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8. Analysis
In this section, we provide the details and results of our analysis of the impact of TIPs on participants’ outcomes. After providing background information about TIPs enrollees, we provide evidence of the impacts on health care usage and self-reported health, followed by a cost-effectiveness analysis. We performed these analyses at three stages: February, 2020, November, 2020, and May, 2021.
8.1 SUMMARY STATISTICS
Details about the number of participants enrolled in TIPs over time, separately for the senior tower (Grace West Manor) and the townhomes, are displayed in Exhibit 1. Enrollment grew steadily during the first few months when the program began, and then began to plateau by the end of 2019. After the interruptions caused by COVID-19, enrollment remained flat for over a year. This is not surprising since during COVID we concentrated efforts on delivering services to existing enrollees, rather than on recruiting more participants. Enrollment picked up again once we resumed outdoor, in-person sessions, through natural means as a result of carrying out readings outdoors, in the middle of the Grace West campus. It is important to note that not all of the enrolled participants were consistently active with TIPs the entire time. By the end of May 2021, 51 participants from the Manor were considered inactive and 20 from the Townhomes. Inactivity could be due to several factors, such as relocating to another residence or loss of interest in the program.
During April and May 2021, individuals who had become inactive in the TIPs program were surveyed. We were interested in better understanding why they had become inactive, and what factors might cause them to return. 32 individuals were interviewed by phone. Of the 32 individuals who were interviewed, 28 (88%) said that they had found the TIPs program to be somewhat or very helpful. As well, 28 (88%) individuals said that they were somewhat or extremely satisfied with the program. When queried about why they had become inactive in TIPs, 18 (56%) individuals cited Covid-19, and 16 (50%) said that they preferred meeting in person (which was no longer possible during the pandemic). When asked if they planned to return to TIPs once the program restarted, 19 (59%) individuals said yes. Those who said that they were not planning to return to TIPs offered an array of reasons, including wishing that the program could be offered on different days or times, that the program would offer more gifts and raffles, that they might like to have reminders about when to attend, that they would prefer to have TIPs in their homes, and that they would return when/if TIPs was once again offered as a group activity.
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Exhibit 1: TIPs Enrollment over Time
180 160 140 120 100 80 60 40 20 0
Grace West Manor Townhomes
Notes: The first solid, vertical line indicates when in-person sessions ceased due to COVID restrictions. The second solid, vertical line indicates when in-person sessions resumed.
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Characteristics of the people enrolled as of May 31, 2021, are displayed in Exhibit 2. Participants from the Manor have an average age of 66, compared to an average age of 40 for Townhome participants, consistent with the age requirements for each site. Over two-thirds of the participants from the Manor are on Medicaid, a government insurance program for low-income adults. At the Townhomes, roughly half of the participants receive Medicaid. The lower rate at the Townhomes probably reflects that these residents are more likely to be working, making them ineligible for Medicaid. Most participants in the program are female (61.6% for the Manor and 73.8% for the Townhomes), likely reflecting high life expectancy for female seniors and increased caregiving responsibilities for females.
Exhibit 2. Characteristics of Enrolled Participants
Site
Number Enrolled Age (average) Medicaid (%, N) Female (%, N) Hospitalized Prior 12 Months (%, N) Re-hospitalized 30 Days Prior 12 Months (%, N)
Chronic Conditions
0 1 2 or more
Grace West Manor Townhomes
159 66 68.6% (109) 61.6% (98) 20.1% (32)
65 40 49.2% (32) 73.8% (48) 6.2% (4)
9.4% (3) 0% (0)
53.5% (85) 17.6% (28) 28.9% (46) 87.7% (57) 7.7% (5) 4.6% (3)
Total
224 53 62.9% (141) 65.2% (146) 16.1% (36)
8.3% (3)
63.4% (142) 14.7% (33) 21.9% (49)
Notes: Data collected on participants through 5/31/2021. Chronic conditions consist of Hypertension, diabetes, and COPD.
Consistent with their older age, enrollees from the Manor have poorer health status, as indicated by hospitalization rates and chronic conditions, than do enrollees from the Townhomes. Over 20 percent of enrollees from the Manor had been hospitalized during the past year (at the time of TIPs enrollment), compared to only 6.2 percent for the Townhome residents. Nearly half of the Manor enrollees have a chronic condition, with 28.9 percent having two or more. Only 13 percent of Townhome enrollees have a chronic condition.
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8.2 ANALYSIS OF HEALTHCARE USAGE
Over the course of the TIPs program, we analyzed the change in hospitalization rates and 30-day readmissions for TIPs enrollees. During our weekly sessions, we asked participants if they had been hospitalized during the past year and readmitted to the hospital within 30 days. Since we collect these data at our initial intake survey, the first response to these questions reflects the “pre-TIPs enrollment” period. Questions asked at later stages, after TIPs enrollment, are annualized to reflect the “post-TIPs enrollment” period. To assess the impact of TIPs, we compare the outcomes in the pre- and post-TIPs periods, with results summarized in Exhibit 3.
Exhibit 3. Hospitalizations and 30-Day Readmissions over Time
Grace West Manor
Townhomes Feb, 2020 Nov, 2020 May, 2021 Feb, 2020 Nov, 2020 May, 2021
A. Hospitalizations in Past Year
pre-TIPs enrollment 23% 21% 20% 6% 6% 6% post-TIPs enrollment 45% 23% 22% 11% 6% 6% impact of TIPs 22% 2% 2% 5% 0% 0%
B. 30-day Readmission in Past Year
pre-TIPs enrollment 10% 9% 9% 0% 0% 0% post-TIPs enrollment 2% 3% 3% 0% 0% 0% impact of TIPs -8% -7% -6% 0% 0% 0%
Notes: All data are reported in percent. Post-TIPs enrollment percent for data through February 2020 are based on estimated annualized outcomes.
For hospitalizations at Grace West, there was an estimated 22% increase in hospitalizations for Grace West residents as of February 2020 compared to the pre-TIPs period. Although the increase was at first a surprise result, it improved over the course of the program, changing to a 2% increase in both November 2020, and May, 2021. A similar trend for hospitalizations was observed for townhome residents, though at a lower scale. In February 2020, there was a 5% increase in hospitalizations. This improved to no change in November 2020, and May 2021. We interpret these results to suggest that there was no overall change in hospitalizations.
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For 30-day readmissions, we found a more consistent and sizable impact for Grace West residents. The decrease in 30-day readmission rate hovered around 6-8% across the three waves, suggesting an enduring impact of TIPs on readmissions. We found no change for Townhouse residents; in fact, there were no 30day readmissions at all for these residents.
We note that COVID hampered our ability to consistently collect data from all participants. Subjects that we were able to contact more recently were more likely to be in worse health. Those in worse health potentially have more health care encounters, biasing our analysis to finding a spurious increase in health care usage. Moreover, our conversations with Beth Israel Hospital, which most residents use when hospitalized, to verify the reliability of these self-reported data, was derailed by the pandemic.
COVID may have also changed health care encounters in at least two important ways: 1) participants may have been infected with COVID-19, thus requiring a hospitalization they may not have otherwise had; and 2) participants may have reduced their use of health care services more generally in an effort to reduce their exposure to COVID-19. The first factor biases our estimates toward a spurious increase in care due to TIPs, while the second biases our estimates toward a spurious decrease. We do not suspect that issue (1) is particularly relevant because only 1 person (out of 95 surveyed) reported having contracted COVID-19 and going to the hospital as a result. Nonetheless, the precise impacts of COVID-19 on this analysis are unknown.
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8.3 ANALYSIS OF SELF-REPORTED HEALTH
While hospital admissions are one metric of interest, they may only represent the tip of the iceberg. To assess whether TIPs impacted other health outcomes, we explored the impacts of TIPs on physical and mental health, focusing solely on the Grace West residents since their health status at the start of the project was much worse on average. To measure health status, we asked three questions, all derived from the Behavioral Risk Factor Surveillance System run by the CDC:
1. “During the past 7 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?”
2. “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 7 days was your mental health not good?”
3. “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 7 days was your physical health not good?”
These measures were only taken after TIPs enrollment, so there is no pre-TIPs measure. We took the first and last measure for each outcome and noted the length of time between the outcomes. Results are shown in Exhibit 4.
Exhibit 4. Changes in Self-reported Health over Time
Feb, 2020 Nov, 2020 May, 2021
early late diff early late diff early late diff usual activity 0.36 0.14 -0.21 0.42 0.08 -0.34 0.40 0.07 -0.33 mental health 0.42 0.16 -0.26 0.41 0.07 -0.34 0.43 0.07 -0.36 physical health 0.49 0.09 -0.39 0.49 0.16 -0.33 0.47 0.13 -0.34
Notes: All outcomes are measured in days per week. ‘early’ reflects the first measurement of each outcome, ‘late’ reflects the last measurement, and ‘diff’ reflects the difference between the early and late measures. As of February 2020, there were 76 enrollees with an average of 8.2 weeks between measures. As of November 2020, there were 143 enrollees, with an average of 30.5 weeks between measures. As of May 2021, there were 148 enrollees, with an average of 45.7 weeks between measures.
Measures of physical and mental health showed considerable improvements over the course of the study. For example, in response to “the number of days physical health was not good during the past 7 days,” enrollees improved from an average of 0.49 days to 0.09 days over the 8 weeks between measurements, resulting in an improvement of 0.39 days per week. These improvements persisted over time, as shown in the results from the November 2020 and May 2021 waves.
While this trend is encouraging, it is important to keep in mind that, like the hospitalization data, this also relies on a self-report. For these data, however, there is no clear way to verify their validity.
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8.4 COST-EFFECTIVENESS ANALYSIS
We conducted a cost-effectiveness analysis (CEA) to succinctly summarize the cost impacts of TIPs. We calculated the annual costs of the TIPs program to Grace West residents based on internal estimates of the cost to deliver services plus any relevant line items in the JRCo budget. We monetized the changes in healthcare utilization based on the changes in outcomes measured from the healthcare usage analysis. Any such analysis is always filled with limitations, and unique circumstances due to the COVID pandemic even further that. We outline several of these caveats below.
I. COST OF TIPS PROGRAM
To estimate the cost of TIPs, we used existing estimates for “TIPs-classic” for one full year. Since the TIPs program was interrupted due to COVID, annual numbers may overstate the full costs. The TIPs costs include the costs of a nurse, TTA, travel, hardware, software, licensing, and other administration tasks. Given that TIPs as delivered at Grace West involved additional costs (involvement of a residential service coordinator, promotions, and other activities to recruit participants, and a security guard) not included in the TIPs classic estimate, we also included costs from the JRCo budget for these items. Exhibit 5 reflects the overall costs to deliver TIPs at Grace West.
Exhibit 5. Estimated Costs to Deliver TIPs program at GW
TIPs costs to serve 50 participants (in first year) TIPs costs per additional 50 participants Number of participants at Grace West Additional budget items
Total costs
$60,000 $25,000 150 $59,886
$169,866
We did not include the cost of wrap-around services since some already existed absent TIPs, and many were secured at no cost. We also did not include indirect costs associated with the project team to coordinate and analyze TIPs. These costs center on establishing TIPs as a viable service and providing proof of concept. That is, these are costs that are not necessary for establishing a new TIPs program and would not be part of the calculus for assessing financial sustainability.
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II. HEALTHCARE SAVINGS FROM TIPS PROGRAM
To measure healthcare savings, we focus on 30-day hospital readmissions as our measure of healthcare utilization. This outcome improved for TIPs residents and is readily monetizable using estimates of the cost of hospitalizations. We used outcomes measured from the November 2020 wave because it reflected roughly one year of services, which corresponds with the timeframe of the cost measurements. Exhibit 6 reflects the monetized healthcare savings from TIPs.
Exhibit 6. Estimated Monetized Healthcare Savings from TIPs at GW
Reduction in 30-day hospital readmissions Hospital charge per readmissiona
Costs to charge ratiob
Total healthcare savings 2 $64,952 0.203 $26,388
aCalculated from NJ State Inpatient Database from readmitted patients over 65 years of age from the ZIP code 07108. bCalculated from CMS files for all hospitals located in Newark.
We recognize that using changes in only this outcome reflects a partial accounting of the full range of impacts for participants because it does not monetize all of the potential benefits to participants. At least three items are not included. One, the hospital costs for readmissions do not reflect the full costs to residents, such as the role of any caregivers and the pain and suffering of the patient. Two, we also found evidence that the program improved health-related quality of life measures, which represents an additional benefit not readily monetized. Three, there may be other benefits to participants that we did not measure, possibly because they have yet to accrue.
An example of an additional health benefits that TIPs enrollees might benefit from is improved COVID outcomes because of the higher COVID vaccination rates (described in Section 3.7). We can combine this finding with information on background COVID rates and vaccine effectiveness to provide an approximate estimate of the number of COVID hospitalizations and positive cases avoided (details of the calculations are provided in Appendix Exhibit 2). We approximate that, because of the improved vaccination rates attributable to TIPs, we avoided 0.26 hospitalizations and 1.90 positive cases of COVID. If we value the change in hospitalizations at current reimbursement rates, this would contribute an additional $6,342 to the healthcare savings, which is roughly 24 percent of the savings shown in Table 6. We recognize these as speculative measures only meant to be suggestive of the potential additional savings
We also note that our estimate of the improvements in readmissions is subject to uncertainty. The pandemic hampered our ability to consistently collect data from all participants and may have changed healthcare encounters in important ways. Unfortunately, there is no readily available solution to address these issues.
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III. COST-EFFECTIVENESS ANALYSIS
Bringing the cost and savings together, we can calculate how much the reduction in healthcare costs offsets the cost of TIPs. Based on costs of $169,886 and healthcare savings of $26,388, we project that 16 percent of the costs of TIPs has been recouped through these healthcare savings. Given that we have erred on the side of overstating the costs and understating the benefits, this is a conservative estimate that likely understates the true percent of costs recouped. We know from resident anecdotes that other health care interventions may have been avoided as a result of TIPs but it is difficult to quantify the benefit due to the qualitative nature of the information.
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