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Purpose: This article explores primary care physicians' (PCPs) self-reported approaches and barriers to management of patients with dementia, with a focus on comparisons in dementia care practices between PCPs in 2 states. Design and Methods: In this cross-sectional study, questionnaires were mailed to 600 randomly selected licensed PCPs in Connecticut and to all 1,017 licensed PCPs in Maine. Results: A total of 422 eligible PCPs responded. Nearly 90% of PCPs prescribed donepezil in the previous year for their dementia patients. Connecticut PCPs were more likely to prescribe several other therapeutics than their Maine counterparts. Connecticut PCPs were more likely to refer dementia patients to adult day care (85% vs. 59%) but less likely to refer to Area Agencies on Aging (21% vs. 44%; both ps < .05); referral rates to Alzheimer's Association chapters were low in both states (30%). A greater proportion of Connecticut PCPs reported barriers to optimal dementia care, including time constraints (54% vs. 31% of Maine PCPs), unfamiliarity with community resources (46% vs. 30%), and reimbursement constraints (45% vs. 23%; all ps [less than or equal to] 05). Two thirds of PCPs were 'very' or 'somewhat' interested in using information technology to assist with dementia diagnosis and management; controlling for other variables, youngest PCPs were more than twice as likely as oldest to profess such interest (adjusted odds ratio = 2.04; 95% confidence interval [CI] = 1.024.08). Implications: Geographic variations are evident in PCP medication prescription patterns, community resource referral patterns, and reported barriers to optimal dementia care. Younger PCPs are more likely to adopt information technology to assist in dementia diagnosis and management. Key Words: Alzheimer's disease, Primary care, Geographic variations, Health information technology doi: 10.1093/geront/gnp106

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 freestanding 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. Keywords: Medicare home health care; hospitalization; rehospitalization; OASIS data

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 socio-demographic 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. Key Words: Medicare and Medicaid integration, Dual eligibles, Linked data, Functional disability, Home- and community-based care

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] [greater than or equal to] 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.

Background: Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization. Methods: National Veterans Health Administration data linked to Medicare claims in fiscal years 2014–2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0–1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities. Results: Veterans with a 0.1 higher BBC were 4.6% (p =.06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities. Conclusion: Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%. [ABSTRACT FROM AUTHOR]

Background and Objectives The "unexpected career" of caregiving has previously been conceptualized in stages: community care through institutional placement/residence, ending with death of the care recipient. Transition programs such as Money Follows the Person (MFP) created a new stage of the caregiving career, caring for someone post–long-term institutionalization, about which little is known. Using Pearlin's Caregiver Stress Process Model, this study explores effects on caregivers from the return of their loved ones to the community after a long-term institutional stay. Research Design and Methods Cross-sectional surveys of 656 caregivers of persons transitioned through Connecticut's MFP program 2014–2018, completed 6 months posttransition. Results Regardless of the age/disability of the care recipient, and despite experiencing high caregiving intensity, caregivers experienced less burden, anxiety, and depression, and higher benefits of caregiving than demonstrated in literature for the general caregiving population. Most felt less stressed than before and during the participant's institutional stay. Factors associated with worse outcomes included worry about safety, strained finances, missing work, and desiring additional services. Black and Hispanic caregivers experienced lower burden and anxiety and higher benefits of caregiving than White caregivers. Discussion and Implications By providing community supports to participants, transition programs can have broad ancillary benefits for caregivers and improve outcomes in the Pearlin model, lessening potentially deleterious effects of an unexpected return to intensive caregiving duties after institutional placement. Positive results for Black and Hispanic caregivers may reflect cultural expectations in caring for family that buffer the adverse effects of caregiving. [ABSTRACT FROM AUTHOR]

This study investigated the relationship between race and strain in family caregivers of hospitalized older patients. Data came from a sample of 176 African American and 194 White American caregivers who were identified as part of a prospective study of changes in functional status of older hospitalized patients. When interaction terms were added to a multivariate model assessing the relationship between race and strain, race lost its significant influence on strain. Instead, its combination with two other variables--being an adult child caregiver and being married--emerged as important correlates. Being an adult child had deleterious consequences for White caregivers, whereas being married had advantageous consequences for African American caregivers. Findings emphasize the need to reevaluate how the race variable is used in future research and the need for hospital staff to be sensitive to racial diversity when working with families to plan for older patients' discharge., The introduction of Medicare's prospective payment system in 1983 greatly reduced the average length of hospital stays for older patients (Kahn et al. 1990). Between 1994 and 1995, average length [...]

As the size of the older population increases, primary care physicians can expect to see growing numbers of patients who present with symptoms of cognitive dysfunction. This study examines how office-based primary care physicians in three states (N = 498) diagnose and manage dementia symptoms using clinical vignettes portraying a 72-year-old woman with either mild or moderate dementia symptoms and her adult daughter. Physicians were more likely to order a variety of laboratory tests than to perform mental and cognitive status tests as part of a diagnostic workup. Respondents also were much more likely to disclose a diagnosis of probable Alzheimer's disease to the daughter in the vignette than to her mother. Differences in reported dementia management behaviors were found according to physician specialty, number of years in practice, and experience with patients with dementia in actual practice. Results suggest that whereas primary care physicians can play a valuable role in the service system for families affected by dementia, barriers must be overcome to improve specific aspects of their diagnostic and management behaviors.

A special geriatric assessment unit in hospitals may reduce the number of elderly patients who are discharged to a nursing home. Elderly hospitalized patients often lose their ability to function independently. Researchers admitted 327 elderly patients to a special geriatric unit in a hospital and compared their outcome to that of 324 elderly patients admitted to the general medical ward. The geriatric unit included structural improvements such as large clocks, rugs and handrails and each patient was assessed daily by a multi-disciplinary team including nurses and social workers. At the time of discharge, more patients in the geriatric unit were able to perform basic activities such as bathing, dressing, eating and using the toilet, compared to those in the ward. Fewer patients in the geriatric unit were transferred to a nursing home and their overall health was better. However, three months after discharge, there was no difference in functional status or overall health between the two groups.