Biomedical subjects

Helena Temkin-Greener

Publications and source records attributed to Helena Temkin-Greener.

10 recordsLinked to original sources

PubMed2006

Cost of caring for Medicare beneficiaries with Parkinson's disease: impact of the CMS-HCC risk-adjustment model.

Previous studies have demonstrated that Medicare risk-adjusted capitation models do not adequately compensate programs serving primarily disabled or frail populations. Using the Medicare Current Beneficiary Survey, we demonstrate that the Centers for Medicare and Medicaid Services-Hierarchical Condition Categories (CMS-HCC) model calculates Medicare capitation payments for Parkinson's patients more accurately than for the general population. The discrepancies between the predicted and actual expenditures estimated at various disability levels were smaller for Parkinson's patients than for other beneficiaries. If the CMS-HCC payment model were to apply to programs that draw a significant percentage of their participants from the Parkinson's disease community, these programs likely would be compensated fairly.

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PubMed2006

Team performance and risk-adjusted health outcomes in the Program of All-Inclusive Care for the Elderly (PACE).

PURPOSE: The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program providing primary, acute, and long-term care to frail elderly individuals. A central component of the PACE model is the interdisciplinary care team, which includes both professionals and non-professionals. The purpose of this study was to examine the association between the team's overall performance and the risk-adjusted health outcomes of program enrollees. DESIGN AND METHODS: The study included interdisciplinary teams in 26 PACE programs and 3,401 individuals enrolled in them. We combined information about individuals' health, functional, and mental status from DataPACE with an overall measure of team performance. We used multivariate regression techniques to test the hypothesis that better team performance is associated with better risk-adjusted health outcomes: survival and short-term (within 3 months of enrollment) and long-term (within 12 months of enrollment) improvements in functional status and in urinary incontinence. RESULTS: Team performance was significantly associated with better functional outcomes (both short and long term) and with better long-term urinary incontinence outcomes. There was no significant association with survival. IMPLICATIONS: This study provides empirical evidence for the relationship between team performance and patient outcomes in long-term care. It suggests that PACE programs can improve patient outcomes by improving the functioning of care teams.

Acute Disease↗

PubMed2006

Informal caregivers and the risk of nursing home admission among individuals enrolled in the program of all-inclusive care for the elderly.

PURPOSE: We sought to determine whether participants in the Program of All-Inclusive Care for the Elderly (PACE) with an informal caregiver have a higher or lower risk of nursing home admission than those without caregivers. DESIGN AND METHODS: We performed a secondary data analysis of 3,189 participants aged 55 years or older who were enrolled in 11 PACE programs during the period from June 1, 1990 through June 30, 1998. Cox proportional hazard models determined whether having any caregiver, as well as specific caregiver characteristics, such as either living separately from the enrollee, being over the age of 75 years, providing personal care, not reducing or quitting work to provide care, or not being a spouse, predicted time to nursing home admission. RESULTS: Fewer than half of the participants (49.4%) lived with a caregiver, and 12.4% had no caregiver. Individuals who lived with their caregiver were frailer than either those who lived separately or those without a caregiver. We measured frailty in terms of functional and cognitive status, incontinence, and multiple behavioral disturbances. The presence of a caregiver did not change the risk for institutionalization. None of the caregiver characteristics were associated with a higher risk of nursing home admission. IMPLICATIONS: Unlike individuals in the general population, participants in PACE who lack an informal caregiver are not at higher risk of institutionalization. Further research is required to ascertain whether PACE's comprehensive formal services compensate for the lack of informal caregiving in limiting the risk for institutionalization.

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PubMed2006

Disenrollment from an acute/long-term managed care program (PACE).

BACKGROUND: The Program of All-Inclusive Care for the Elderly (PACE) is an acute/long-term managed care plan designed to care for the most frail and vulnerable Medicare beneficiaries. To our knowledge, this is a first study to examine patterns and predictors of disenrollment from PACE. OBJECTIVE: PACE, with its comprehensive delivery system, dual capitation, and a focus on the most vulnerable population, may be expected to achieve low rates of exit and little selective dissenrollment. This study examines whether these goals have been accomplished. RESEARCH DESIGN: The study includes 30 PACE programs and 14,657 individuals enrolled in them. Individual-level records, obtained from an administrative database, contain information on sociodemographics, caregiver support, health status and disability, medical history, service utilization, and disenrollment. Program-level variables also were included. Cox proportional hazard models, with time-varying and time-invariant covariates, were employed to predict time to disenrollment. RESULTS: Our findings show a low level of disenrollment. We find no increase in disenrollment risk by age, functional or cognitive impairment, Medicaid eligibility, or diagnoses. Certain characteristics (eg, nursing treatments) appear to reduce the disenrollment hazard, whereas others (eg, hospital admissions, private pay status) significantly increase it. The risk of disenrollment also increases with longer nursing home stays, until 80-90 days, whereupon it begins to decline. CONCLUSIONS: Both enrollee and program-level attributes predict program disenrollment. Programmatic and quality of care improvements may be needed to further minimize disenrollment, particularly in programs experiencing rates that are substantially greater than the average.

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PubMed2004

Variations in risk-adjusted outcomes in a managed acute/long-term care program for frail elderly individuals.

OBJECTIVE: To develop and investigate the properties of three performance measures based on risk-adjusted health outcomes for a frail, elderly, community-dwelling population enrolled in a managed, acute, and long-term care program. DESIGN: Retrospective analyses of an administrative dataset containing individual level records with information about socioeconomics, health, functional and cognitive status, diagnoses, and treatments. We estimated risk-adjustment models predicting mortality, decline in functional status, and decline in self-assessed health. Each model includes individual risk factors and indicator variables for the program site in which the individual enrolled. Sites were ranked based on their performance in each risk-adjusted outcome, and the properties of these performance measures were investigated. SETTING: Twenty-eight sites of the Program of All-Inclusive Care for the Elderly (PACE) that provide primary, acute, and long-term care services under capitated Medicare and Medicaid payment to a nursing home certifiable, and functionally and cognitively frail community-dwelling elderly population. STUDY PARTICIPANTS: Three thousand one hundred and thirty-eight individuals who were newly enrolled between 1 January 1998 and 31 December 1999. The average age of these enrollees was 78 years, 27% were male, 50% were diagnosed with dementia, and they had approximately 4 Activities of Daily Living limitations and 7.4 Instrumental Activities of Daily Living limitations. MAIN OUTCOME MEASURES: Risk-adjustment models, performance ranking for each site, and correlations between performance rankings. RESULTS: We present risk-adjustment models for mortality, change in functional status, and self-assessed health status. We found substantial variation across sites in performance, but no correlation between performance with respect to different outcomes. CONCLUSIONS: The variations in outcomes suggest that sites can improve their performance by learning from the practices of those with the best outcomes. Further research is required to identify processes of care that lead to best outcomes.

Activities of Daily Living↗

PubMed2004

Measuring interdisciplinary team performance in a long-term care setting.

OBJECTIVES: The objectives of this study were to test the reliability and the validity of a survey instrument for assessing interdisciplinary team performance in long-term care settings and to measure team performance in the Program of All-Inclusive Care for the Elderly (PACE). RESEARCH DESIGN AND METHODS: The analysis is based on 1220 surveys completed by team members of 26 PACE programs. Cronbach's alphas, analysis of variance, and regression models were used to assess the reliability and the validity of the instrument. Multivariate regression analysis was used to examine factors associated with team performance in PACE. RESULTS: Cronbach's alphas ranging from 0.76 to 0.89 demonstrate good-to-high reliability for all domains of the team process and performance (effectiveness). Construct validity is demonstrated through the results of the regression analysis showing that leadership, communication, coordination, and conflict management are positive and significant (P <0.001) predictors of team cohesion and team effectiveness. The data also support the appropriateness of aggregating individual-level responses to the unit level. Perceived team effectiveness significantly (P <0.05) increases with: age of the respondents; longer length of the team's professional work experience; shorter duration of the team's PACE experience; more ethnically diverse composition of the team; greater ethnic concordance between team members and the participants; and greater perceived resource availability. CONCLUSIONS: Several of the factors influencing team effectiveness in PACE are potentially modifiable and, therefore, could offer insights for improving team practice.

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PubMed2004

Social support and risk-adjusted mortality in a frail older population.

OBJECTIVE: The objective of this study was to test the hypothesis that social support is an important predictor of mortality in a frail older population receiving formal long-term care services. RESEARCH DESIGN AND METHODS: The analysis is based on 3138 individuals enrolled in 28 Programs of All-Inclusive Care for the Elderly (PACE). Information about the enrollees is obtained from dataPACE. Semiparametric Cox proportional hazards models are estimated to assess the importance of individual risk factors, program effect, and social support. RESULTS: The introduction of the social support variables into the mortality model containing the sociodemographic, health needs, and the PACE-site indicator variables results in a significant improvement of the overall model fit. Several social support variables are statistically significant predictors of mortality. Controlling for all participant and caregiver characteristics, participants whose caregiver is a spouse have a significantly lower risk of mortality (hazard ratio = 0.63) compared with those whose caregiver is not a spouse. Furthermore, caregivers' assistance with meals confers a significantly lower risk of morality (hazard ratio = 0.66) compared with no assistance with meals. CONCLUSIONS: This study shows that certain aspects of informal caregiving are important factors enhancing survival in a population of frail, nursing home-certifiable individuals enrolled in a health program that already provides extensive services, including personal care, chores, and meals. Further research to better differentiate between the affective versus the instrumental dimensions of social support is needed to guide programs on how to balance the use of resources to provide both the necessary formal services and the support for the informal caregivers.

Activities of Daily Living↗

PubMed2004

The growing pains of integrated health care for the elderly: lessons from the expansion of PACE.

The early success of the demonstration Program of All-Inclusive Care for the Elderly (PACE) led to its designation as a permanent Medicare program in 1997. But the growth in the number of programs and enrollment has lagged and does not meet expectations. This article offers insights into the mechanisms influencing the expansion of PACE, from information obtained in interviews and surveys of administrators, medical directors, and financial officers in 27 PACE programs. Sixteen barriers to expansion were found, including competition, PACE model characteristics, poor understanding of the program among referral sources, and a lack of financing for expansion. This experience offers important lessons for providing integrated health care to the frail elderly.

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PubMed2002

Predicting place of death in the program of all-inclusive care for the elderly (PACE): participant versus program characteristics.

OBJECTIVES: To assess the relationship between participant-specific and program-specific characteristics and the place of death in the Program of All-Inclusive Care for the Elderly (PACE). DESIGN: A retrospective, population-based, cross-sectional study. SETTING: PACE is a community-based managed care model serving a frail, nursing home-eligible population of Medicare beneficiaries. PARTICIPANTS: Two thousand two hundred sixty-three PACE decedents from 12 sites that were fully capitated for Medicare and Medicaid by mid-1997. MEASUREMENTS: Participant-specific characteristics include the range of demographic, functional, and cognitive status; skilled care needs; medical conditions; and advance care directives measures. The PACE site-specific indicator was also included to assess the effect of program sites on place of death. Bivariate, logistic, and multinomial logit models were employed. RESULTS: The probability of death at home is twice as great (45%) for PACE program participants as for the general population of older Americans. Twenty-one percent of PACE participants die in hospitals, compared with 53% of Medicare beneficiaries. Participants who are older and live in the community have a significantly greater (P< .05) probability of dying at home than does an average PACE enrollee. Those with a do-not-resuscitate order are 7.4% less likely to die in the hospital than are those without. PACE participants with a live-in informal caregiver are 10.3% (P< .05) less likely to die at home than those without a caregiver. When all participant characteristics were accounted for, there remained significant variation in the place of death by PACE plan. We found the least amount of site-specific variation in deaths occurring at home and the most variation in deaths occurring in hospitals. CONCLUSION: Nationally, the low rate of home death has prompted some to conclude that it is unlikely that we will, as a society, decide to take our dying older people back into our homes. The PACE experience suggests that it is possible to modify this trend. The results indicate that patient and program characteristics are both important in predicting the place of death. The variation across PACE sites suggests that an opportunity for narrowing these gaps, and reducing the proportion of hospital deaths, exists. The PACE end-of-life practice style could potentially be applied to other populations and may have important public policy implications.

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PubMed2002

Health care services utilization at the end of life in a managed care program integrating acute and long-term care.

BACKGROUND: The period preceding death is often characterized by increased utilization of medical resources. There is an ongoing debate on the reasons for and the appropriateness of increased utilization at the end of life. OBJECTIVES: To study end-of-life practices in the PACE program and to assess the contribution of individual characteristics versus program site to the variation in use of services. RESEARCH DESIGN: Retrospective analyses of utilization and health status data for the last 3 years before death. Multivariate regression techniques were used to estimate models predicting utilization of services and the percent of variation explained by individual characteristics and program sites in relation to time from death. SUBJECTS: The study comprised 2160 persons enrolled in 10 PACE sites who died before 2000. MEASURES: Monthly utilization by service type (eg, hospital, nursing home, primary care physicians), socioeconomic, and health status data. RESULTS: Utilization of health services increases as early as 7 months before death, with the largest increase in the last month. The increase is dominated by hospital use. During the last month before death variation across program sites explains twice as much of the variation in service utilization as does variation in individual characteristics. CONCLUSIONS: The variation in end-of-life practices across PACE program sites, which are not attributed to differences in individual characteristics, raises two important questions: what are the causes for these variations; and are these variations desirable? Further research is required to answer both questions.

Activities of Daily Living↗