医疗保险资助的居家临床护理：为社区居住的痴呆症患者提供的基本医疗服务机制。
Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism.
机构信息
Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA.
Division of Geriatric Medicine and Gerontology, The Center for Transformative Geriatric Research, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
出版信息
J Am Geriatr Soc. 2022 Apr;70(4):1127-1135. doi: 10.1111/jgs.17621. Epub 2021 Dec 22.
BACKGROUND
Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access.
METHODS
Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia.
RESULTS
Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas.
CONCLUSION
Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.
背景
在过去的十年中，医疗保健已从医疗机构转移到家庭环境中，尤其是在痴呆症患者中。然而，目前尚不清楚家庭临床服务如何支持痴呆症患者，以及哪些因素影响了服务的可及性。
方法
我们利用 2012-2017 年国家健康老龄化趋势研究与医疗保险索赔数据的链接，确定了 6664 名居住在社区、年龄≥70 岁的参加按服务收费医疗保险的成年人。通过自我报告、认知访谈和/或代理评估每年确定痴呆症状况。每年评估四种家庭临床护理（家庭医疗护理（HBMC）（即，执业护士、医生或医生助理就诊）、熟练家庭保健护理（SHHC）、足病护理和其他类型的家庭临床服务（例如，行为健康））的情况。我们比较了按痴呆症状况调整后的家庭临床护理使用率，并确定了与痴呆症患者使用家庭临床护理相关的社会人口统计学、健康和环境特征。
结果
近一半（44.4%）的痴呆症患者每年接受任何形式的家庭临床护理，而没有痴呆症的患者这一比例仅为 14.4%。与没有痴呆症的患者相比，痴呆症患者接受了更多的每种家庭临床护理，包括 HBMC 使用量增加了五倍（95%CI=3.8-6.2）和 SHHC 使用量增加了一倍（95%CI=2.0-2.5）。在调整后的模型中，西班牙裔/拉丁裔痴呆症患者接受 HBMC 的可能性较小（OR=0.32；95%CI=0.11-0.93）。居住在护理机构、东北部和大都市地区的患者更有可能使用 HBMC、足病护理和其他家庭临床护理。
结论
尽管近一半的居住在社区的痴呆症患者接受家庭临床护理，但基于种族/族裔和环境背景，利用率存在显著差异。为了减少痴呆症患者在医疗保健提供方面的潜在不平等，需要更多地了解这些因素如何影响利用率。
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