Orla C. Sheehan

Medicare claims indicators of healthcare utilization differences after hospitalization for ischemic stroke: Race, gender, and caregiving effects

Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.

Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices

BACKGROUND The unique needs of homebound adults receiving home-based medical care (HBMC) (ie, home-based primary care and home-based palliative care services) are ideally provided by interdisciplinary care teams (IDTs) that provide coordinated care. The composition of team members from an array of organizations and the unique dimension of providing care in the home present specific challenges to timely access and communication of patient care information. The objective of this work was to develop a conceptual framework and corresponding quality indicators (QIs) that assess how IDT members for HBMC practices access and communicate key patient information with each other. METHODS A systematic review of peer-reviewed and gray literature was performed to inform a framework for care coordination in the home and the development of candidate QIs to assess processes by which all IDT members optimally access and use patient information. A technical expert panel (TEP) participated in a modified Delphi process to assess the validity and feasibility of each QI and to identify which would be most suitable for testing in the field. RESULTS Thematic analysis of literature revealed 4 process themes for how HBMC practices might engage in high-quality care coordination: using electronic medical records, conducting interdisciplinary team meetings, sharing standardized patient assessments, and communicating via secure e-messaging. Based on these themes, 9 candidate QIs were developed to reflect these processes. Three candidate QIs were assessed by the TEP as valid and feasible to measure in an HBMC practice setting. These indicators focused on use of IDT meetings, standardized patient assessments, and secure e-messaging. CONCLUSION Translating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.

Development of Quality Indicators to Address Abuse and Neglect in Home-Based Primary Care and Palliative Care

To develop candidate quality indicators (QIs) for the quality standard of “addressing abuse and neglect” in the setting of home‐based medical care.

Is self or caregiver report comparable to Medicare claims indicators of healthcare utilization after stroke

Abstract Background: Claims data from Medicare or other payers might not generalize to other populations regarding service use after stroke especially among younger patients. However, high agreement between self-report and Medicare claims data would support the use of self-reported healthcare utilization data in these populations. Methods: A population-based sample of 147 stroke participants with traditional fee-for service Medicare and their family caregivers was examined. Concordance with Medicare claims was examined for stroke participant self-report for Emergency Room visits, hospitalizations, and physician visits for a six-month period after stroke, and for both stroke participant and caregiver reports of receipt of Physical Therapy (PT), Speech and Language Pathology (SLP), or Home Health Agency (HHA) visits. Results: Agreement was good for Emergency Room visits (kappa 0.75), hospitalization (kappa 0.70), and physician visits (Prevalence Adjusted Bias Adjusted Kappa [PABAK] 0.69) but more moderate for physical therapy, speech and language therapy, and home health agency visits (kappa 0.56–0.63). Caregiver agreement with Medicare claims was similar to stroke participant agreement. African Americans were less likely to self-report therapy compared to whites (OR 0.32 PT, 0.38 SLP, 0.29 HHA, p < 0.03). Younger stroke participants reported lower levels of Emergency Room visits than claims (OR 0.81, p = 0.001). Conclusion: Healthcare utilization after stroke can be reliably assessed from Medicare claims, Stroke participant, or Caregiver report for salient events such as hospitalizations and Emergency Room visits. Self-report and caregiver report appear to be less reliable for identifying use of therapy or home health services. Caution should be used when interpreting disparities based on self-report data alone in these areas.

A Quality of Care Framework for Home-Based Medical Care

More than 6 million adults in the United States are homebound or semi-homebound and would benefit from home-based medical care (HBMC). There is currently no nationally recognized quality of care framework for home-based medical care. We sought to capture diverse stakeholder perspectives on the essential aspects of quality HBMC and create a quality of care framework for homebound adults. A qualitative analysis of semistructured interviews from purposive sampling of key HBMC stakeholders was performed. Leaders from 12 exemplar HBMC practices (clinicians and administrators), advocacy groups (American Association of Retired Persons, National Partnership for Women and Families, Kaiser Family Foundation), and representatives from 3 key professional medical societies associated with HBMC participated in phone interviews. Semistructured interviews were based on domains of quality developed by the National Quality Forum (NQF) for individuals with multiple chronic conditions. We identified 3 categories of quality HBMC: provider and practice activities; provider characteristics; and outcomes for patients, caregivers, and providers. Within these 3 categories, we identified 10 domains and 49 standards for quality HBMC. These included 3 new domains (comprehensive assessment, patient/caregiver education, and provider competency) as well as specification and adaptation of the NQF Framework for Multiple Chronic Conditions domains for HBMC. Notably, several quality domains emanating from the NQF Framework for Multiple Chronic Conditions (transitions, access, and patient/caregiver engagement) were applicable to HBMC. This quality of care framework serves as a guide for HBMC practices seeking to improve their care quality and as a starting point for health systems and payers to ensure value from HBMC practices with whom they work.