Gerald M. Eggert

Nursing Homes as Acute Care Providers A Pilot Study of Incentives to Reduce Hospitalizations

This program was designed to encourage treatment of episodes of acute illness in skilled nursing facilities in order to avoid costly and potentially traumatic admission to hospital. It is part of the Monroe County Long Term Care Program, Inc, system of case management and Medicare and Medicaid waivers, and consists of financial incentives, paid by Medicare, to facilities and to responsible physicians to evaluate and care for acutely ill patients in the SNFs when medically safe and feasible. A retrospective evaluation using a physician assessment committee concluded that among the first 112 patients in the program, 76% were very probably saved hospitalization or at least an emergency room visit. Acute bacterial infection was the most common category of episode, occurring in 46% of cases. Considerable savings to both Medicare and Medicaid were estimated to have resulted.

Patient Satisfaction, Empowerment, and Health and Disability Status Effects of a Disease Management–Health Promotion Nurse Intervention Among Medicare Beneficiaries With Disabilities

PURPOSE To report the impact on patient and informal caregiver satisfaction, patient empowerment, and health and disability status of a primary care-affiliated disease self-management-health promotion nurse intervention for Medicare beneficiaries with disabilities and recent significant health services use. DESIGN AND METHODS The Medicare Primary and Consumer-Directed Care Demonstration was a 24-month randomized controlled trial that included a nurse intervention. The present study (N = 766) compares the nurse (n = 382) and control (n = 384) groups. Generalized linear models for repeated measures, linear regression, and ordered logit regression were used. RESULTS The patients whose activities of daily living (ADL) were reported by the same respondent at baseline and 22 months following baseline had significantly fewer dependencies at 22 months than did the control group (p = .038). This constituted the vast majority of respondents. In addition, patient satisfaction significantly improved for 6 of 7 domains, whereas caregiver satisfaction improved for 2 of 8 domains. However, the intervention had no effect on empowerment, self-rated health, the SF-36 physical and mental health summary scores, and the number of dependencies in instrumental ADL. IMPLICATION If confirmed in other studies, this intervention holds the potential to reduce the rate of functional decline and improve satisfaction for Medicare beneficiaries with ADL dependence.

Individual versus Team Case Management in Optimizing Community Care for Chronically Ill Patients with Dementia

Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.

Depression and Suicidal Behaviors in Medicare Primary Care Patients Under Age 65

OBJECTIVE: To examine suicidal behavior and depression prevalence among a group of Medicare patients under age 65 with functional impairment and recent significant health care services use.DESIGN: An observational study of baseline characteristics of participants in a randomized controlled trial.SETTING: A Medicare demonstration (N=1,605) that enrolled primary care patients in 8 counties in New York, 6 counties in West Virginia, and 5 counties in Ohio.PATIENTS/PARTICIPANTS: All demonstration participants under age 65 (n=164). Participants were required to have impairment in at least 2 activities of daily living or 3 instrumental activities of daily living, and to have had recent significant health care use.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The Paykel questionnaire for suicidal ideation and attempts, the Mini-international Neuropsychiatric Interview Major Depressive Episode module, and the 15-item Geriatric Depression Scale were administered at baseline; 14.8% of the patients indicated suicidal ideation during the past year, 4.9% reported a suicide attempt during that time, 25.9% indicated at least 1 lifetime suicide attempt, 34.6% had a major depressive episode in the last month, and 58.3% had clinically significant depressive symptoms during the previous week.CONCLUSIONS: These levels of suicidal ideation and behaviors and of deprssion are far higher than those found in studies of nonelderly American adults, and may indicate the need for routine screening in this population.

Impact of body mass index on the effectiveness of a disease management-health promotion intervention on disability status.

Purpose. To examine the impact of body mass index (BMI) on the effectiveness of a disease management—health promotion intervention among community-dwelling Medicare beneficiaries with disabilities. Design. Secondary data analyses of a randomized controlled trial. Settings. Nineteen counties in upstate New York and on the West Virginia—Ohio border. Subjects. Four hundred fifty-two Medicare beneficiaries who participated in the Medicare Primary and Consumer-Directed Care Demonstration between August 1998 and June 2002 and completed the 22-month follow-up. Intervention. Multicomponent disease management—health promotion intervention involving patient education, individualized health promotion coaching, medication management, and physician care management. Measures. Body mass index and dependence in Activies of Daily Living (ADLs). Analysis. Multivariate linear regression. Results. The intervention resulted in significantly less worsening in ADLs dependence among normal-weight participants (coefficient, − .42; p = .04). However, the intervention did not have a significant effect for underweight participants (F test p = .33 vs. underweight participants in the control group) or overweight or obese participants (F test p = .78 vs. overweight or obese participants in the control group). Conclusions. A positive effect of the intervention on disability was found among normal-weight participants but not among underweight or overweight or obese participants. Future health promotion interventions should take into consideration the influence of BMI categories on treatment effects.

Impact of a Disease Management-Health Promotion Nurse Intervention on Personal Assistance Use and Expenditures

The purpose of this study is to evaluate the effect of a primary care affiliated disease management-health promotion nurse intervention on paid personal assistance (PA) use and expenditures among Medicare beneficiaries with disabilities. We analyzed data on 570 community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Primary and Consumer-Directed Care Demonstration, a randomized controlled trial. We estimated a two-part model to test the effect of the nurse intervention on PA use and expenditures during the 2 years after study entry. Adjusting for covariates, average annual PA expenditures were

Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

1,464 (29%) lower per person in the intervention group as compared to the control group. The findings of this study will help policy makers and practitioners understand the potential benefit of primary care affiliated nurse home visiting interventions on PA expenditures.

Case management: a randomized controlled study comparing a neighborhood team and a centralized individual model.

PURPOSE To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. METHODS The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to

Gaining Control of the Long Term Care System: First Returns from the ACCESS Experiment

250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. FINDINGS The voucher was associated with a 32.4% (P < .01) increase in the probability of choosing agency providers and a 12.5% (P= .03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. CONCLUSIONS This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS.