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Medicaid-funded home and community-based services (HCBSs) reach large numbers of individuals living with dementia who would otherwise reside in nursing homes with Medicaid funding. Medicaid HCBSs also often augment care provided by family and other informal caregivers to individuals living with dementia. Although Medicaid-funded HCBSs are offered in most states in lieu of nursing home care, they have been largely overlooked as health care system partners for implementation and testing of evidence-based dementia care interventions using embedded pragmatic clinical trial (ePCT) designs. In this article, we make the case for the importance of Medicaid-funded HCBSs as dementia care ePCT partners because of the volume of vulnerable clients with dementia served and the potential positive impacts that evidence-based dementia care programs can have on clients and their informal caregivers. This article first characterizes the Medicaid HCBS setting in terms of populations served and organizational arrangements across states. We then characterize strengths and potential limitations presented by Medicaid HCBSs as settings within which to implement dementia care ePCTs, using as a conceptual framework the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool and its domains. We draw on our experiences implementing the Care of Persons with Dementia in their Environments (COPE) program in a statewide Medicaid HCBS setting to highlight how these potential ePCT partners can help optimize pragmatic approaches to several PRECIS-2 domains. We found that partners are especially effective in implementing pragmatic ways to determine eligibility for evidence-based dementia care programs; assist with recruitment of eligible individuals; incorporate dementia care interventions into the range of existing HCBSs; and track outcomes relevant to persons living with dementia, caregivers, HCBS providers, and Medicaid insurance stakeholders. We conclude with recommendations for researchers, potential ePCT partners, and policymakers to help facilitate the growth of dementia care ePCTs in Medicaid HCBS settings across the United States., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable., Data Sources: Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services., Study Design: Retrospective cohort design., Data Extraction: The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File., Principal Findings: The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable., Conclusions: The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates., (© Health Research and Educational Trust.)

Purpose: Functional capacity is widely recognized as a key factor in maintaining the ability of older people to live independently and safely at home. Promoting functional capacity is an important priority particularly in HHC. The purpose of the study was to examine predictors of functional capacity change among HHC patients with HF., Materials and Methods: Clinical and administrative data from 2005 from the Medicare Chronic Conditions Warehouse were linked at the population level for HHC patients with a primary diagnosis of HF. The primary outcome was change in functional capacity score from HHC admission to HHC discharge., Results: Over the course of the episode (M=44 days), most (70%) patients improved, 15.6% stayed the same, and 14.4% declined in activities of daily living (ADL) scores. The mean change score was modest (mean=-0.74, SD=1.11) with a median change of -0.58. Multivariate analyses (R(2)=0.23) showed that the largest influence was the admission ADL score followed by receiving any physical therapy (PT), admission ability to manage oral medications, cognitive functioning, rehabilitation prognosis, and urinary incontinence., Discussion: There is a modest rate of improvement from admission to discharge that likely represents the progressive nature of HF and/or the short time frames over which HHC is provided. Providers may want to use the predictive factors to identify patients most at risk for functional decline., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.

Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

This study evaluated the criterion validity of the Outcome and Assessment Instrument Set (OASIS) items that measure activities of daily living (ADLs), instrumental activities of daily living (IADLs), cognitive functioning, and depression. A convenience sample of patients (n = 203) from five home care agencies participated in the study. Patient OASIS items were compared to data collected using gold standard instruments. Correlations range from .44 to .69 for ADLs and .20 to .68 for IADLs. A correlation of .62 was found for cognitive functioning while correlations for depressive symptoms are .36 and .26. OASIS ADLs and cognitive status items are sufficiently valid, but the OASIS depression item is not sufficiently sensitive to the prevalence of these conditions.

This study determined the extent to which fall risk assessment and management practices for older patients were implemented in Medicare-certified home health agencies (HHAs) in a defined geographic area in southern New England that had participated in evidence-based fall prevention training between October 2001 and September 2004. The standardized in-service training sessions taught home health nurses and rehabilitation therapists how to conduct assessments for five evidence-based risk factors for falls in older adults--mobility impairments, balance disturbances, multiple medications, postural hypotension, and home environmental hazards--using techniques shown to be efficacious in clinical trials. Twenty-six HHAs participated in these in-service training sessions; 19 of these participated in a survey of nurses and rehabilitation therapists between October 2004 and September 2005. Self-reported assessment and management practices implemented with older patients during home healthcare visits were measured in this survey, and HHA-level measures for each fall risk factor were constructed based on proportions of clinicians reporting assessment and management practices that were recommended in the fall prevention training sessions. For all fall risk factors except postural hypotension, 80% or more of clinicians in all HHAs reported implementing recommended fall risk management practices. Greater variation was found regarding fall risk assessment practices, with fewer than 70% of clinicians in one or more HHAs reporting recommended assessment practices for all risk factors. Results suggest that evidence-based training for home healthcare clinicians can stimulate fall risk assessment and management practices during home health visits. HHA-level comparisons hold the potential to illustrate the extent of diffusion of evidence-based fall prevention practices within and between agencies.

This study determined factors associated with an increased risk of ending Medicare home health care because of hospitalization and examined specific types of and reasons for hospitalization. Sample members (N = 922) were followed from admission to discharge as they received home care from Ohio Medicare-certified home care agencies between December 1999 and March 2002. Potential patient-level risk factors were predisposing, enabling, or need variables, and an agency-level variable denoting hospital affiliation or free-standing status was examined as a second-level risk factor. Among those hospitalized (18.3%), more than 80.0% experienced emergency hospitalizations, mostly for acute exacerbations of chronic diseases. Statistically significant risk factors for hospitalization included dyspnea severity, functional disability level, skin or wound problems, diabetes, case mix score, and guarded rehabilitation prognosis. Home care agencies might reduce hospitalizations by using clinical prognosis as a key resource for team communication and by helping patients and families anticipate potential acute exacerbations of chronic diseases and manage these events at home.

Purpose: The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures., Design and Methods: Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997., Results: In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures., Implications: Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

The Outcomes and Assessment Information Set (OASIS) is now used extensively for regulatory, reimbursement, research, and clinical purposes in home health care. However, little is known about the interrater reliability of OASIS items based on assessments from home-health-agency clinicians. Therefore, we evaluated OASIS item interrater reliability among 88 patients from 21 agencies. Of 25 items studied, all except 2 had weighted kappa values of kappa > or = 0.60. We conclude that OASIS item interrater reliability was highly adequate in this study, but we recommend routine interrater-reliability evaluation by agencies to maximize the quality of OASIS data nationally.

From 1999 to 2003, the home health industry in the United States moved from an environment with extremely diverse data collection protocols and little or no dissemination of quality-related information, to an environment in which uniformly collected clinical data are transformed into information and then into publicly available reports using federally mandated quality indicators. This speed to action has raised many questions about the adequacy of home healthcare data and their use as quality-monitoring tools. This article summarizes current evidence about the scientific and clinical adequacy of data currently used to measure home healthcare quality and discusses roles of a variety of policy stakeholders in implementing and refining data, information, and quality indicators that are now the cornerstones of federal home healthcare quality policy. The scientific adequacy of Outcome and Assessment Information Set data is acceptable but bears routine monitoring and review; efforts should be made to develop home healthcare quality indicators sensitive to nursing interventions and published clinical practice guidelines for specific medical conditions; and policy stakeholders should collaborate to maximize the utility of home healthcare quality reports now disseminated to consumers, providers, and insurers.

There is little information regarding the accuracy of the Outcomes and Assessment Information Set (OASIS), the patient assessment tool mandated for use in Medicare-funded home health care. The purposes of this study were to evaluate the accuracy of OASIS completion by home health nurses and rehabilitation therapists, to compare responses of nurses and therapists, and to determine whether dispersion of answers would affect the home health resource group (HHRG) to which patients were assigned for Medicare home health care payments to agencies. Using a video simulation of admission and discharge visits, 436 clinicians from 29 Ohio home health care agencies scored selected OASIS items. Although the majority of the items were rated accurately, discrepancies were found between clinician responses and the "correct" answer on several items. Nurses and therapists provided similar ratings on most items studied, but for most cases in which discrepancies were found, nurses were more likely to agree with the "correct" answer. Discrepancies most often led to patients being assigned to lower-payment HHRGs. Continued monitoring of OASIS data collection accuracy is recommended to maximize the value of the OASIS instrument in home health care research, practice, and policy., (Copyright 2003 Wiley Periodicals, Inc.)

Background: The Outcome and Assessment Information Set (OASIS) is the universal clinical assessment tool for adult nonmaternity patients receiving skilled care at home from Medicare-certified home health agencies in the United States. Anticipating increased use of OASIS data for research purposes, this article explored the usefulness of Rasch modeling to address disability measurement challenges presented by the unique response category structure of the seven activities of daily living (ADL) and eight instrumental ADL (IADL) items in the OASIS., Objectives: To illustrate how Rasch model statistics can be used to evaluate OASIS ADL and IADL item unidimensionality and model fit; to illustrate how Rasch modeling simultaneously estimates ADL and IADL item difficulty, thresholds between item response categories, and person disability; and to compare Rasch estimates of item difficulty and person disability scores to estimates based on more conventional Likert scoring techniques., Subjects: Medicare-eligible home health care patients (n = 583) served by one of 12 home care agencies in Ohio between November 1999 and September 2000., Measures: ADL and IADL items were measured three ways: according to the original OASIS scoring (raw Likert); transformed raw Likert scores accounting for the nonuniform item structure (corrected Likert); and Rasch Partial Credit model scores., Results: The items bathing and telephone use showed evidence of unexpected response patterns; recoding of these items was necessary for good Rasch model fit. Partial Credit model results revealed that interval distances between response categories varied widely across the 15 ADL and IADL items. When ADL and IADL items were ranked by level of difficulty, results were similar between Rasch and corrected Likert measurement approaches; however, corrected Likert person scores were found to be nonlinear at highest and lowest disability levels when plotted against Rasch person scores., Conclusions: Rasch modeling can help improve the precision of disability measurement in Medicare home care patients when using ADL and IADL items from the OASIS instrument.

Objectives Physical therapist intervention studies can be deemed ineffective when, in fact, they may not have been delivered as intended. Measurement of treatment fidelity (TF) can address this issue. The purpose of this study was to describe TF of a home-based intervention, identify factors associated with TF, and examine whether components of TF were associated with the outcome of change in 6-minute walk distance (∆6MWD). Methods This is a secondary analysis of community-dwelling hip fracture participants who completed standard therapy and were randomly assigned to the active intervention (Push). Push was 16 weeks of lower extremity strengthening, function, and endurance training. TF was defined as delivery (attendance rate, exercise duration) and receipt (progression in training load, heart rate reserve [HRR] during endurance training, and exercise position [exercise on floor]). The outcome was ∆6MWD. Independent variables included baseline (demographic and clinical) measures. Descriptive statistics were calculated; linear and logistic regressions were performed. Results Eighty-nine participants were included in this analysis; 59 (66%) had attendance of 75% or greater. Participants walked for 20 minutes or more for 78% of sessions. The average training load increased by 22%; the mean HRR was 35%; and 61 (69%) participants exercised on the floor for at least 75% of sessions. Regression analyses showed that a higher body mass index and greater baseline 6MWD were related to components of TF; 4 out of 5 components of TF were significantly related to ∆6MWD. The strongest TF relationship showed that those who exercised on the floor improved by 62 m (95% CI = 31–93 m) more than those who did not get on the floor. Conclusions Measures of TF should extend beyond attendance rate. This analysis demonstrates how measures of TF, including program attendance, progression in training load, endurance duration, and exercising on the floor were significantly related to improvement in 6MWD in participants post hip fracture. Impact This careful analysis of treatment fidelity assured that the intervention was delivered and received as intended. Analysis of data from a large trial with participants after hip fracture showed that regular attendance, frequent endurance training for 20 minutes, increases in lower extremity training loads, and exercising on the floor were associated with improvements in the outcome of 6-minute-walk distance. The strongest association with improvement was exercising on the floor. [ABSTRACT FROM AUTHOR]

Background: Dementia, depression, and delirium alone or in combination (3Ds) can threaten independence among older adults, and polypharmacy may further accelerate decline. Clinical pharmacists can play an important role on multidisciplinary home-based care teams by identifying medication therapy problems (MTPs) involving cognition. Within a larger ongoing clinical trial, this paper describes cognition-related MTPs and pharmacist recommendations among older adults with 3Ds followed by a home-based care team. Methods: We conducted a retrospective analysis of medication data among Medicare Advantage members aged ≥ 65 years living at home in Connecticut with International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes related to 3Ds; analyses include the first 105 subjects randomized to the home-based care team from March 2017 to January 2019. Advanced practice registered nurses conducted in-home medication reconciliations along with medical and cognitive assessments. Clinical pharmacists then conducted medication reviews centered on agents treating or exacerbating 3Ds. After review by the study advanced practice registered nurse, geriatrician, and psychiatrist, salient recommendations were forwarded to primary care providers for consideration. Medication therapy problems related to cognition were retrospectively abstracted and classified as: (1) indication: underuse or overuse; (2) effectiveness: ineffective agent or low dose (mainly for antidepressants); and (3) safety: undesirable effect (e.g., impaired cognition, dementia treatment side effects), unsafe medication (e.g., potentially inappropriate medications that can harm cognition), drug interaction, or high dose. Results: Pharmacists identified 166 cognitive MTPs, with a mean (standard deviation) of 1.58 (1.35) [range 0–6] MTPs per subject. Indication MTPs represented 34% of total MTPs, of which 79% involved underuse and 21% overuse; effectiveness represented 13% of total MTPs; and safety represented over half (52%) of all MTPs, with benzodiazepines and anticholinergics frequently implicated. Recommendations commonly included medication reduction (discontinuation 23% and dose reduction 19%). We found MTPs involving cognition among most (79%) patients. Conclusions: Our study findings support the role of pharmacists on multidisciplinary teams to identify cognitively harmful medications, dementia treatment side effects, and untreated cognitive conditions. Clinical Trial Registration: ClinicalTrials.gov NCT02945085. [ABSTRACT FROM AUTHOR]

This study examined experiences of 156 informal caregivers of older adults who transitioned to the community through the Connecticut Money Follows the Person (MFP) Rebalancing Demonstration after prolonged nursing home stays. Caregiver burden, positive aspects of caregiving, depressive symptoms, anxiety, and comparative subjective stress were examined in relation to caregiver demographics and care receiver characteristics with a cross-sectional survey. Caregivers reported low burden, depressive symptoms, and anxiety, and fairly high levels of positive aspects of caregiving and satisfaction with community services. Most caregivers were less stressed compared to the time the care recipient was in, or before they entered, a nursing home. Live-in caregivers experienced more positive aspects of caregiving, but adult children reported higher burden than other caregivers. Unmet service needs also increased caregiver burden. Programs like MFP are a viable option with broadly positive outcomes from a caregiver's perspective. Enthusiasm for increasing access to community care is growing for older adults who otherwise would reside in nursing homes for extended periods. Identifying unmet service needs and needs for targeted functional support could further enhance caregiver experiences and contribute to the successful transition of older adults to the community. [ABSTRACT FROM AUTHOR]

Background Dementia is the leading cause of loss of independence in older adults worldwide. In the U.S., approximately 15 million family members provide care to relatives with dementia. This paper presents the rationale and design for a translational study in which an evidence-based, non-pharmacologic intervention for older adults with dementia and family caregivers (CGs) is incorporated into a publicly-funded home care program for older adults at risk for nursing home admission. Methods The 4-month Care of Persons with Dementia in their Environments (COPE) intervention is designed to optimize older adults' functional independence, and to improve CG dementia management skills and health-related outcomes. COPE features 10 in-home occupational therapy visits, and 1 in-home visit and 1 telephone contact by an advanced practice nurse. COPE was deemed efficacious in a published randomized clinical trial. In the present study, older adults with dementia enrolled in the Connecticut Home Care Program for Elders (CHCPE) and their CGs are randomly assigned to receive COPE plus their ongoing CHCPE services, or to continue receiving CHCPE services only. Outcomes The primary outcome for older adults with dementia is functional independence; secondary outcomes are activity engagement, quality of life, and prevention or alleviation of neuropsychiatric symptoms. CG outcomes include perceived well-being and confidence in using activities to manage dementia symptoms. Translational outcomes include net financial benefit of COPE, and feasibility and acceptability of COPE implementation into the CHCPE. COPE has the potential to improve health-related outcomes while saving Medicaid waiver and state revenue-funded home care program costs nationwide. [ABSTRACT FROM AUTHOR]

The Outcomes and Assessment Information Set (OASIS) is now used extensively for regulatory, reimbursement, research, and clinical purposes in home health care. However, little is known about the interrater reliability of OASIS items based on assessments from home-health-agency clinicians. Therefore, we evaluated OASIS item interrater reliability among 88 patients from 21 agencies. Of 25 items studied, all except 2 had weighted kappa values of κ &ges; 0.60. We conclude that OASIS item interrater reliability was highly adequate in this study, but we recommend routine interrater-reliabilily evaluation by agencies to maximize the quality of OASIS data nationally. [ABSTRACT FROM AUTHOR]

Expected changes in home health care reimbursement will require a shift in focus from a visit-based unit to some other yet-to-be-defined unit of resource consumption. Little research has been done to understand other measures of resource consumption, however, especially those examining disciplinary differences. The purpose of this study was to provide empirical evidence on other measures of resource consumption as a way to frame discussions on alternative measures. Information is presented from a study of 102 home health care patients from 10 agencies in Ohio who completed an episode of care and remained at home. While the mean time per visit was similar for all disciplines (46 to 55 minutes), there were differences in the number of visits provided by various disciplines (home care aide services had the highest mean number of visits with 11.8). The mean cost per day for all services was $43.80 while the mean cost per episode was $1,160. Recommendations for further research include similar examinations using a more rigorous sampling methodology and including disparate populations of patients. [ABSTRACT FROM AUTHOR]

Presents the results of a study which examined the relationships between measures of home care resource consumption, and patient outcome measures, in patients who began home care with Medicare-certified home agencies in Ohio. How home care resource consumption is associated with patient trajectories into and out of episodes of home care.