Nurses in clinical and administrative positions play critical roles in the design and delivery of home care services to Medicare patients. Medicare home care reimbursement today is governed by a prospective payment system (PPS), and quality of Medicare home care is increasingly focused on maximizing patient outcomes through the new Outcomes Based Quality Improvement (OBQI) initiative. Evidence to assist Medicare home care decision makers, however, remains sparse regarding actual staff resource use patterns in the Medicare PPS era. Moreover, little is known about patient-level risk factors at home care admission that lead to unfavorable outcomes including hospitalization, functional disability at home care discharge, and clinical symptom frequency and severity at home care discharge. Results to date from our initial NINR-funded study (R01 NR05081), based on 1,284 Medicare home care patients in Ohio, have yielded evidence to inform these knowledge gaps. In this application, we propose to build directly on our initial study by using data from a nationally representative sample of Medicare home care patients in the PPS era. We will use Outcome Assessment Information Set data linked to Medicare claims data to achieve the following specific aims: (1) To determine the most important patient-level risk factors for ending an episode of Medicare home care due to hospitalization, accounting for potential effects of home care agency factors and county-level market factors; (2) To determine the most important patient-level risk factors for greater functional disability and clinical symptoms among patients remaining at home after discharge, accounting for potential effects of home care agency factors and county-level market factors; (3) To determine how staff-specific resource use measures are associated with functional disability and clinical symptoms among patients remaining at home after discharge, accounting for the effects of patient-level risk factors, home care agency factors, and county-level market factors; (4) To determine patterns and predictors of hospitalization, functional and clinical outcomes, and staff-specific resource use, among patients grouped within the same Home Health Resource Groups (HHRGs). HHRGs are used to calculate payments to agencies under Medicare PPS. Patient-level risk factors will be organized according to the Andersen model of health services use and outcomes. Patient outcome measures will include hospitalization, functional disability, pain frequency limiting activity, and dyspnea severity. Resource use measures will include amount and intensity of home visits made by nurses, rehabilitation therapists, and other clinical staff. Results will help provide useful scientific evidence to Medicare home care agency decision makers in the PPS and OBQI eras.
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