility fixed-effects and robust SEs were used to examine the within-facility difference in hospitalizations between Medicaid and private-pay residents. A set of sensitivity analyses were performed to examine the robustness of the findings. RESULTS: The prevalence of all-cause hospitalization during a 180-day follow-up period was 23.3% among Medicaid residents compared with 21.6% among private-pay residents. After accounting for individual characteristics and facility effects, the probability of any all-cause hospitalization was 1.8-percentage point (P<0.01) higher for Medicaid residents than for private-pay residents within the same facility. We also found that Medicaid residents were more likely to be hospitalized for discretionary conditions (5% increase in the likelihood of discretionary hospitalizations), but not for nondiscretionary conditions. The findings from the sensitivity analyses were consistent with the main analyses. CONCLUSIONS: We observed a higher hospitalization rate among Medicaid NH residents than private-pay residents. The difference is in part driven by the financial incentives NHs have to hospitalize Medicaid residents.

High-intensity telemedicine-enhanced acute care for older adults: an innovative healthcare delivery model.

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models.

A qualitative evaluation of a telemedicine-enhanced emergency care program for older adults.

OBJECTIVES: To document the experiences of patients, their caregivers, healthcare personnel, and staff members with a program that provides telemedicine-enhanced emergency care to older adults residing in senior living communities (SLCs) and to delineate perceived barriers and facilitators. DESIGN: Qualitative study. SETTING: A primary care geriatric medicine practice. PARTICIPANTS: Stakeholders associated with telemedicine visits: patients, family caregivers, telemedicine dispatcher, certified telemedicine assistants, telemedicine providers, and SLC staff. MEASUREMENTS: Between June and August 2011, telemedicine encounters were observed, and field notes were recorded. After each telemedicine visit, all participants were interviewed using a semistructured guide. Discrete statements from interviews and field notes were coded and arranged into themes. Concordance or discordance in field notes and stakeholder responses were grouped for analysis. RESULTS: After 10 telemedicine visits and 34 interviews from 21 unique participants, redundancy was achieved. Participants and their families overwhelmingly reported satisfaction with their care, remarking particularly on the convenience, speed, and completeness of the evaluation. Participants reported some unmet expectations regarding provider presence at home and visit length. Providers thought telemedicine made them more efficient overall and improved diagnostic certainty but considered in-person visits to be superior. All stakeholders, including patients, noted inadequate telemedicine technician training, leading to low confidence levels and performance difficulties. Participants, providers, and telemedicine technicians cited problems with the reliability, weight, and size of the equipment as serious challenges, decreasing their satisfaction and increasing their frustration. CONCLUSION: Telemedicine-enhanced emergency care is an acceptable method of providing emergency care to older adults in SLCs. Stakeholders report a number of advantages. Training and technology barriers require particular attention.