Characterizing and Targeting Potentially Preventable Hospitalizations in Dementia
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PROJECT SUMMARY Hospitalizations in persons living with dementia (PLWD) are common and increase risk of adverse outcomes. While hospitalizations may not always be avoidable or harmful, reducing potentially preventable hospitalizations (PPH) in dementia is a national public health goal. PPH are hospitalizations for which timely ambulatory care might have prevented hospitalization. PPH are typically identified by hospital diagnosis. The accuracy of diagnosis-based PPH algorithms has been questioned in general populations. The accuracy is even more questionable in dementia as PLWD face unique challenges in receiving medical care. Individual and behavioral factors at the PLWD, caregiver, and clinician level may influence hospitalization, and systems factors may be magnified in the setting of cognitive, functional, and behavioral impairments. Given the growing population and complexity of care for PLWD, Medicare recently launched a comprehensive dementia care model, Guiding an Improved Dementia Experience (GUIDE). Care delivery requirements and payment incentives in GUIDE provide unique opportunity to advance research and care practices that reduce PPH. Research to better understand and target PPH is essential for GUIDE programs to reduce PPH, however, as GUIDE was designed using evidence-based dementia care models that had limited impact on hospitalization. The long-term objective of the proposal is to reduce PPH in PLWD. To achieve this objective, accurate identification of PPH and deeper understanding of mechanisms leading to hospitalization are first needed. Addressing PPH in real-world care delivery also requires the perspective of key informants involved in hospitalization for PLWD: caregivers, primary care providers, emergency department providers, and health systems. To advance toward our long-term goal, we propose the following aims within the Johns Hopkins Medicine and Atrium Health Wake Forest Baptist health systems, both of which have GUIDE programs. First, we will use electronic medical record data and established protocols for physician adjudication in 700 PLWD hospitalizations to accurately determine the proportion that are PPH, individual and systems factors associated with PPH, and potential mechanisms by which these factors lead to PPH. Second, we apply mixed methods and physician adjudication to 100 likely PPH for PLWD, leveraging caregiver interviews and clinician surveys in addition to medical records. We will ascertain behavioral factors contributing to PPH alongside deeper examination of individual and systems factors and PPH mechanisms. Lastly, we develop a set of informant- driven strategies to reduce PPH within GUIDE programs. National caregiver, clinician, and care team focus groups and a health system advisory board will prioritize identified factors leading to PPH and linked prevention strategies. GUIDE teams at Johns Hopkins and Wake Forest, currently led by study investigators, will implement select strategies. Preliminary feasibility data will be used to refine the final set of recommended strategies. Results of the proposal will inform current care practices and future research to effectively reduce PPH in PLWD.
