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RESEARCH OBJECTIVE: Over 40 million older Americans rely on informal care (unpaid assistance for personal care such and instrumental support, including toileting, bathing, and shopping). Prior work illustrates 68–230% greater spending on post‐acute care after surgery for Medicare beneficiaries compared to older commercial insurance enrollees. Such enhanced access to post‐acute care may reduce the need for family and friend caregiving support for rehabilitation following acute medical events. While use of informal care is substantial among older Americans, little is known about informal support for patients after acute medical events, and how formal post‐acute care influences its use. STUDY DESIGN: We used 1998 to 2018 Health and Retirement Study (HRS) data to assess changes in weekly hours of informal care received by individuals experiencing acute events before and after Medicare eligibility. We created two similar cohorts of individuals near the Medicare eligibility age: pre‐Medicare, or individuals ages 59–66 and not covered by Medicare; and Medicare, or individuals ages 67–74. We used a threshold of 67, rather than 65, for the Medicare cohort to account for the two‐year lookback period used in HRS survey questions. The cohorts were matched using inverse probability treatment weights. A regression discontinuity design assessed three types of caregiving – the proportion of respondents receiving care, intensity of care among care recipients, and care intensity among all respondents – before and after Medicare eligibility. We estimated generalized linear models with a log link and gamma distribution that regressed informal care on Medicare status, a centered age variable, and an interaction between Medicare status and centered age. Sensitivity analyses included stratification by surgery type and by sex. POPULATION STUDIED: 4264 Health and Retirement Study participants near the age of Medicare eligibility in one of three self‐reported acute medical cohorts: stroke, heart surgery, or joint surgery. PRINCIPAL FINDINGS: Among near‐retirement individuals, 2031 (47.6%) had a stroke, 1038 (24.3%) underwent heart surgery, and 1038 (28.0%) underwent joint surgery. Of the 937 (22.3%) of patients who reported receiving care from an informal caregiver, average care measured 34.0 (SD: 49.2) weekly hours. Mean (SD) weekly informal caregiving hours were 7.5 (27.0) overall, and 12.1 (34.7), 3.8 (18.5), and 2.9 (14.1) for stroke, heart surgery, and joint surgery patients, respectively. In adjusted analyses, the proportion of stroke patients receiving informal care decreased from 39.5% to 28.6% (or by 28%) and the average weekly amount of care decreased from 21.0 to 10.3 hours (or 51%) after Medicare enrollment. Non‐significant decreases were observed for the other medical cohorts. There was a non‐significant average decrease of 22.8 hours (or 40%) in the intensity of care received by men after one of three events. CONCLUSIONS: Access to Medicare coverage was associated with a 51% reduction in informal care received by older Medicare stroke patients, potentially by increasing access to post‐acute services. IMPLICATIONS FOR POLICY OR PRACTICE: Post‐acute care is increasingly targeted for cost savings under Medicare policies, which may restrict access to post‐acute care and rehabilitation, impacting demand for informal care for older adults with stroke.

This study aimed (1) to estimate the impact of an incremental reduction in excess readmissions on a hospital’s Medicare reimbursement revenue, for hospitals subject to penalties under the Medicare’s Hospital Readmissions Reduction Program and (2) to evaluate the economic case for an investment in a readmission reduction program. For 2,465 hospitals with excess readmissions in the Fiscal Year 2016 Hospital Compare data set, we (1) used the Hospital Readmissions Reduction Program statute to estimate hospital-specific Medicare reimbursement gains per an avoided readmission and (2) carried out a pro forma analysis of investment in a broad-scale readmission reduction program under conservative assumptions regarding program effectiveness and using program costs from earlier studies. For an average hospital, avoiding one excess readmission would result in reimbursement gains of $10,000 to $58,000 for Medicare discharges. The economic case for investments in a readmission reduction effort was strong overall, with the possible exception of hospitals with low excess readmissions.

Background Although common and preventable, healthcare-acquired infections (HAI) are associated with high risk for hospital readmission. This risk may increase when follow-up care is not provided. However, whether infection-related readmissions are more common in older adults discharged from the hospital to a skilled nursing facility (SNF) vs. home or home healthcare is unknown. Methods We used 2013–14 national discharge data and logistic regression models to retrospectively examine the relationship of discharge disposition (home, SNF, home healthcare) with unplanned readmission for the same HAI observed at the index admission, among Medicare beneficiaries 65, controlling for patient sociodemographics, comorbidity score, and length of stay during index hospitalization. Results Of 318,134 index admissions involving HAI treatment, 158,682 (50%) were discharged to a SNF, 76,523 (24%) to home, and 82,929 (26%) to home health. Overall, 7,867 (2.5%) of index admissions involving treatment for an HAI resulted in a linked HAI readmission. HAI readmissions were more common for Clostridium difficile infections (4.0%) and urinary tract infections (UTI, 2.3%) than for ventilator-acquired pneumonia (1.4%) or surgical site infections (1.1%) (P < 0.001). Being discharged home or to home healthcare, compared with a SNF, was associated with increased odds (OR: 1.63, P < 0.001 for each) of HAI readmission. This was equivalent to a 1.2% lower risk of a linked HAI readmission for those discharged to a SNF compared with home or home healthcare. This risk difference was observed to increase with greater patient comorbidity scores. Conclusion We conclude that Clostridium difficile and UTIs result in higher risk for readmission than other HAIs. Patients discharged to nursing facilities are protected from readmission. Further research into identifying modifiable mechanisms for HAI readmission, in order to improve post-hospital care of infection at home, is needed. Disclosures All authors: No reported disclosures.

This study examined differences between paid and unpaid family/friend caregivers to better understand the consumer-driven caregiving workforce. We compared economic vulnerability, unhealthy behavior, and serious emotional distress for 475 paid and 10,500 unpaid family/friend informal caregivers from the 2009 California Health Interview Survey. We then estimated whether caregiver status moderated the relationship between economic vulnerability and health outcomes. Compared to unpaid family/friend caregivers, paid family/friend caregivers had a 27% greater risk ( p = .002) of economic vulnerability. Among all family/friend caregivers, the probabilities of serious emotional distress and unhealthy behaviors increased by >100% and 28% for those with the greatest compared to the least economic vulnerability, and caregiver type did not moderate these relationships. To address economic and health vulnerabilities of paid informal caregivers, policy makers might increase wages in consumer-driven programs. These changes could prove beneficial to both paid informal caregivers and their care recipients, while reducing long-term inefficiencies in consumer-driven programs.