The Effects of State Medicaid Policies on the Dynamic Savings Patterns of the Elderly

States have considerable flexibility in determining Medicaid policies such as financial eligibility criteria, subsidies for home- and community-based services, and reimbursements rates to skilled nursing facilities, among other things. An understanding of how differences in Medicaid programs across states and time affect the elderlys' demand for Medicaid coverage of long-term care is necessary for evaluating future changes in the Medicaid program structure. We use data from the 1993, 1995, 1998, and 2000 waves of the Asset and Health Dynamics of the Elderly and variation in state Medicaid policies over time to estimate our dynamic framework capturing the sequential asset and gift decisions that determine eligibility for Medicaid. We also model the long-term care decisions of married and single individuals conditional on endogenous insurance coverage and health transitions. To control for the impact of unobserved heterogeneity in all outcomes, the structural equations of the empirical model are estimated jointly, allowing for correlation in the error structure across equations and over time. In this paper we focus on the asset and gifting decisions of the elderly over time. We find that many of the Medicaid policy variables that differ across states have a significant but small effect on the savings decisions of the elderly, with single elderly individuals exhibiting more response than married elderly individuals.

A multi-period location-allocation model for nursing home network planning under uncertainty

This paper proposes a multi-period location- allocation problem arising in nursing home network planning. We present a strategic model in which the improvement of service accessibility through the planning horizon is appropriately addressed. Unlike previous research, the proposed model modifies the allocation pattern to prevent unacceptable deterioration of the accessibility criterion. In addition, the problem is formulated as a covering model in which the capacity of facilities as well as the demand elasticity are considered. The uncertainty in demands within each time period is captured by adopting a distributionally robust approach. The model is then applied to a real case study for nursing home planning network in Shiraz city, Iran

Performance Measures to Assess Resiliency and Efficiency of Transit Systems

Transit agencies are interested in assessing the short-, mid-, and long-term performance of infrastructure with the objective of enhancing resiliency and efficiency. This report addresses three distinct aspects of New Jersey’s Transit System: 1) resiliency of bridge infrastructure, 2) resiliency of public transit systems, and 3) efficiency of transit systems with an emphasis on paratransit service. This project proposed a conceptual framework to assess the performance and resiliency for bridge structures in a transit network before and after disasters utilizing structural health monitoring (SHM), finite element (FE) modeling and remote sensing using Interferometric Synthetic Aperture Radar (InSAR). The public transit systems in NY/NJ were analyzed based on their vulnerability, resiliency, and efficiency in recovery following a major natural disaster

An Integrated Framework for Staffing and Shift Scheduling in Hospitals

Over the years, one of the main concerns confronting hospital management is optimising the staffing and scheduling decisions. Consequences of inappropriate staffing can adversely impact on hospital performance, patient experience and staff satisfaction alike. A comprehensive review of literature (more than 1300 journal articles) is presented in a new taxonomy of three dimensions; problem contextualisation, solution approach, evaluation perspective and uncertainty. Utilising Operations Research methods, solutions can provide a positive contribution in underpinning staffing and scheduling decisions. However, there are still opportunities to integrate decision levels; incorporate practitioners view in solution architectures; consider staff behaviour impact, and offer comprehensive applied frameworks. Practitioners’ perspectives have been collated using an extensive exploratory study in Irish hospitals. A preliminary questionnaire has indicated the need of effective staffing and scheduling decisions before semi-structured interviews have taken place with twenty-five managers (fourteen Directors and eleven head nurses) across eleven major acute Irish hospitals (about 50% of healthcare service deliverers). Thematic analysis has produced five key themes; demand for care, staffing and scheduling issues, organisational aspects, management concern, and technology-enabled. In addition to other factors that can contribute to the problem such as coordination, environment complexity, understaffing, variability and lack of decision support. A multi-method approach including data analytics, modelling and simulation, machine learning, and optimisation has been employed in order to deliver adequate staffing and shift scheduling framework. A comprehensive portfolio of critical factors regarding patients, staff and hospitals are included in the decision. The framework was piloted in the Emergency Department of one of the leading and busiest university hospitals in Dublin (Tallaght Hospital). Solutions resulted from the framework (i.e. new shifts, staff workload balance, increased demands) have showed significant improvement in all key performance measures (e.g. patient waiting time, staff utilisation). Management team of the hospital endorsed the solution framework and are currently discussing enablers to implement the recommendation

Modelling and (re-)planning periodic home social care services with loyalty and non-loyalty features

This work was partially supported by the Fundacao para a Ciencia e a Tecnologia (Portuguese Foundation for Science and Technology) through the project UID/MAT/00297/2019 (Centro de Matematica e Aplicacees).The aging population alongside little availability of informal care are two of the several factors leading to an increased need for assisted living support. In this work, we tackle a home social care service problem, motivated by two real case studies where a new loyalty scheme must be considered: within a week, patient-caregiver loyalty should be pursued but, between weeks, the caregivers must rotate among patients (non-loyalty). In addition, a common situation in this kind of service is also addressed: the need of a constant re-planning caused by the leaving of patients and the arrival of new ones. This new plan should be such that minimum disturbance is caused to the visiting hours of current patients, the caregivers’ travelling time between visits is minimized, and the workload is balanced among caregivers. A multi-objective optimization approach based on mixed-integer models is developed. Results on the two real case studies show that both institutions can efficiently re-plan their activities without much disturbance on the visits of their patients, and with a patient-caregiver loyalty scheme suiting their needs.authorsversionpublishe

Costs and consequences in perioperative care: Analytic models in studies on pain treatment and on haemodynamic optimization of elderly patients

ABSTRACT Background Because resources are scarce in health care, costs and consequences of new interventions must be assessed to support informed policy decisions. This thesis analyses the cost-effectiveness of advanced postoperative pain treatment and perioperative haemodynamic optimization by applying decision modelling as an analytic framework. 1. Postoperative pain treatment refers to epidural analgesia and to patient-controlled in travenous analgesia. Based on the superior analgesic effect found in clinical trials, epidural analgesia is regarded as the gold standard following major surgery, but a drawback is the high failure rate (10–15%). Considering that approximately 40 000 patients are treated by epidural analgesia per year in Sweden, costs and consequences of this clinical problem are substantial. 2. Haemodynamic optimization refers to fluid protocols targeted to increase blood flow, referred to as goal-directed haemodynamic treatment. These protocols are beneficial in the perioperative care of high-risk patients, but there is lack of evidence in elderly patients. In Sweden 20 000 patients are operated on each year for proximal femoral fracture, with poor postoperative outcome. Large trials are required to assess whether any protocol of the goaldirected haemodynamic treatment is beneficial in the elderly population, in terms of outcome and health care costs. Considering the cost and complexity of such a trial, a prior costeffectiveness analysis might be adequate to guide the initiation of such a trial. Methods 1. Epidural analgesia vs. patient-controlled intravenous analgesia: Paper I: A decision-analytic cost-effectiveness model was developed to analyse data of a clinical database on pain treatment following major abdominal surgery. Paper II: Postoperative intensive care costs were analysed on data from patients included in a previously published trial on postoperative pain treatment following thoracoabdominal oesophagectomy. 2. Goal-directed haemodynamic treatment vs. traditional fluid treatment in elderly patients: Paper III: A decision-analytic cost-effectiveness model was developed, and relevant data from published trials and national registries were analysed. As the clinical outcome for elderly patients was previously unknown, reasonable estimates are applied in the model. Paper IV: The prior cost-effectiveness analysis (Paper III) guided the initiation of a large (n = 460) randomized clinical trial in elderly patients with proximal femoral fracture, and interim analyses of safety and efficacy were conducted (n = 100). Given the interim efficacy data, the monetary value of further data collection was analysed by calculating the expected value of perfect information. Results 1. The epidural analgesia is not cost-effective and no saving of the postoperative costs can be achieved, given the available evidence in Swedish clinical routine (Papers I–II). 2. The goal-directed haemodynamic treatment is predicted to be cost-effective in elderly patients, based on the available evidence and on the prior estimates of clinical outcome before the initiation of the trial. The expected value of perfect information is high, indicating that collecting further data by continuing the trial is potentially worthwhile (Papers III–IV). Conclusions 1. The analyses of epidural analgesia challenge its position as the gold standard and may assist revision of clinical policy decisions on postoperative pain treatment. 2. The analyses of the goal-directed haemodynamic treatment in elderly patients using a decision-analytic cost-effectiveness model suggest the usefulness of the initiation and continuation of a large clinical trial