Patterns of Healthcare Utilization and Spending Among Homebound Older Adults in the USA: an Observational Study

A National Survey on Point of Care Ultrasonography Use Among Veterans Affairs Clinicians in Home Care and Skilled Nursing Facilities

INTRODUCTION

Older adults who are homebound and those in skilled nursing facilities (SNFs) often have limited access to point of care imaging to inform clinical decision making. Point-of-care ultrasonography (POCUS) can help span this gap by augmenting the physical examination to aid in diagnosis and triaging. Although training in POCUS for medical trainees is becoming more common and may focus on settings such as the emergency department, intensive care unit, and inpatient care, little is known about POCUS training among practicing clinicians who work outside of these settings. We conducted a national needs assessment survey around experience with POCUS focused on practicing clinicians in the sub-acute, long-term, and home-based care settings in the Veterans Affairs (VA) health system.

METHODS

An electronic survey was developed and sent out to clinicians via Listservs for the VA long-term and sub-acute care facilities [Community Living Centers (CLCs)], Home Based Primary Care outpatient teams, and Hospital in Home teams to assess current attitudes, previous training, and skills related to POCUS.

RESULTS

Eighty-eight participants responded to the survey, for an overall response rate of 29% based on the number of emails on each Listserv, representing CLC, home-based primary care, and hospital in home. Sixty percent of clinicians reported no experience with POCUS, and 76% reported that POCUS and POCUS training would be useful to their practice. More than 50% cited lack of training and lack of equipment as 2 significant barriers to POCUS use.

DISCUSSION

This national needs assessment survey of VA clinicians reveals important opportunities for training in POCUS for clinicians working with older adults who are receiving home care homebound or living in SNFs.

Prevalence of cognitive impairment in home health physical therapy

BACKGROUND

The prevalence of cognitive impairment in home health physical therapy (HHPT) is unknown. We sought to identify the prevalence of cognitive impairment, including cognitive impairment no dementia (CIND) and dementia, among older adults who used HHPT, and if cognitive impairment prevalence was higher among those with HHPT-relevant characteristics.

METHODS

For our cross-sectional analysis, we identified 963 fee-for-service Medicare beneficiaries with HHPT claims (>85 years old: 28.8%, women: 63.7%, non-Hispanic White: 82.1%) in the 2014 and 2016 waves of the Health and Retirement Study (HRS) and used a validated algorithm to categorize cognitive status as normal, CIND, or dementia. We estimated the population prevalence and calculated age, gender, race/ethnicity adjusted odds ratio (aOR) of CIND and dementia for characteristics relevant to HHPT service delivery including depression, walking difficulty, fall history, incontinence, moderate-vigorous physical activity (MVPA) ≤1x/week, and community-initiated HHPT using multinomial logistic regression.

RESULTS

The population prevalence of cognitive impairment was 46.4% (CIND: 27.3%, dementia: 19.1%). The prevalence of cognitive impairment was greater among those with depression (46.7% vs. 39.5%), difficulty walking across the room (58.9% vs. 41.8%), fall history (49.1% vs. 42.9%), MVPA ≤1x/week (50.0% vs. 38.0%), and community-initiated HHPT (55.2% vs. 40.2%). Compared to normal cognitive status, the odds of cognitive impairment were greater for those with MVPA≤1x/week (CIND: aOR = 1.57 [95% CI: 1.05-2.33], dementia: aOR = 2.55 [95% CI: 1.54-4.22]), depression (dementia: aOR = 1.99 [95% CI: 1.19-3.30]), difficulty walking across the room (dementia: aOR = 2.54 [95% CI: 1.40-4.60]), fall history (dementia: aOR = 1.85 [95% CI: 1.20-2.83]), and community-initiated HHPT (dementia: aOR = 1.72 (95% CI: 1.13-2.61]).

CONCLUSION

There is a high prevalence of CIND and dementia in HHPT, and no characteristics had a low prevalence of cognitive impairment. Physical therapists should be ready to identify cognitive impairment and adapt home health service delivery for this vulnerable population of older adults.

The heterogeneity of the homebound: A latent class analysis of a national sample of homebound older adults

BACKGROUND

Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics.

MATERIALS AND METHODS

Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression.

RESULTS

We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%).

CONCLUSIONS

This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population.