Using data from their detailed analysis of senior medical services offered by nearly 5,000 U.S. hospitals before the 2009 passage of the Affordable Care Act (ACA), researchers led by a Johns Hopkins geriatrician say they have developed a Senior Care Services Scale (SCSS) that suggests a serious “mismatch” between what’s offered and what older adult populations need.
After studying what and where services were available in 1999 and 2006 nationwide, the team determined that over time, hospitals offered more inpatient specialty care and fewer post-acute community-based services, such as intermediate care, assisted living and home health services. Moreover, the researchers concluded, the services were often where older adults were not.
“The distribution of services we found did not mirror the distribution of where older adults reside in the United States, even before passage of the ACA and the increased access to services it offers,” says Alicia I. Arbaje, M.D., M.P.H., lead author of the study report, director of transitional care research at Johns Hopkins Bayview Medical Center and assistant professor of medicine at the Johns Hopkins University School of Medicine.
The better news, says Arbaje, is that the new SCSS tool offers important and novel baseline information about senior care services that can be used by hospital and other health care groups to organize, integrate and track care for a growing population of older adults nationwide. And it can also be used by the public, the researchers say, to help assess whether a health care system near them is offering services they need.
In their report on the work, “Prevalence, Geographic Variation, and Trends in Hospital Services Relevant to the Care of Older Adults: Development of the Senior Care Services Scale and Examination of Measurement Properties,” published in the September 2015 issue of Medical Care, a journal of the American Public Health Association, the investigators say the SCSS is a valuable resource for other researchers and policymakers as well because it can be used to monitor trends in geriatric health services on a local, regional and national scale.
For the study, Arbaje and her team looked back and analyzed services reported by 4,998 hospitals in 1999 and 4,831 hospitals in 2006, all held in a database from the American Hospital Association Annual Survey of Hospitals.
Researchers found that inpatient and post-acute services for seniors were concentrated in the northern part of the United States — northwestern, north central and northeastern regions — and in some metropolitan areas elsewhere. The southwestern, south central and southeastern U.S. had the lowest concentration of services — they were in the 25th percentile or below.
Those service locations, Arbaje noted, did not mirror where older adults live, which includes areas concentrated in the central part of the country, along with large pockets in the southwest and Florida.
Inpatient specialty services covered by the analysis included geriatrics, palliative care, psychiatric geriatrics, pain management, social work, case management, rehabilitation and hospice. Post-acute services, provided outside of hospitals but often part of health care systems, included skilled nursing, intermediate care, other long-term care, assisted living, retirement housing, adult day care and home health services.
Because the ACA has increased the number of insured people, including those on Medicaid, access to and demand for services have grown. That means, Arbaje says that, “hospitals offering fewer post-acute services may be less prepared to participate in accountable care organizations organized to coordinate a continuum of care safely and more cost-effectively.”
“If those hospitals are not partnered with post-acute care services providers or the hospitals lack resources to ensure that older adults have what they need after discharge, then the hospitals are less able to manage the risks they face of what happens to patients after they leave,” she says.
Arbaje adds that: “The apparent mismatch of hospital services and demographic trends suggests that many hospitals in the United States may not provide a seamless continuum of care for an increasing population of older adults.”
Other authors of the report are Qilu Yu, Ph.D., and Bruce Leff, M.D., of the Johns Hopkins University School of Medicine; and Karina Newhall, M.D., of Dartmouth Hitchcock Medical Center.
Arbaje is a former Robert Wood Johnson Clinical Scholar at The Johns Hopkins University, supported by the Robert Wood Johnson Foundation grant number 047945, Princeton, New Jersey. She is also a former clinical and research fellow in the Johns Hopkins Division of Geriatric Medicine and Gerontology, supported by National Institute of Aging grant number T32-AG-000120 and a former Johns Hopkins Clinical Research Scholar, supported by grant number KL2TR001077. This research was primarily conducted while Arbaje was a Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program Scholar, supported by grant number 63518. She also received support from the John A. Hartford Foundation and the National Patient Safety Foundation. Arbaje currently receives funding from the Johns Hopkins University School of Nursing Center for Innovative Care in Aging and the Agency for Healthcare Research and Quality (grant number 1K08HS022916). Newhall was a Medical Student Training in Aging Research Geriatric Summer Scholar at The Johns Hopkins University. The funders had no role in any of the following activities: design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.
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