Tele-emergency services provide immediate and synchronous audio/video connections, most commonly between rural low-volume hospitals and an urban "hub" emergency department. We performed a systematic literature review to identify tele-emergency models and outcomes. We then studied a large tele-emergency service in the upper Midwest. We sent a user survey to all seventy-one hospitals that used the service and received 292 replies. We also conducted telephone interviews and site visits with ninety clinicians and administrators at twenty-nine of these hospitals. Participants reported that tele-emergency improves clinical quality, expands the care team, increases resources during critical events, shortens time to care, improves care coordination, promotes patient-centered care, improves the recruitment of family physicians, and stabilizes the rural hospital patient base. However, inconsistent reimbursement policy, cross-state licensing barriers, and other regulations hinder tele-emergency implementation. New value-based payment systems have the potential to reduce these barriers and accelerate tele-emergency expansion.

People who are eligible for both Medicare and Medicaid, known as “dual eligibles,” disproportionately are members of racial or ethnic minority groups. They face barriers accessing primary care, which in turn increase the risk of potentially preventable hospitalizations and emergency department (ED) visits for ambulatory care–sensitive conditions. Federally qualified health centers provide services known to address barriers to primary care. We analyzed 2008–10 Medicare data for elderly and nonelderly disabled dual eligibles residing in Primary Care Service Areas with nearby federally qualified health centers. Among our findings: There were fewer hospitalizations for ambulatory care–sensitive conditions among blacks and Hispanics who used these health centers than among their counterparts who did not use them (16 percent and 13 percent fewer, respectively). Use of the health centers was also associated with 3 percent and 12 percent fewer hospitalizations for ambulatory care–sensitive conditions among nonelderly disabled blacks and Hispanics, respectively. These findings suggest that federally qualified health centers can reduce disparities in preventable hospitalizations for some dual eligibles. However, further efforts are needed to reduce preventable ED visits among dual eligibles receiving care in the health centers.

Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.

Coadministration of glargine in combination with an insulin infusion in the acute management of DKA is feasible. Further study is needed to determine the true efficacy in terms of TCAG and hospital LOS.

Tele-ICU was particularly valued when critical access hospitals retained critical care patients during special circumstances and when the tele-ICU hub could monitor patients to provide relief for local providers and nurses. Tele-ICU can aid rural hospitals, but multiple delivery models are warranted to meet disparate needs.

Informal caregivers may face barriers accessing services like respite care, training, and support groups. Using multinomial logistic regression, I modeled caregivers' probability of using all services sought ("all services used") and nonuse of any services sought ("any unused services") as a function of caregiver and care-recipient characteristics. Care-recipient health and function, especially dementia and need for medical task assistance, were associated with all services used and any unused services, and any unused services were more likely among adult children caring for their parents, caregivers of Black and Hispanic older adults, caregivers providing intensive care, caregivers living in metropolitan areas, and residents of states that spend more on increasing access to caregiver services under the National Family Caregiver Support Program. Regularly scheduled caregiving was associated with higher likelihood of all services used, but not with any unused services. Steps should be taken to increase access for caregivers who provide intensive care, care to dementia patients, or assistance with medical tasks and for Hispanic families.

Objective To examine the relationship between federally qualified health center (FQHC) use and hospital‐based care among individuals dually enrolled in Medicare and Medicaid. Data Sources Data were obtained from 2012 to 2018 Medicare claims. Study Design We modeled hospital‐based care as a function of FQHC use, person‐level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30‐day unplanned returns. We stratified all models on the basis of eligibility and rurality. Data Extraction Methods Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end‐stage renal disease. Principal Findings After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person‐years among both age‐eligible (−14.8 [−17.5, −12.1]; −6.6 [−7.5, −5.6]) and disability‐eligible duals (−11.3 [−14.4, −8.3]; −6 [−7.4, −4.6]) as well as a lower probability of observation stays (−0.8 pp age‐eligible; −0.4 pp disability‐eligible) and unplanned returns (−2.1 pp age‐eligible; −1.9 pp disability‐eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person‐years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability‐eligible duals (a decrease of more than 60% compared with the pre‐PPS period) and increases in the probability of hospitalization (1.1 pp age‐eligible; 0.8 pp disability‐eligible) and ACS hospitalization (0.5 pp age‐eligible; 0.3 pp disability‐eligible) (a decrease of roughly 50% compared with the pre‐PPS period). Conclusions FQHC use is associated with reductions in hospital‐based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.

Older adults frequently experience adverse consequences as the result of unmet care needs, including not getting dressed and going without food when hungry. Previous studies have noted that characteristics of the caregiver network may be associated with unmet needs. Using National Health and Aging Trends Study data, I modeled the association between care configurations and unmet needs for men and women. In generalized linear models, formal care was not associated with unmet need among women or men. Compared with recipients of spousal care, men receiving care from one nonspousal caregiver, and men and women receiving care from any other configuration, had higher odds of unmet needs. The level of difficulty with daily tasks was strongly associated with unmet needs. These findings support monitoring older adults not receiving spousal care, increasing access to formal care, and regularly assessing level of difficulty with daily tasks in clinical and research settings.