Outcomes of Home Health Care for High-Risk Rural Medicare - - PowerPoint PPT Presentation

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Outcomes of Home Health Care for High-Risk Rural Medicare - - PowerPoint PPT Presentation

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Community Factors and Outcomes of Home Health Care for High-Risk Rural Medicare Beneficiaries TRACY MROZ, PHD UNIVERSITY OF WASHINGTON LONG TERM SERVICES AND SUPPORTS INTEREST GROUP MEETING JUNE 24, 2017 Collaborators WWAMI Rural Health

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Community Factors and Outcomes of Home Health Care for High-Risk Rural Medicare Beneficiaries

TRACY MROZ, PHD – UNIVERSITY OF WASHINGTON

LONG TERM SERVICES AND SUPPORTS INTEREST GROUP MEETING JUNE 24, 2017

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Collaborators

WWAMI Rural Health Research Center Department of Family Medicine University of Washington https://depts.washington.edu/fammed/rhrc/

  • C. Holly A. Andrilla, MS
  • Susan M. Skillman, MS
  • Lisa A. Garberson, PhD
  • Davis G. Patterson, PhD
  • Eric H. Larson, PhD
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Acknowledgement of Funding

This research was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement #U1CRH03712. The information, conclusions, and opinions expressed in this presentation are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

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Background

  • Home health is playing an increasing role in

post-acute care

  • Incentives exist to improve outcomes following acute

care hospitalization and reward value over volume

  • Medicare Hospital Readmissions Reduction Program
  • Public quality reporting
  • Bundling demonstrations
  • Comprehensive care for joint replacement
  • Home health value-based purchasing model
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Rural Home Health Care

  • Rural home health patients tend to be sicker and

at higher risk for hospitalization (Probst & Bhavsar, 2014)

  • Delivering home health services in rural areas can

be particularly challenging and access is sometimes limited despite current payment incentives to serve rural beneficiaries (CMS, 2014;

Skillman et al., 2016; Probst et al., 2014)

  • Communities that are economically-

disadvantaged may also have higher risk for readmissions (Kind, 2014)

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Study Question

Are community factors associated with

  • utcomes of care for rural Medicare

beneficiaries receiving home health for high-risk conditions?

Hypothesis: Rurality, geographic region, available health resources, and local economy will be associated with hospital readmissions, emergency department use, and community discharge.

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Design and Data Sources

  • Retrospective cohort analysis of rural Medicare

beneficiaries who utilized home health care between 2011 and 2013

  • Medicare administrative data:
  • Outcomes and Assessment Information Set (OASIS)
  • Home health claims
  • Enrollment file
  • Area Health Resource File (AHRF)
  • County Typology Codes from U.S. Department of

Agriculture Economic Research Service (USDA ERS)

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Eligibility

  • Medicare Fee-for-Service beneficiary
  • Aged 65 or over at time of home health admission
  • Rural-residing based on beneficiary’s ZIP code
  • Discharged from acute care hospital within 14 days prior

to home health admission

  • Began home health episode on or after January 1, 2011

and ended on or before December 31, 2013

  • Primary diagnosis of acute myocardial infarction, heart

failure, pneumonia, or COPD

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Outcomes

  • Community discharge following the initial

episode of home health (Y/N)

  • Hospital readmission during the initial home

health episode (Y/N)

  • Emergency department use during the initial

home health episode (Y/N)

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Community Factors

  • Rurality categorized as large rural, small rural, or isolated

small rural based on 2010 Rural-Urban Commuting Area (RUCA) codes (Morrill et al., 1999)

  • Geographic location categorized into one of nine divisions

defined by the U.S. Census Bureau

  • Available health resources including number of acute

care hospital beds, skilled nursing facility beds, home health agencies, rural health clinics, and primary care physicians in each county standardized by county-level Medicare enrollment ages 65 and over

  • County-level economic indicators as dichotomous

variables representing persistent poverty, low education, low employment, and population loss

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Patient Characteristics

  • Age
  • Sex
  • Race
  • Dual eligibility status
  • Diagnosis
  • Clinical severity
  • Functional status at admission
  • Cognitive status at admission
  • Living situation
  • Caregiving needs
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Analysis

  • Complete case analysis
  • Hierarchical multiple logistic regression models

using general estimating equation methods to account for clustering of beneficiaries within counties

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Results: Patient Characteristics

48,802 rural Medicare Fee-for-Service beneficiaries eligible

  • 58% female
  • 30% over age 85
  • 8% non-white
  • 29% dually-eligible for Medicare and Medicaid
  • 31% live alone
  • 59% with cardiac dx versus 41% with pulmonary dx
  • Moderate (46%) to high (45%) clinical severity
  • Moderate (62%) to low (22%) functional status
  • Intact cognition (55%) to mild impairment (35%)
  • 78% required caregiver assistance with medication management and

61% required caregiver assistance for supervision and safety

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Results: Community Factors

Large rural 52% Small rural 28% Isolated small rural 20%

Rurality of Beneficiary Residence

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Results: Community Factors

1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific

Number of Beneficiaries by Census Division

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RESULTS: Community Factors

  • Among 1,797 rural counties:
  • 37.5% were designated as “low employment”
  • 15.1% were designated as “low education”
  • 12.3% were designated as “persistent poverty”
  • 16.7% were designated as “population loss”
  • On average rural counties had (per 1,000 Medicare

beneficiaries ages 65+):

  • 16.5 acute care hospital beds
  • 50.5 SNF beds
  • 2.9 primary care physicians
  • 0.6 rural health clinics
  • 0.3 home health agencies
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RESULTS: Adjusted Analyses

  • Rurality not significantly associated with any outcomes
  • Economic indicators
  • Counties with versus without low employment had:
  • 9% higher odds of readmissions
  • 10% higher odds of emergency department visits
  • Counties with versus without persistent poverty had:
  • 12% lower odds of community discharge
  • 10% higher odds of readmissions
  • Population loss and low education not significantly

associated with any outcomes

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RESULTS: Adjusted Analyses

  • Available health resources
  • Counties with lower numbers of skilled nursing facility

beds had significantly:

  • Higher odds of community discharge (OR 1.12 lowest

quartile versus highest quartile)

  • Lower odds of emergency department visits (OR .93 lowest

quartile versus highest quartile)

  • Lower odds of readmissions (OR .94 lowest quartile versus

highest quartile)

  • Availability of acute hospital beds, home health

agencies, primary care physicians, and rural health clinics not significantly associated with any outcomes

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  • Geographic location significantly associated with all outcomes

RESULTS: Adjusted Analyses

Census Division Community Discharge Hospital Readmissions ED Visits

New England (CT, ME, MA, NH, RI, VT) (reference)

  • Middle Atlantic (NJ, NY, PA)

.92 1.14 .93

East North Central (IL, IN, MI, OH, WI)

.90 1.10 1.03

West North Central (IA, KS, MN, MO, NE, ND, SD)

.98 .99 .93

South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)

.86 1.18 .94

East South Central (AL, KY, MS, TN)

.64 1.52 1.05

West South Central (AR, LA, OK, TX)

.45 1.66 1.19

Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)

.74 1.11 1.12

Pacific (AK, CA, HI, OR, WA)

.92 0.93 1.01

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10 20 30 40 50 60 70 80 New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific

Adjusted Rates of Outcomes of Home Health Care for High-Risk Rural Medicare Beneficiaries

Community Discharge Hospital Readmission Emergency Department Use

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Outcomes of Home Health Care for High-Risk Rural Medicare Beneficiaries by Census Division

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KEY FINDINGS

  • Region of U.S. highly related to outcomes of home

health care for high-risk rural Medicare beneficiaries

  • Pacific, New England, and West North Central census

divisions had the best overall outcomes while East South Central and West South Central had the worst

  • verall outcomes
  • Most other community factors not associated with
  • utcomes or magnitude of associations smaller

compared to geographic region

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STUDY LIMITATIONS

  • Selection bias into home health
  • No comparison with urban beneficiaries
  • Medicare Advantage not included
  • Lack of accounting of care processes in home

health that may be related to outcomes

  • Could not examine outcomes after home health

discharge or verify outcomes using hospital claims data

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CONCLUSIONS & IMPLICATIONS

  • Regional variation generally consistent with previous

research on acute and post-acute care outcomes

  • Region appears more important to outcomes than
  • ther community factors

− Lessons to be learned from high performing areas − Room for improvement in low performing areas

  • Drivers of regional variation and targets for

intervention

  • Impact of policies that incentivize value and

efficiency on rural beneficiaries

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Policy Brief

Mroz TM, Andrilla CHA, Skillman SM, Garberson LA, Patterson

  • DG. Community factors and outcomes of home health care for

high-risk rural Medicare beneficiaries. Policy Brief #161. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, Oct 2016. Available

  • WWAMI Rural Health Research Center

https://depts.washington.edu/fammed/rhrc/

  • Rural Health Research Gateway

https://www.ruralhealthresearch.org/publications/1069

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References

  • Centers for Medicare and Medicaid Services (CMS). (2014). Report to Congress: Medicare home

health study: an investigation on access to care and payment for vulnerable patient populations. Downloaded from www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html.

  • Kind AJH, Jencks S, Brock J, Yu M, Bartels C, Ehlenbach W, Greenberg C, Smith M. (2014).

Neighborhood socioeconomic disadvantage and 30 day rehospitalizations: an analysis of Medicare

  • data. Ann Intern Med, 161(11): 765-774.
  • Morrill R, Cromartie J, Hart LG. (1999). Metropolitan, urban, and rural commuting areas: toward a

better depiction of the U.S. settlement system. Urban Geography, 20(8): 727-748.

  • Probst JC, Bhavsar GP. Differences in case-mix between rural and urban recipients of home health
  • care. Columbia, SC: South Caroline Rural Health Research Center, October 2014.
  • Probst JC, Towne S, Mitchell J, Bennett KJ, Chen R. Home health care agency availability in rural
  • counties. Columbia, SC: South Carolina Rural Health Research Center, June 2014.
  • Skillman SM, Patterson DG, Coulthard C, Mroz TM. Access to rural home health services: views from

the field. Final Report #152. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, Feb 2016.

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Contact Information

Tracy Mroz, PhD Department of Rehabilitation Medicine University of Washington tmroz@uw.edu