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Background Measures of socioeconomic disadvantage may enable improved targeting of programs to prevent rehospitalizations, but obtaining such information directly from patients can be difficult. Measures of US neighborhood socioeconomic disadvantage are more readily available, although rarely employed clinically. Objective To evaluate the association between neighborhood socioeconomic disadvantage at the census block-group level, as measured by Singh’s validated Area Deprivation Index (ADI), and 30-day rehospitalization. Design Retrospective cohort study Setting United States Patients Random 5% national sample of fee-for-service Medicare patients discharged with congestive heart failure, pneumonia or myocardial infarction, 2004–2009 (N = 255,744) Measurements 30-day rehospitalizations. Medicare data were linked to 2000 Census data to construct an ADI for each patient’s census block-group, which were then sorted into percentiles by increasing ADI. Relationships between neighborhood ADI grouping and rehospitalization were evaluated using multivariate logistic regression models, controlling for patient sociodemographics, comorbidities/severity, and index hospital characteristics. Results The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate=21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates rose from 22% to 27% with worsening ADI. This relationship persisted after full adjustment, with the most disadvantaged neighborhoods having a rehospitalization risk (adjusted risk ratio = 1.09, confidence interval 1.05–1.12) similar to that of chronic pulmonary disease (1.06, 1.04–1.08) and greater than that of diabetes (0.95, 0.94–0.97). Limitations No direct markers of care quality, access Conclusions Residence within a disadvantaged US neighborhood is a rehospitalization predictor of magnitude similar to chronic pulmonary disease. Measures of neighborhood disadvantage, like the ADI, could potentially be used to inform policy and post-hospital care. Primary Funding Source National Institute on Aging

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications including dehydration, malnutrition, and pneumonia, as well as reduced quality of life. Age-related changes place older adults at risk for dysphagia for two major reasons: One is that natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age and dysphagia is a co-morbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia and age-related diseases are discussed herein. Relatively recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake and nutritional assessment for older adults are reviewed relative to their relations to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, while oropharyngeal dysphagia may be life-threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. While the state of the evidence calls for more research, this review indicates the behavioral, dietary and environmental modifications emerging in this past decade are compassionate, promising and in many cases preferred alternatives to the always present option of tube feeding.

Background Nurses in skilled nursing facilities (SNFs) play a key role in initiating/transitioning care for the >5 million patients who transition from hospitals-to-SNFs annually. Although hospital discharge processes are well studied, little is known about the SNF nursing processes or the SNF-based consequences of variation in transitional care quality. Objective To examine how SNF nurses transition the care of patients admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. Design Qualitative study using grounded dimensional analysis, focus groups and in-depth interviews. Setting 5 Wisconsin SNFs. Participants 27 registered nurses. Results SNF nurses rely heavily on written hospital discharge communication to effectively transition patients into the SNF. Nurses cited multiple inadequacies of hospital discharge information, including regular problems with medication orders (including the lack of opioid prescriptions for pain), little patient psychosocial/functional history, and inaccurate information regarding current health status. These communication inadequacies necessitated repeated phone clarifications, created care delays (including delays in pain control), increased SNF staff stress, frustrated patients/family members, directly contributed to negative SNF facility image, and increased a patient's rehospitalization risk. SNF nurses identified a specific list of information/components that they need to facilitate a safe, high-quality transition. Conclusion Nurses note multiple deficiencies in hospital-to-SNF transitions, with poor quality discharge communication being identified as the major barrier to safe and effective transitions. This information should be used to refine and support the dissemination of evidence-based interventions which support transitions of care, including the Interventions to Reduce Acute Care Transfers II (INTERACT) program.

A growing body of evidence has shown that neighborhood characteristics have significant effects on quality metrics that evaluate health plans or health care providers. Using a data set of an urban teaching hospital patient discharges, this study aimed to determine whether a significant effect of neighborhood characteristics, measured by the Area Deprivation Index, could be observed on patients' readmission risk, independent of patient-level clinical and demographic factors. This study found that patients residing in more disadvantaged neighborhoods had significantly higher 30-day readmission risks compared to those living in less disadvantaged neighborhoods, even after accounting for individual-level factors. Those who lived in the most extremely socioeconomically challenged neighborhoods were 70% more likely to be readmitted than their counterparts who lived in less disadvantaged neighborhoods. These findings suggest that neighborhood-level factors should be considered along with individual-level factors in future work on adjustment of quality metrics for social risk factors.

Individuals with autism spectrum disorder (ASD) experience increased morbidity and decreased life expectancy compared to the general population, and these disparities are likely exacerbated for those individuals who are otherwise disadvantaged. We conducted a review to ascertain what is known about health and health system quality (e.g., high quality care delivery, adequate care access) disparities in ASD. Nine studies met final inclusion criteria. Seven studies identified racial disparities in access to general medical services for children with ASD. No studies examined disparities in health outcomes or included older adults. We present a model of health disparities (Fundamental Causes Model) that guides future research. Additional work should examine health disparities, and their causal pathways, in ASD, particularly for older adults.

Objective Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety‐net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. Study Design Retrospective cohort study. Data Sources/Study Setting Claims data for 2 952 605 fee‐for‐service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015. Principal Findings Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety‐net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety‐net hospitals saw their penalty decline; 4‐7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety‐net hospitals. Conclusions Accounting for social risk can have a major financial impact on safety‐net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively low amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.