Hospital at Home services: An inventory of fee-for-service payments to inform Medicare reimbursement.

BACKGROUND: Hospital at Home (HaH) is a growing model of care with proven patient benefits. However, for the types of services required to provide an episode of HaH, full Medicare reimbursement is traditionally paid only if care is provided in inpatient facilities. DESIGN: This project identifies HaH services that could be reimbursable under Medicare to inform episodic care within fee-for-service (FFS) Medicare. SETTING: All data are derived from acute services provided from the Mount Sinai HaH program between 2014 and 2017 as part of a Center for Medicare and Medicaid Innovation (CMMI) demonstration program. PARTICIPANTS: The sample was limited to patients with one of the following five admitting diagnoses: urinary tract infection (n = 70), pneumonia (n = 60), cellulitis (n = 45), heart failure (n = 37), and chronic lung disease (n = 24) for a total of 236 acute episodes. MEASUREMENTS: HaH services were inventoried from three sources: electronic medical records, Medicare billing and itemized vendor billing. For each admitting diagnosis, four reimbursement scenarios were evaluated: (1) FFS Medicare without a home health episode, (2) FFS Medicare with a home health episode, (3) two-sided risk ACO with a home health episode, and (4) two-sided risk ACO without a home health episode. RESULTS: Across diagnoses, there were 1.5-1.9 MD visits and 1.5-2.7 nursing visits per episode. The Medicare FFS model without home health care had the lowest reimbursement potential ($964-$1604) per episode. The Medicare fee-for-service within ACO models with home health care had the greatest potential for reimbursement $4519-$4718. There was limited variation in costs by diagnosis. CONCLUSION AND RELEVANCE: Though existing payment models might be used to pay for many HaH acute services, significant gaps in reimbursement remain. Extending the benefits of HaH to the Medicare beneficiaries that are likely to derive the greatest benefit will require new payment models for FFS Medicare.

Cost-effectiveness of PoNDER health visitor training for mothers at lower risk of depression: findings on prevention of postnatal depression from a cluster-randomised controlled trial.

BACKGROUND: There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score <12 at 6-weeks postnatal. METHODS: Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (<12) and at-risk (⩾12). RESULTS: In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%). CONCLUSIONS: PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.

Nurse Home Visiting for Families Experiencing Adversity: A Randomized Trial.

OBJECTIVES: Nurse home visiting (NHV) may redress inequities in children's health and development evident by school entry. We tested the effectiveness of an Australian NHV program (right@home), offered to pregnant women experiencing adversity, hypothesizing improvements in (1) parent care, (2) responsivity, and (3) the home learning environment at child age 2 years. METHODS: A randomized controlled trial of NHV delivered via universal child and family health services was conducted. Pregnant women experiencing adversity (≥2 of 10 risk factors) with sufficient English proficiency were recruited from antenatal clinics at 10 hospitals across 2 states. The intervention comprised 25 nurse visits to child age 2 years. Researchers blinded to randomization assessed 13 primary outcomes, including Home Observation of the Environment (HOME) Inventory (6 subscales) and 25 secondary outcomes. REULTS: Of 1427 eligible women, 722 (50.6%) were randomly assigned; 306 of 363 (84%) women in the intervention and 290 of 359 (81%) women in the control group provided 2-year data. Compared with women in the control group, those in the intervention reported more regular child bedtimes (adjusted odds ratio 1.76; 95% confidence interval [CI] 1.25 to 2.48), increased safety (adjusted mean difference [AMD] 0.22; 95% CI 0.07 to 0.37), increased warm parenting (AMD 0.09; 95% CI 0.02 to 0.16), less hostile parenting (reverse scored; AMD 0.29; 95% CI 0.16 to 0.41), increased HOME parental involvement (AMD 0.26; 95% CI 0.14 to 0.38), and increased HOME variety in experience (AMD 0.20; 95% CI 0.07 to 0.34). CONCLUSIONS: The right@home program improved parenting and home environment determinants of children's health and development. With replicability possible at scale, it could be integrated into Australian child and family health services or trialed in countries with similar child health services.

Cost-Effectiveness of a Home Visit Program for Patients with Heart Failure in Brazil: Evidence from a Randomized Clinical Trial.

OBJECTIVE: Estimate the cost-effectiveness of a nurse-led home visit (HV) intervention as compared with the standard HF management, within a randomized clinical trial in Brazil. STUDY DESIGN: Cost-effectiveness study within a randomized trial. METHODS: To assess the cost-effectiveness of four home visits and four telephone calls by nurses in the management of patients with HF within a randomized clinical trial (RCT: NCT01213875) in a perspective Public (PHS-Public Healthcare System) and private healthcare systems of Brazil during time frame of 24 weeks. The outcome was a composite endpoint hospital readmission rate (first visit to the emergency room (ER) and hospital readmission), or all-cause death and incremental cost-effectiveness ratio (ICER) of the study intervention to conventional management. RESULTS: Home-based intervention was associated with a reduction in composite endpoint (RR 0.73; 95% confidence interval 0.54 - 0.99; P = 0.049), but at greater cost from the PHS perspective. The ICER at 24 weeks was R$585 per hospital readmission visit prevented. Within the private health insurance framework, home visits were associated with lower costs and lower readmission rates. Results were sensitive to the relative risk of the study intervention, admissions and intervention costs. CONCLUSIONS: In Brazil, an intervention based on nurse-led home visits of patients with HF showed a favorable cost-effectiveness profile within the framework of the PHS and was dominant within the private healthcare system. Our analysis suggests that implementation of this program could not only benefit patients, but also provide a financial incentive to health administrators.

Health visiting cuts only save problems for later.

It feels as inevitable as the turning of the leaves - that time of year when winter pressures begin to loom, as staff shortages and cuts to training places become more apparent.

Work characteristics and psychological symptoms among GPs and community nurses: a preliminary investigation in China.

OBJECTIVE: To determine the effect of work characteristics on the psychological symptoms of general practitioners' (GPs) and community nurses. DESIGN, SETTING AND PARTICIPANTS: A stratified sampling cross-sectional survey was performed at the 12 community health services centres involved 233 GPs and 202 community nurses in three cities of Hubei Province in central China. The independent variables were career prospects, superior recognition, salary fairness, professional-patient relationship and self-perceived workload. The dependent variables were the General Health Questionnaire. RESULTS: The generalized linear regression showed the career prospects had a significant association with GPs' psychological health, whereas career prospects, self-perceived workload and superior recognition had significant association on the psychological health of community nurses. However, salary fairness and professional-patient relationship were not statistically significant for GPs or community nurses. CONCLUSIONS: A better understanding of the effects of career prospects on the psychological health of GPs and community nurses, and improvements in superior recognition and workload on the psychological health of community nurses, would improve psychological symptoms of primary-level medical staff.

Can We Reduce the Utilization of Home-Visiting Nurse Services After Primary Total Joint Arthroplasty?

BACKGROUND: Home-visiting nurse services (HVNSs) after total joint arthroplasty (TJA) are touted as advantageous compared with inpatient rehabilitation. No study has established the utility of HVNSs compared with discharge home without services. METHODS: A retrospective single-surgeon consecutive series of 509 primary TJA patients compared discharge disposition, length of stay, complications, and patient satisfaction between 2 cohorts. The cohorts were defined by the elimination of routine HVNSs. RESULTS: Surprisingly, without routine HVNSs, more patients were discharged home (95% vs 88.3% with routine HVNSs) and mean length of stay significantly decreased. Complication rate was similar (2.9% vs 3.9% with routine HVNSs). Patient satisfaction remained favorable. We estimated that eliminating HVNSs avoids excess costs of $1177 per hip and $1647 per knee arthroplasty. CONCLUSIONS: With dramatically diminished HVNS utilization after primary TJA, there was an associated decrease in length of stay and no increase in complication rate suggesting no compromise of patient care with significant cost savings.

Nurse Family Partnership: Comparing Costs per Family in Randomized Trials Versus Scale-Up.

The literature that addresses cost differences between randomized trials and full-scale replications is quite sparse. This paper examines how costs differed among three randomized trials and six statewide scale-ups of nurse family partnership (NFP) intensive home visitation to low income first-time mothers. A literature review provided data on pertinent trials. At our request, six well-established programs reported their total expenditures. We adjusted the costs to national prices based on mean hourly wages for registered nurses and then inflated them to 2010 dollars. A centralized data system provided utilization. Replications had fewer home visits per family than trials (25 vs. 31, p = .05), lower costs per client ($8860 vs. $12,398, p = .01), and lower costs per visit ($354 vs. $400, p = .30). Sample size limited the significance of these differences. In this type of labor intensive program, costs probably were lower in scale-up than in randomized trials. Key cost drivers were attrition and the stable caseload size possible in an ongoing program. Our estimates reveal a wide variation in cost per visit across six state programs, which suggests that those planning replications should not expect a simple rule to guide cost estimations for scale-ups. Nevertheless, NFP replications probably achieved some economies of scale.

Informal care motivations and intergenerational transfers in European countries.

This work sets out to analyze the motivations adult children may have to provide informal care, considering the monetary transfers they receive from their parents. Traditional motivations, such as altruism and exchange, are matched against more recent social bond theories. Our findings indicate that informal caregivers receive less frequent and less generous transfers than non-caregivers; that is, caregivers are more prone to suppress their self-interested motivations in order to prioritize the well being of another person. Additionally, long-term public care benefits increase both the probability of receiving a transfer and its amount, with this effect being more intense for both the poorest and richest households. Our findings suggest that if long-term care benefits are intended to increase the recipients' welfare and represent a higher fraction of total income for the poorest households, the effectiveness of these long-term care policies may be diluted.