Dramatic Increase In Patients Going From Hospitals To Home Care

The number of patients who needed home health care after being discharged from hospitals surged by about 70 percent (2.3 million to 4 million) from 1997 to 2008, according to the latest News and Numbers from the Agency for Healthcare Research and Quality.


In contrast, the number of patients routinely discharged to their homes without the need for additional care grew by less than 8 percent, from 27 million to 29 million patients, during the period.


The federal agency also found during 1997-2008:


- Some 5 million hospital patients were discharged to nursing homes and other long-term care facilities - an increase of 35 percent (from 3.7 million to 5 million).


- There was a 40 percent increase in the number of patients (264,000 to 370,000) who left the hospital against medical advice.


- Hospitals transferred an additional 4 percent of patients to other hospitals (846,000 to 878,000 )


- Fewer patients died in the hospital - a decrease of 5 percent (from 852,000 to 811,000).


This AHRQ News and Numbers summary is based on Exhibit 1.5 in HCUP Facts and Figures 2008, which provides highlights of the latest data from the 2008 Nationwide Inpatient Sample, a part of AHRQ's Healthcare Cost and Utilization Project.

Home Health Advance Beneficiary Notice (HHABN) Being Revised - Again, USA

Home health agencies will recall that a revised Home Health Advance Beneficiary Notice (HHABN) was slated to go into effect on May 1, but it ran into a roadblock. This came in the form of agencies' comments on the revised form and challenges to CMS's estimate of how much of a burden it would create for providers. So CMS has gone back and revised the HHABN once more, this time with comments due on July 24, with the intent of requiring home health agencies to use only this form as of September 1. In the meantime, providers should continue to use the current HHABN. CMS is seeking Office of Management and Budget approval of its new form, in a clearance package that you can access through aahomecare (go to Advocacy and Government Relations by clicking on the button on left of homepage and see Home Health heading on the Advocacy page).



Agencies must issue an HHABN in cases where they believe that items and/or services will not be reimbursed by Medicare (Option 1), they will no longer provide care for financial or business reasons (Option 2), or a beneficiary's homecare services are being reduced as a result of physician's orders (Option 3). CMS has simplified the language on the notices, which are in both English and Spanish, and has provided a much more realistic estimate of the frequency of issuance and burden on providers. Medicare estimates that 87.9 percent of HHABNs will fall into the Option 3 category and that agencies will issue an average of 2.12 notices during an episode of care.



You may want to provide input to CMS and OMB after reviewing CMS's six-document clearance package. If you have any comments please also e-mail them to Ann Howard at ahowardaahomecare by July 17 so that we can incorporate your input into AAHomecare's comments. In addition to the OMB clearance documents, HHAs will want to review 26 new Q&As that CMS posted on its beneficiary notices website on June 20. (See Advocacy and Government Relations at aahomecare by clicking on the button on left of homepage and see Home Health heading on the Advocacy page).


American Association for Homecare

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Caregivers And Physicians Need Education About Battery Ingestion In Children

Ten years of case studies at a pediatric hospital and a thorough literature review have shown that it is not uncommon for children to ingest small "button" batteries, either through swallowing or inserting the batteries into their noses.



In a paper presented at the 2009 American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting & OTO EXPO in San Diego, researchers revealed that a significant lack of knowledge about the dangers of button batteries exists in the lay population and in healthcare providers.



Button batteries are miniature disc batteries that are typically used to power hearing aids, watches, calculators, and many commonly used items, including small toys and musical greeting cards. Each year, more than 3,000 people of all ages in the U.S. unintentionally swallow these batteries, according to the National Capital Poison Center in Washington, DC. Sixty-two percent of battery ingestions involve children under the age of 5, with a peak incidence in 1- and 2-year-olds.



While many children who ingest button batteries recover with few long-term health issues, some develop long-term complications that significantly deteriorate quality of life, such as tracheostomy-tube or gastrostomy-tube dependence, vocal paralysis, and septal perforation with saddle nose deformity. The authors say expeditious identification and treatment of button battery ingestion is crucial, for which continuing education must be provided to pediatricians, primary care, urgent care, and emergency room care providers, and otolaryngologists.



The authors also concluded that increased public awareness is necessary to diminish the incidence of such ingestions. Industry changes, including improved packaging and button battery markings, will also be fundamental to this process.



Title: Button battery ingestion in the pediatric population

Presenters: Dale Amanda Tylor, MD and Seth Pransky, MD

Louisiana Nursing Home Owners Likely To File Lawsuit Against State For Lower Medicaid Rate Increase In 2009, Health Official Says

Louisiana Department of Health and Hospitals Secretary Alan Levine on Friday said that the state likely would face a lawsuit from nursing home owners if Medicaid cuts approved by the state House are not restored, the New Orleans Times-Picayune reports (Moller, New Orleans Times-Picayune, 5/24). The House this month approved a $30 billion state budget for fiscal year 2009 that is $240 million less than Gov. Bobby Jindal's (R) proposed budget.

Jindal's original budget called for a $600 million increase in Medicaid funding, including about $21 million for new initiatives. The House Appropriations Committee cut the spending increase by $183 million but did not specify where the reductions would come from. In a letter to House and Senate leaders last week, Levine wrote that the cuts would affect a wide range of health care providers, and the biggest reductions would be for hospitals, nursing homes and pharmacies.

Levine said that implementing the Medicaid cuts would include $38.6 million in payment cuts to nursing homes (Kaiser Daily Health Policy Report, 5/22). On Friday during a state Senate Finance Committee hearing, Levine said nursing homes are entitled by law to receive a rate increase that would cost the state about $69 million.

Commissioner of Administration Angele Davis has asked lawmakers to restore the health care cuts. Doing so, however, could bring the proposed budget near the constitutional cap on state spending, according to the Times-Picayune (New Orleans Times-Picayune, 5/24).


Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation.

© 2008 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Chronic Disease Care Poorer In Nursing And Residential Homes Under GP Target Scheme, UK

The quality of chronic disease care under the GP pay for performance system is poorer for residents of care homes than those living in the community, according to a study published on bmj today.


The Quality and Outcomes Framework (QOF) for general practice is a voluntary system of financial incentives, which has been in place since 2004. Part of the programme includes specific targets for GPs to demonstrate high quality care for patients with chronic diseases.


The study found that, although pay for performance systems do not invariably disadvantage residents of care homes, GPs are much more likely to exclude them from quality targets, which may compromise their care.



The authors, led by Dr Sunil Shah from St George's, University of London, say that pay for performance systems should include measures relevant to care home residents to improve chronic disease care in this often vulnerable group.


Dr Shah and his team studied data from The Health Improvement Network (THIN), a large database of primary care records from 326 UK general practices, to assess the quality of chronic disease care for care home and community residents.


They identified 10,387 care home and 403,259 community residents aged 65 to 104 years who were registered for 90 or more days with their general practitioner.


Even after adjusting for age, sex and dementia diagnosis, they found that attainment of quality targets was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators suitable for older people in care homes.


The largest differences were for prescribing in heart disease and monitoring of diabetes. Smaller differences were seen for use of antiplatelet therapy and monitoring of blood pressure.


Residents of care homes were also more likely to be excluded from all QOF targets for a condition. For example, 34% of patients with stroke in care homes were excluded compared with 17% in the community, and 35% compared with 9% for diabetes.


This difference persisted even after taking account of patients with dementia or with limited life expectancy.


This is the first study to examine quality of care for residents in care home since the introduction of pay for performance in the primary care contract and shows a need to improve care for chronic diseases among older people in care homes, say the authors.


They acknowledge that, for some interventions, lower attainment of quality indicators may be appropriate, but argue that "high disease wide exceptions suggest a less individualised approach and may act as a disincentive to good disease management."


They conclude: "Our current findings support enhancement of pay for performance systems to include measures that are particularly relevant to residents of care homes and vulnerable older people in the community, such as pain management, falls and continence care."


Link to paper


Source
British Medical Journal

Study Reveals Cultural Differences In Attitudes Towards Caring For People With Dementia

People of south Asian or Black Caribbean origin are far more likely to hold a 'traditional' view of caregiving than White British people, new research shows.



The study, published in the September issue of the British Journal of Psychiatry, found that south Asian and Black Caribbean carers of people with dementia are more likely to perceive their caring role as natural, expected and virtuous.



In contrast, White British people are more likely to hold a 'non-traditional' caregiving ideology, deriving little or no reward from such a relationship and believing their own lives are put 'on hold' while they perform caring duties.



In the UK, around two-thirds of older people with dementia are supported in the community, and family members are the most important source of dementia care. This is particularly true among ethnic minority populations, who are less likely to access specialist healthcare of social care services.



Researchers at the Institute of Psychiatry, King's College London carried out in-depth qualitative interviews with 32 carers of people with dementia: 10 were Black Caribbean (9 women, 1 man), 10 south Asian (5 women, 5 men) and 12 White British (11 women, 1 man). The participants were recruited from four socially and ethnically diverse south London boroughs - Lambeth, Southwark, Lewisham and Croydon.



Carers fell into one of two groups (traditional and non-traditional) according to whether they held three core interrelated beliefs: that caregiving is natural, expected and virtuous. The majority of the south Asian, half of the Black Caribbean and only a minority of White British participants were found to possess a traditional ideology.



Most south Asian and Black Caribbean carers with traditional ideologies possessed strong religious values. For them, providing care was consistent with being a 'good' Hindu or Christian and was therefore the normal thing to do.



Others felt a natural inclination towards caregiving. For example, a high proportion of Black Caribbean carers had experience in the nursing profession, and felt this equipped them to deal with the caregiving role.



Many traditional caregivers viewed their role as a natural part of their life course, either as the spouse or the child of someone with dementia. One south Asian son said: "You know, as Indians, we always look after our parents??¦my father looked after me when I was young and he has done lots and lots of things for me so it's my turn to look after him."



Sons and daughters of south Asian and Black Caribbean origin with traditional ideologies viewed caring less as a necessity and more as an opportunity to reciprocate parental support. One daughter, born in the Caribbean, reflected on how her attitude towards caregiving differed from that of her British-born siblings: "It's something I want to do and I'm glad I can do it. It's almost a privilege to do, but then, you know, I??¦as I said I grow up in Jamaica and it's probably a cultural thing. Whereas my younger siblings don't have quite the same dedication, they'll do it because it's Dad but it's not their duty."
















Having a traditional caregiving ideology was found to help carers derive rewards from the relationship and feel that their lives, although changed, were ongoing. This contrasts sharply with those with non-traditional ideologies, for whom caregiving often signified the end of their relationship and, to a large extent, their lives.



For example, one White British woman with a non-traditional ideology caring for her mother said: "In a way she's not my Mum anymore, that's the hard bit, she's just sometimes??¦she can be a difficult old lady that you have to keep your eye on."



The researchers found that caregiving had a negative impact on carer health across all participants - both traditional and non-traditional. Many felt that they were constantly battling exhaustion and were sleep-deprived.



Overall, caregivers with a traditional ideology were more likely to be satisfied with the support they received from professional health and social care services. Conversely, some carers with non-traditional ideologies were eager to relinquish their caregiving responsibility, were more demanding of services and more likely to feel their needs were not being met.



The study's authors make recommendations of ways in which carers with both traditional and non-traditional ideologies can be better supported.



For those with traditional ideologies, professional care staff should reassure carers that it is both natural and necessary to take time for themselves. Significantly, some south Asian carers saw asking for professional help as a failure to fulfil their responsibilities. Therefore, services might be considered more acceptable if they communicated their commitment to supporting - rather than substituting - family members in the caregiving role.



Carers with non-traditional ideologies may benefit from a change in governmental policy and the benefits system to directly support and promote the role of family carers. Specific grants or targeted benefits would help legitimise the caregiving role as well as directly help those who care.



Reference:


"Attitudes and support needs of Black Caribbean, south Asian and White British carers of people with dementia in the UK."
Lawrence V, Murray J, Samsi K and Banerjee S (2008)
British Journal of Psychiatry, 193: 240-246


Royal College of Psychiatrists


The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the United Kingdom and the Republic of Ireland. We promote mental health by:


- Setting standards and promoting excellence in mental health care

- Improving understanding through research and education

- Leading, representing, training and supporting psychiatrists

- Working with patients, carers and their organisations


Royal College of Psychiatrists

Death At Home Less Distressing For Cancer Patients And Families

Cancer patients who die in the hospital or an intensive care unit have worse quality of life at the end-of-life, compared to patients who die at home with hospice services, and their caregivers are at higher risk for developing psychiatric illnesses during bereavement, according to a study by researchers at Dana-Farber Cancer Institute.


One striking finding of the study, reported in the September 13th issue of the Journal of Clinical Oncology, was that bereaved caregivers of patients who died in an intensive care unit (ICU) were five times more likely to be diagnosed with Posttraumatic Stress Disorder (PTSD), compared with caregivers of patients who died at home with hospice services.


"This is the first study to show that caregivers of patients who die in ICUs are at a heightened risk for developing PTSD," wrote the authors, led by Alexi Wright, MD, a medical oncologist and outcomes researcher at Dana-Farber. The American Medical Association Glossary defines PTSD as "feelings of anxiety experienced after a particularly frightening or stressful event, which include recurring dreams, difficulty sleeping, and a feeling of isolation."


In addition, families and loved ones of patients who died in the hospital, though not in an ICU, were at higher risk of developing Prolonged Grief Disorder (PGD), an intense and disabling form of grief which lasts more than 6 months.


The report comes at a time of growing concern over the appropriateness of aggressive, hospital-based end-of-life care for terminal cancer patients. The authors noted that although most cancer patients would prefer to spend their last days at home, 36 percent die in a hospital and 8 percent in an ICU and may be subjected to invasive and painful procedures at the end of life.


In contrast to home or hospice care that emphasizes alleviating pain and discomfort and providing a peaceful death, ICU care can be traumatic for patients and their family and caregivers, said Wright.


The report, whose senior author is Holly Prigerson, PhD, director of Dana-Farber's Center for Psycho-oncology & Palliative Care Research, contains findings from a prospective, longitudinal study of advanced cancer patients recruited at seven cancer centers from 2002 to 2008. Patients and caregivers mainly family members were interviewed at the beginning of the study. Their medical charts were reviewed at that point and after the patients died, on average 4.5 months later. Within two weeks of the death, researchers interviewed the caregiver most closely involved with the patient's care during the last week of life; they interviewed the caregiver again six months later.


In the interviews, the researchers asked the caregivers to assess the patients' quality of life and physical and psychological stress during the last week of life. The researchers also evaluated the caregivers' own mental health at the beginning of the study to uncover any pre-existing psychiatric illnesses and again six months after the patient's death.


After analyzing the data on 342 patient-caregiver pairs, the investigators found that patients who had died in the hospital or an ICU experienced more physical and emotional distress and worse quality of life than those dying at home. Among the caregivers, they determined that 4 of 19 caregivers (21 percent) of patients dying in an ICU developed PTSD, compared with 6 of 137 (4.4 percent) when death occurred in the home/hospice setting. A similar elevated risk of prolonged grief disorder was found in caregivers when patients died in the hospital, but not in an ICU.


These findings are important for both patients and physicians, said Wright. "If patients are aware that more-aggressive care may affect not only their quality of life, but also their loved ones after their death, they may make different choices."


In addition to Wright and Prigerson, the paper's other authors are Tracy Balboni, MD, Ursula Matulonis, MD, and Susan Block, MD, of Dana-Farber, and Nancy L. Keating, MD, of Harvard Medical School.


The research was supported by grants from the National Institute of Mental Health and the National Cancer Institute.