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Thompson MP, Hou H, Likosky DS, Pagani FD, Falvey J, Bowles KH, Wadhera RK, Sterling MR. Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2024; 17:e010459. [PMID: 38770653 PMCID: PMC11251853 DOI: 10.1161/circoutcomes.123.010459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting. METHODS Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers. RESULTS A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge. CONCLUSIONS A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.
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Affiliation(s)
- Michael P. Thompson
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Hechuan Hou
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kathryn H. Bowles
- University of Pennsylvania School of Nursing, Philadelphia, PA
- VNS Health, New York, NY
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Jones CD, Moss A, Sevick C, Roczen M, Sterling MR, Portz J, Lum HD, Yu A, Urban JA, Khazanie P. Factors Associated With Mortality and Hospice Use Among Medicare Beneficiaries With Heart Failure Who Received Home Health Services. J Card Fail 2024; 30:788-799. [PMID: 38142043 DOI: 10.1016/j.cardfail.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Although many Medicare beneficiaries with heart failure (HF) are discharged with home health services, little is known about mortality rates and hospice use in this group. OBJECTIVES To identify risk factors for 6-month mortality and hospice use among patients hospitalized due to HF who receive home health care, which could inform efforts to improve palliative and hospice use for these patients. METHODS A retrospective cohort analysis was conducted in a 100% national sample of Medicare fee-for-service beneficiaries with HF who were discharged to home health care between 2017 and 2018. Multivariable Cox regression models examined factors associated with 6-month mortality, and multivariable logistic regression models examined factors associated with hospice use at the time of death. RESULTS A total of 285,359 Medicare beneficiaries were hospitalized with HF and discharged with home health care; 15.5% (44,174) died within 6 months. Variables most strongly associated with mortality included: age > 85 years (hazard ratio [HR] 1.66, 95% CI 1.61-1.71), urgent/emergency hospital admission (HR 1.68, 1.61-1.76), and "serious" condition compared to "stable" condition (HR 1.64, CI 1.52-1.78). Among 44,174 decedents, 48.2% (21,284) received hospice care at the time of death. Those with lower odds of hospice use at death included patients who were: < 65 years (odds ratio [OR] 0.65, CI 0.59-0.72); of Black (OR 0.64, CI 0.59-0.68) or Hispanic race/ethnicity (OR 0.79, CI 0.72-0.88); and Medicaid-eligible (OR 0.80, CI 0.76-0.85). CONCLUSIONS Although many patients hospitalized for HF are at risk of 6-month mortality and may benefit from palliative and/or hospice services, our findings indicate under-use of hospice care and important disparities in hospice use by race/ethnicity and socioeconomic status.
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Affiliation(s)
- Christine D Jones
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO; Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of Geriatrics, Department of Medicine, University of Colorado, Aurora, CO.
| | - Angela Moss
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Carter Sevick
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Madeline R Sterling
- Division of General Internal Medicine, Department of Medicine at Weill Cornell Medicine, New York, NY
| | - Jennifer Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Hillary D Lum
- Division of Geriatrics, Department of Medicine, University of Colorado, Aurora, CO
| | - Amy Yu
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Jacqueline A Urban
- Division of General Internal Medicine, Department of Medicine, University of Colorado, Aurora, CO
| | - Prateeti Khazanie
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO
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Keeney T, Wu C, Savini A, Stone S, Travis A, Vranceanu AM, Steinhauser K, Greer J, Pastva AM, Ritchie C. Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure. J Palliat Med 2024; 27:526-531. [PMID: 38394228 PMCID: PMC11000320 DOI: 10.1089/jpm.2023.0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.
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Affiliation(s)
- Tamra Keeney
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cecilia Wu
- Mass General Brigham Home Care, Boston, Massachusetts, USA
| | - Alicia Savini
- Mass General Brigham Home Care, Boston, Massachusetts, USA
| | - Sarah Stone
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aniyah Travis
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research (CHOIR), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen Steinhauser
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Joseph Greer
- Department of Psychiatry, Massachusetts General Hospital
| | - Amy M. Pastva
- Department of Orthopedic Surgery, Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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4
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Levitan EB, Goyal P, Ringel JB, Soroka O, Sterling MR, Durant RW, Brown TM, Bowling CB, Safford MM. Myocardial infarction and physical function: the REasons for Geographic And Racial Differences in Stroke prospective cohort study. BMJ PUBLIC HEALTH 2023; 1:e000107. [PMID: 37920711 PMCID: PMC10618954 DOI: 10.1136/bmjph-2023-000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Objective To examine associations between myocardial infarction (MI) and multiple physical function metrics. Methods Among participants aged ≥45 years in the REasons for Geographic And Racial Differences in Stroke prospective cohort study, instrumental activities of daily living (IADL), activities of daily living (ADL), gait speed, chair stands, and Short Form-12 physical component summary (PCS) were assessed after approximately 10 years of follow-up. We examined associations between MI and physical function (no MI [n = 9,472], adjudicated MI during follow-up [n = 288, median 4.7 years prior to function assessment], history of MI at baseline [n = 745], history of MI at baseline and adjudicated MI during follow-up [n = 70, median of 6.7 years prior to function assessment]). Models were adjusted for sociodemographic characteristics, health behaviours, depressive symptoms, cognitive impairment, body mass index, diabetes, hypertension, and urinary albumin to creatinine ratio. We examined subgroups defined by age, gender, and race. Results The average age at baseline was 62 years old, 56% were women, and 35% Black. MI was significantly associated with worse IADL and ADL scores, IADL dependency, chair stands, and PCS, but not ADL dependency or gait speed. For example, compared to participants without MI, IADL scores (possible range 0-14, higher score represents worse function) were greater for participants with MI during follow-up (difference: 0.37 [95% CI 0.16, 0.59]), MI at baseline (0.26 [95% CI 0.12, 0.41]), and MI at baseline and follow-up (0.71 [95% CI 0.15, 1.26]), p < 0.001. Associations tended to be greater in magnitude among participants who were women and particularly Black women. Conclusion MI was associated with various measures of physical function. These decrements in function associated with MI may be preventable or treatable.
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Affiliation(s)
- Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Parag Goyal
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Joanna Bryan Ringel
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Orysya Soroka
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Madeline R. Sterling
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Raegan W. Durant
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M. Brown
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - C. Barrett Bowling
- Department of Veterans Affairs, Durham Geriatrics Research Education and Clinical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Monika M. Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
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Chae S, Davoudi A, Song J, Evans L, Hobensack M, Bowles KH, McDonald MV, Barrón Y, Rossetti SC, Cato K, Sridharan S, Topaz M. Predicting emergency department visits and hospitalizations for patients with heart failure in home healthcare using a time series risk model. J Am Med Inform Assoc 2023; 30:1622-1633. [PMID: 37433577 PMCID: PMC10531127 DOI: 10.1093/jamia/ocad129] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVES Little is known about proactive risk assessment concerning emergency department (ED) visits and hospitalizations in patients with heart failure (HF) who receive home healthcare (HHC) services. This study developed a time series risk model for predicting ED visits and hospitalizations in patients with HF using longitudinal electronic health record data. We also explored which data sources yield the best-performing models over various time windows. MATERIALS AND METHODS We used data collected from 9362 patients from a large HHC agency. We iteratively developed risk models using both structured (eg, standard assessment tools, vital signs, visit characteristics) and unstructured data (eg, clinical notes). Seven specific sets of variables included: (1) the Outcome and Assessment Information Set, (2) vital signs, (3) visit characteristics, (4) rule-based natural language processing-derived variables, (5) term frequency-inverse document frequency variables, (6) Bio-Clinical Bidirectional Encoder Representations from Transformers variables, and (7) topic modeling. Risk models were developed for 18 time windows (1-15, 30, 45, and 60 days) before an ED visit or hospitalization. Risk prediction performances were compared using recall, precision, accuracy, F1, and area under the receiver operating curve (AUC). RESULTS The best-performing model was built using a combination of all 7 sets of variables and the time window of 4 days before an ED visit or hospitalization (AUC = 0.89 and F1 = 0.69). DISCUSSION AND CONCLUSION This prediction model suggests that HHC clinicians can identify patients with HF at risk for visiting the ED or hospitalization within 4 days before the event, allowing for earlier targeted interventions.
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Affiliation(s)
- Sena Chae
- College of Nursing, The University of Iowa, Iowa City, Iowa, USA
| | - Anahita Davoudi
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Jiyoun Song
- Columbia University School of Nursing, New York City, New York, USA
| | - Lauren Evans
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Mollie Hobensack
- Columbia University School of Nursing, New York City, New York, USA
| | - Kathryn H Bowles
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | | | - Yolanda Barrón
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Sarah Collins Rossetti
- Columbia University School of Nursing, New York City, New York, USA
- Department of Biomedical Informatics, Columbia University, New York City, New York, USA
| | - Kenrick Cato
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Sridevi Sridharan
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Maxim Topaz
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
- Columbia University School of Nursing, New York City, New York, USA
- Data Science Institute, Columbia University, New York City, New York, USA
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6
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Bensson-Ravunniarath M, Bryan Ringel J, Avgar A, Wiggins F, Lee A, McDonald MV, Guerrero LR, Kallas J, Gusoff G, Shen M, Tseng E, Dell N, Czaja S, Lindquist LA, Sterling MR. Having a Say Matters: The Association Between Home Health Aides' Voice and Job Satisfaction. Risk Manag Healthc Policy 2023; 16:1791-1800. [PMID: 37705993 PMCID: PMC10497062 DOI: 10.2147/rmhp.s420207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023] Open
Abstract
Purpose Despite a rapidly growing need for home health aides (HHAs), turnover rates are high. While this is driven in large part by the demanding nature of their work and low wages, another factor may be that HHAs are often not considered part of the medical team which can leave them feeling unheard by other healthcare professionals. We sought to determine whether this concept, or HHAs' perceived voice, was associated with job satisfaction. Methods and Design This cross-sectional survey of English- and Spanish-speaking HHAs caring for adults with heart failure (HF) was conducted from June 2020 to July 2021 in New York, NY in partnership with a labor management fund of a large healthcare union that provides benefits and training to HHAs. Voice was assessed with a validated 5-item scale (total score range 5 to 25). Job Satisfaction was assessed with the 5-item Work Domain Satisfaction Scale (total score range 5 to 35). Multivariable linear regression analysis was used to examine the association between voice and job satisfaction. Results A total of 413 HHAs employed by 56 unique home care agencies completed the survey; they had a mean age of 48 years, 97.6% were female, 60.2% were Hispanic, and they worked as HHAs for a median of 10 years (IQR, 5, 17). They had a median Voice score of 18 (IQR 15-20) and mean job satisfaction score of 26.4 (SD 5.6). Higher levels of voice (1.75 [0.46-3.04]) were associated with greater job satisfaction (p=0.008). When adjusting for Race/Ethnicity, HF training, and HF knowledge, the association between Voice and job satisfaction remained significant ((1.77 [0.40-3.13]). Conclusion HHAs with a voice in the care of their patients experienced greater job satisfaction. Voice may be an important target for interventions aiming to improve HHAs' retention in the field.
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Affiliation(s)
| | | | - Ariel Avgar
- Cornell University, School of Industrial Labor Relations, Ithaca, NY, USA
| | - Faith Wiggins
- 1199SEIU Training and Employment Fund, New York, NY, USA
| | - Ann Lee
- 1199SEIU Training and Employment Fund, New York, NY, USA
| | | | | | - John Kallas
- Cornell University, School of Industrial Labor Relations, Ithaca, NY, USA
| | | | - Megan Shen
- Clinical Research Division, Fred Hutch Cancer Center, Seattle, WA, USA
| | - Emily Tseng
- Cornell Tech, Cornell University, New York, NY, USA
| | - Nicola Dell
- Cornell Tech, Cornell University, New York, NY, USA
| | - Sara Czaja
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lee A Lindquist
- Division of Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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7
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Stevens-Lapsley JE, Derlein D, Churchill L, Falvey JR, Nordon-Craft A, Sullivan WJ, Forster JE, Stutzbach JA, Butera KA, Burke RE, Mangione KK. High-intensity home health physical therapy among older adult Veterans: A randomized controlled trial. J Am Geriatr Soc 2023; 71:2855-2864. [PMID: 37224397 PMCID: PMC10684313 DOI: 10.1111/jgs.18413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events. METHODS We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization. RESULTS There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds. CONCLUSIONS Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program.
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Affiliation(s)
- Jennifer E Stevens-Lapsley
- Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Danielle Derlein
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Churchill
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amy Nordon-Craft
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - William J Sullivan
- VA Tennessee Valley Healthcare System, Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeri E Forster
- VA Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Julie A Stutzbach
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- School of Physical Therapy, Regis University, Denver, Colorado, USA
| | - Katie A Butera
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen K Mangione
- College of Health Science, Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
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8
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Sterling MR, Ringel JB, Riegel B, Goyal P, Arbaje AI, Bowles KH, McDonald MV, Kern LM. Home Health Care Workers' Interactions with Medical Providers, Home Care Agencies, and Family Members for Patients with Heart Failure. J Am Board Fam Med 2023; 36:369-375. [PMID: 36948539 PMCID: PMC10329236 DOI: 10.3122/jabfm.2022.220204r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/21/2022] [Accepted: 11/14/2022] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Despite providing frequent care to heart failure (HF) patients, home health care workers (HHWs) are generally considered neither part of the health care team nor the family, and their clinical observations are often overlooked. To better understand this workforce's involvement in care, we quantified HHWs' scope of interactions with clinicians, health systems, and family caregivers. METHODS Community-partnered cross-sectional survey of English- and Spanish-speaking HHWs who cared for a HF patient in the last year. The survey included 6 open-ended questions about aspects of care coordination, alongside demographic and employment characteristics. Descriptive statistics were performed. RESULTS Three hundred ninety-one HHWs employed by 56 unique home care agencies completed the survey. HHWs took HF patients to a median of 3 doctor appointments in the last year with 21.9% of them taking patients to ≥ 7 doctor appointments. Nearly a quarter of HHWs reported that these appointments were in ≥ 3 different health systems. A third of HHWs organized care for their HF patient with ≥ 2 family caregivers. CONCLUSIONS HHWs' scope of health-related interactions is large, indicating that there may be novel opportunities to leverage HHWs' experiences to improve health care delivery and patient care in HF.
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Affiliation(s)
- Madeline R Sterling
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM).
| | - Joanna Bryan Ringel
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
| | - Barbara Riegel
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
| | - Parag Goyal
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
| | - Alicia I Arbaje
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
| | - Kathryn H Bowles
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
| | - Margaret V McDonald
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
| | - Lisa M Kern
- From the Weill Cornell Medicine, New York, NY (MRS, JBR, PG, LMK); University of Pennsylvania School of Nursing, Philadelphia (BR, KHB); Johns Hopkins University School of Medicine, Baltimore, MD (AIA); Center for Home Care Policy & Research at VNS Health, New York, NY (KHB, MVM)
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Stawnychy MA, Ringel JB, Riegel B, Sterling MR. Better Preparation and Training Determine Home Care Workers' Self-Efficacy in Contributing to Heart Failure Self-Care. J Appl Gerontol 2023; 42:651-659. [PMID: 35801567 PMCID: PMC9825674 DOI: 10.1177/07334648221113322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Identify determinants of home care workers' (HCW) self-efficacy in contributing to heart failure (HF) self-care. METHODS Secondary analysis of a survey (n = 328) examining characteristics of HCWs caring for adults with HF in New York. Self-efficacy assessed using Caregiver Self-Efficacy in Contributing to Self-Care Scale. Standardized scores range 0-100; ≥ 70 points indicate adequate self-efficacy. Characteristics determined by self-efficacy (low vs. adequate). Prevalence ratios with 95% confidence intervals (PR [95% CI]) were estimated using multivariable Poisson regression with robust standard errors. RESULTS Home care workers with adequate self-efficacy had at least some prior HF training (55% vs. 17%, p < .001) and greater job satisfaction (90% vs. 77%, p = .003). Significant determinants for adequate self-efficacy were employment length (1.02 [1.00-1.03], p = .027), preparation for caregiving (3.10 [2.42-3.96], p < .001), and HF training (1.48 [1.20-1.84], p < .001). CONCLUSION Home care agencies and policy-makers can target caregiving preparation and HF training to improve HCWs' confidence in caring for adult HF patients.
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Affiliation(s)
- Michael A. Stawnychy
- Robert Wood Johnson Foundation Future of Nursing Scholar
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Mary Mackillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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10
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Keeney T, Lake D, Varma H, Resnik L, Teno JM, Grabowski DC, Gozalo P. Trends in post-acute care and outcomes for Medicare beneficiaries hospitalized for heart failure between 2008 and 2015. J Am Geriatr Soc 2023; 71:730-741. [PMID: 36318635 PMCID: PMC10023288 DOI: 10.1111/jgs.18109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 03/18/2023]
Abstract
BACKGROUND Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty. METHODS Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status. RESULTS Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients. CONCLUSIONS Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.
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Affiliation(s)
- Tamra Keeney
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital
- Mongan Institute Center for Aging and Serious Illness Research, Massachusetts General Hospital
- Department of Health Services, Policy & Practice, Brown University, School of Public Health
| | - Derek Lake
- Center for Gerontology and Health Care Research, Brown University School of Public Health
| | - Hiren Varma
- Center for Gerontology and Health Care Research, Brown University School of Public Health
- Department of Health Services, Policy & Practice, Brown University, School of Public Health
| | - Linda Resnik
- Department of Health Services, Policy & Practice, Brown University, School of Public Health
- Research Department, Providence VA Medical Center
| | - Joan M. Teno
- School of Medicine, Oregon Health & Science University
| | | | - Pedro Gozalo
- Center for Gerontology and Health Care Research, Brown University School of Public Health
- Department of Health Services, Policy & Practice, Brown University, School of Public Health
- Research Department, Providence VA Medical Center
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11
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Sterling MR, Lau J, Rajan M, Safford M, Akinyelure OP, Kern LM. Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. J Am Geriatr Soc 2023; 71:810-820. [PMID: 36468538 PMCID: PMC10023304 DOI: 10.1111/jgs.18135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Older adults see multiple outpatient providers and increasingly use home health care (HHC) services. Previous studies attempting to draw inferences about the association between HHC use and patient outcomes have been mixed. Whether HHC is associated with care coordination and how both influence outcomes are unknown. In addition, prior studies have not taken the patient perspective into account. We examined the association between receiving HHC and self-reported gaps in care coordination and separately, preventable adverse outcomes. METHODS The analysis for this cross-sectional study was conducted between October 2021 and June 2022, using data on 4296 Medicare beneficiaries from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who completed a survey on care coordination from 2017 to 2018. The associations between the receipt of HHC and two outcomes (a gap in care coordination, and separately, a preventable adverse event) were examined with Poisson models with robust standard errors. Potential confounders were accounted for through propensity score-based inverse probability weighting. RESULTS Among 4296 participants, 430 (10%) received HHC and they were older and had more comorbidities and ambulatory visits than those without HHC. HHC was not associated with differences in self-reported gaps in care coordination (33.3% HHC vs. 32.5% no-HHC, p = 0.70). HHC recipients reported more preventable drug-drug interactions (9.1% vs. 4.0%, p < 0.001) but not more preventable ED visits or hospital admissions. In IPW-adjusted models, HHC was not associated with gaps in care coordination (p = 0.60) but was associated with double the risk of a preventable adverse outcome (aRR 2.06; CI: 1.37, 3.10, p < 0.001). CONCLUSIONS HHC recipients were significantly more likely (than those without HHC) to report a potentially preventable adverse event (particularly a drug-drug interaction), suggesting an opportunity to improve patient safety by leveraging the observations of older adults receiving HHC.
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Affiliation(s)
| | - Jennifer Lau
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Mangala Rajan
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Monika Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | | | - Lisa M. Kern
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
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12
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Sterling MR, Cho J, Leung PB, Silva AF, Ringel J, Wiggins F, Herring N, Powell A, Toro O, Lee A, Loughman J, Obodai M, Poon A, Goyal P, Kern LM, Safford MM. Development and Piloting of a Community-Partnered Heart Failure Training Course for Home Health Care Workers. Circ Cardiovasc Qual Outcomes 2022; 15:e009150. [PMID: 36378772 PMCID: PMC9674373 DOI: 10.1161/circoutcomes.122.009150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 10/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite their unique contributions to heart failure (HF) care, home healthcare workers (HHWs) have unmet educational needs and many lack HF caregiving self-efficacy. To address this, we used a community-partnered approach to develop and pilot a HF training course for HHWs. METHODS We partnered with the Training and Employment Fund, a benefit fund of the largest healthcare union in the United States, to develop a 2-hour virtual HF training course that met HHWs' job-specific needs. English and Spanish-speaking HHWs interested in HF training, with access to Zoom, were eligible. We used a mixed methods design with pre/postsurveys and semi-structured interviews to evaluate the course: (a) feasibility, (b) acceptability, and (c) effectiveness (change in knowledge [Dutch Heart Failure Knowledge Scale range 0-15] and caregiving self-efficacy [HF Caregiver Self-efficacy Scale range 0-100]). RESULTS Of the 210 HHWs approached, 100 were eligible and agreed, and 70 enrolled. Of them, 53 (employed by 15 different home care agencies) participated. Posttraining data showed significant improvements (pretraining mean [SD] versus posttraining mean [SD]; P value) in HF knowledge (11.21 [1.90] versus 12.21 [1.85]; P=0.0000) and HF caregiving self-efficacy (75.21 [16.57] versus 82.29 [16.49]; P=0.0017); the greatest gains occurred among those with the lowest pre-training scores. Participants found the course engaging, technically feasible, and highly relevant to their scope of care. CONCLUSIONS We developed and piloted the first HF training course for HHWs, which was feasible, acceptable, and improved their HF knowledge and caregiving self-efficacy. Our findings warrant scalability to the workforce at large with a train-the-trainer model.
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Affiliation(s)
| | | | | | | | | | - Faith Wiggins
- 1199SEIU-Training and Employment Funds, New York, NY
| | | | | | - Oscar Toro
- 1199SEIU-Training and Employment Funds, New York, NY
| | - Ann Lee
- 1199SEIU-Training and Employment Funds, New York, NY
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13
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Goto Y, Miura H, Ito N. Comparison between the Chief Care Manager and the Normal Care Manager on Hospitalization and Discharge Coordination Activities in Japan: An Online Cross-Sectional Study of Care Managers in Aichi Prefecture. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12122. [PMID: 36231421 PMCID: PMC9565180 DOI: 10.3390/ijerph191912122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/18/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
The Japanese long-term care insurance system came into operation in the year 2000 and the chief care manager certification system was established in 2006 to improve the quality of care management. Certified chief care managers are expected to perform the role of a specialist. The purpose of this study was to determine the impact of the chief care manager certificate in coordination with hospitals. In this online cross-sectional survey, responses were obtained from 448 care managers engaged in long-term care activities with all in-home long-term care support providers. Among these 448 care managers, 301 had the chief care manager certificate. Of these care managers, ≥90% regularly asked their patients about their "values" and ≥80% provided their patients with hospitalization and discharge support. Of the care managers who provided their patients with hospitalization support, 80% provided the hospitals with information regarding patient "values" at the time of hospitalization, and 50% provided the hospitals with information regarding patient "values" and information. The chief care manager certificate had positive effects on confidence in hospitalization and discharge support. However, no significant difference was observed between the activities of chief and normal care managers in terms of hospitalization and discharge support.
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Affiliation(s)
- Yuko Goto
- Correspondence: ; Tel.: +81-562-46-2311
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14
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Kilaru AS, Illenberger N, Meisel ZF, Groeneveld PW, Liu M, Mondal A, Mitra N, Merchant RM. Incidence of Timely Outpatient Follow-Up Care After Emergency Department Encounters for Acute Heart Failure. Circ Cardiovasc Qual Outcomes 2022; 15:e009001. [PMID: 36073354 PMCID: PMC9489651 DOI: 10.1161/circoutcomes.122.009001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care. METHODS We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios. RESULTS The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care. CONCLUSIONS Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.
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Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Nicholas Illenberger
- Department of Population Health, NYU Grossman School of Medicine (N.I.), New York, New York
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Manqing Liu
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard University Boston, Massachusetts (M.L.)
| | - Angira Mondal
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics (N.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Raina M Merchant
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
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15
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Sterling MR, Cené CW, Ringel JB, Avgar AC, Kent EE. Rural-urban differences in family and paid caregiving utilization in the United States: Findings from the Cornell National Social Survey. J Rural Health 2022; 38:689-695. [PMID: 35355330 PMCID: PMC9492623 DOI: 10.1111/jrh.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE While rates of family caregiving and paid caregiving are increasing, how often they occur together ("shared care") and whether utilization varies geographically are unknown. We examined differences in family and paid caregiving utilization by rurality and region in the United States. METHODS The 2020 Cornell National Social Survey is an annual cross-sectional telephone-based survey of a random sample of 1,000 US adults. Participants were asked if they have been a family caregiver, including if they provided care alongside a paid caregiver. Rural-Urban Commuting Area Codes and Census areas classified rurality and region. The association between residence and the prevalence of caregiving was determined with multivariable Poisson regression. FINDINGS Among 857 participants with geographic and caregiving data, 11.8% (n = 101) were rural dwellers and 34.2% were family caregivers. Rural residence (vs urban) was associated with a higher prevalence of family caregiving (PR: 1.59 [1.22, 2.06]), and Western residence (vs Northeast) was associated with a lower prevalence of family caregiving (PR: 0.63 [0.46, 0.87], P = .01). Forty percent of family caregivers shared care with a paid caregiver. There was no significant difference in shared care by rural residence in unadjusted (31.8% rural vs 43.1% urban, P = .22) or adjusted models (PR: 0.85 [0.51, 1.41], P = .53). CONCLUSIONS Although family caregiving was more prevalent in rural areas and certain regions, shared care did not differ by rurality or region. Studies are needed to understand why rural residents do more family caregiving without additional support from paid caregivers, and what the implications are for caregivers and care recipients.
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Affiliation(s)
| | - Crystal W. Cené
- University of North Caroline at Chapel Hill, Chapel Hill, NC
| | | | | | - Erin E. Kent
- University of North Caroline at Chapel Hill, Chapel Hill, NC
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16
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Sterling MR, Essien UR. Implementing Equity: Improving Blood Pressure and Glycemic Control Among Adults With Heart Failure. Circ Heart Fail 2022; 15:e009650. [PMID: 35477264 PMCID: PMC9117513 DOI: 10.1161/circheartfailure.122.009650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Madeline R Sterling
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY (M.R.S.)
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh, PA (U.R.E.).,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, PA (U.R.E.)
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17
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Sterling MR, Ringel JB, Pinheiro LC, Safford MM, Levitan EB, Phillips E, Brown TM, Nguyen OK, Goyal P. Social Determinants of Health and 30-Day Readmissions Among Adults Hospitalized for Heart Failure in the REGARDS Study. Circ Heart Fail 2022; 15:e008409. [PMID: 34865525 PMCID: PMC8849604 DOI: 10.1161/circheartfailure.121.008409] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND It is not known which social determinants of health (SDOH) impact 30-day readmission after a heart failure (HF) hospitalization among older adults. We examined the association of 9 individual SDOH with 30-day readmission after an HF hospitalization. METHODS AND RESULTS Using the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), we included Medicare beneficiaries who were discharged alive after an HF hospitalization between 2003 and 2014. We assessed 9 SDOH based on the Healthy People 2030 Framework: race, education, income, social isolation, social network, residential poverty, Health Professional Shortage Area, rural residence, and state public health infrastructure. The primary outcome was 30-day all-cause readmission. For each SDOH, we calculated incidence per 1000 person-years and multivariable-adjusted hazard ratios of readmission. Among 690 participants, the median age was 76 years at hospitalization (interquartile range, 71-82), 44.3% were women, 35.5% were Black, 23.5% had low educational attainment, 63.0% had low income, 21.0% had zip code-level poverty, 43.5% resided in Health Professional Shortage Areas, 39.3% lived in states with poor public health infrastructure, 13.1% were socially isolated, 13.3% had poor social networks, and 10.2% lived in rural areas. The 30-day readmission rate was 22.4%. In an unadjusted analysis, only Health Professional Shortage Area was significantly associated with 30-day readmission; in a fully adjusted analysis, none of the 9 SDOH were individually associated with 30-day readmission. CONCLUSIONS In this modestly sized national cohort, although prevalent, none of the SDOH were associated with 30-day readmission after an HF hospitalization. Policies or interventions that only target individual SDOH to reduce readmissions after HF hospitalizations may not be sufficient to prevent readmission among older adults.
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Affiliation(s)
- Madeline R. Sterling
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Joanna Bryan Ringel
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Laura C. Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Monika M. Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, A.L
| | - Erica Phillips
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Todd M. Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, A.L
| | - Oanh K. Nguyen
- Division of Hospital Medicine, University of California at San Francisco, San Francisco, CA
| | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY., Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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18
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Jones CD, Thomas J, Ytell K, Roczen ML, Levy CR, Jordan SR, Lum HD, Gritz M. Is Health Information Exchange Participation Associated With Hospital Readmissions From Home Health Care? J Am Med Dir Assoc 2022; 23:170-173.e2. [PMID: 34480865 PMCID: PMC10955507 DOI: 10.1016/j.jamda.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/27/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, Aurora, CO, USA.
| | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kate Ytell
- Data Science to Patient Value Program, ACCORDS, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marisa L Roczen
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cari R Levy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, Aurora, CO, USA; Division of Health Care Policy and Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah R Jordan
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; VA Eastern Colorado Geriatrics Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Mark Gritz
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Data Science to Patient Value Program, ACCORDS, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Division of Health Care Policy and Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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19
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The Influence of Preparedness, Mutuality, and Self-efficacy on Home Care Workers' Contribution to Self-care in Heart Failure: A Structural Equation Modeling Analysis. J Cardiovasc Nurs 2022; 37:146-157. [PMID: 33315614 PMCID: PMC8196074 DOI: 10.1097/jcn.0000000000000768] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Home care workers (HCWs) are increasingly caring for patients with heart failure (HF). Previous studies have shown that they contribute to HF patients' care, but how their preparedness and their relationship with patients (mutuality) influence caregiving is unknown, as well as the role of HCWs' self-efficacy. OBJECTIVE Guided by the Situation-Specific Theory of Caregiver Contribution to HF Self-Care, we investigated the influence of HCWs' preparedness and mutuality on HCWs' contribution to HF self-care and the mediating effect of HCWs' self-efficacy in the process. METHODS We conducted a cross-sectional survey of HCWs who cared for patients with HF. The survey included the Caregiver Preparedness Scale, Mutuality Scale, Caregiver Contribution to Self-Care of HF Index, and Caregiver Self-Efficacy in Contributing to Self-Care Scale. We performed structural equation modeling and a mediation analysis. RESULTS A total of 317 HCWs employed by 22 unique home care agencies across New York, NY, completed the survey. They had a median age of 50 years, 94% were women, and 44% were non-Hispanic Black. Results demonstrated that mutuality had a direct influence on HCW contribution to self-care and preparedness influenced their contribution to self-care, but only through the mediation of self-efficacy. CONCLUSION Home care workers' preparedness, mutuality, and self-efficacy have important roles in influencing their contribution to HF self-care. As a workforce increasingly involved in the care of patients with HF, knowing the mechanisms underpinning HCWs' contribution to self-care may illuminate future interventions aimed at improving their contributions and HF patient outcomes.
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Hsu B, Korda RJ, Lindley RI, Douglas KA, Naganathan V, Jorm LR. Use of health and aged care services in Australia following hospital admission for myocardial infarction, stroke or heart failure. BMC Geriatr 2021; 21:538. [PMID: 34635068 PMCID: PMC8504055 DOI: 10.1186/s12877-021-02519-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular diseases (CVD), including myocardial infarction (MI), stroke and heart failure (HF) are the leading cause of death amongst the older population worldwide. The aim of this study is to investigate trajectories of use of health and aged care services after hospital admission for MI, stroke or HF among community-dwelling people not previously receiving aged care services. METHODS The study population comprised people aged 65+ years from the 45 and Up Study with linked records for hospital stays, aged care services and deaths for the period 2006-14. Among those with an index hospital admission for MI, stroke or HF, we developed Sankey plots to describe and visualize sequences and trajectories of service use (none, re-hospitalization, community care, residential care, death) in the 12 months following discharge. We used Cox proportional hazards models to estimate hazard ratios (HRs), for commencing community care and entering residential care (and the other outcomes) within 3, 6 and 12 months, compared to a matched group without MI, stroke or HF. RESULTS Two thousand six hundred thirty-nine, two thousand five hundred and two thousand eight hundred seventy-three people had an index hospitalization for MI, stroke and HF, respectively. Within 3 months of hospital discharge, 16, 32 and 29%, respectively, commenced community care (multivariable-adjusted HRs: 1.26 (95%CI:1.18-1.35), 1.53 (95%CI:1.44-1.64) and 1.39 (95%CI:1.32-1.48)); and 7, 18 and 14%, respectively, entered residential care (HRs: 1.25 (95%CI:1.12-1.41), 2.65 (95%CI:2.42-2.91) and 1.50 (95%CI:1.37-1.65)). Likewise, 26, 15 and 28%, respectively, were rehospitalized within 3 months following discharge (multivariable-adjusted HRs: 4.78 (95%CI:4.31-5.32), 3.26 (95%CI:2.91-3.65) and 4.94 (95%CI:4.47-5.46)). CONCLUSIONS Older people hospitalized for major CVD may be vulnerable to transition-related risks and have poor health trajectories, thus emphasizing the value of preventing such events and care strategies targeted towards this at-risk group.
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Affiliation(s)
- Benjumin Hsu
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia. .,School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Rosemary J Korda
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia
| | - Richard I Lindley
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kirsty A Douglas
- ANU Medical School, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Repatriation Hospital and University of Sydney, Sydney, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia
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21
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Nazir S, Ahuja KR, Ariss RW, Changal K, Khuder SA, Moukarbel GV. Home health care utilization trend, predictors, and association with early rehospitalization following endovascular transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:1-6. [PMID: 34045166 DOI: 10.1016/j.carrev.2021.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Home healthcare (HHC) utilization is associated with higher rates of rehospitalization in patients with heart failure and transcatheter mitral valve repair. This study sought to assess the utilization, predictors, and the association of HHC with 30-day readmission in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS/MATERIALS We queried the Nationwide Readmission Database from January 2012 to December 2017 for TAVR discharges with and without HHC referral. Using multivariate analysis, we identified predictors of HHC utilization, and its association with outcomes. RESULTS Of 60,950 TAVR discharges, 21,724 (35.7%) had HHC referral. On multivariable analysis, female sex (OR, 1.34; 95% CI, 1.29-1.40), non-elective admission (OR, 1.49; 95% CI, 1.42-1.56), diabetes mellitus (OR, 1.09; 95% CI, 1.05-1.13), prior stroke (OR, 1.06; 95% CI, 1.01-1.12), anemia (OR, 1.16; 95% CI, 1.11-1.21), and in-hospital complications including cardiogenic shock (OR, 1.37; 95% CI, 1.16-1.50), cardiac arrest (OR, 1.22; 95% CI, 1.00-1.50), stroke (OR, 2.62; 95% CI, 2.20-3.18), and new Permanent pacemaker (OR, 1.49; 95% CI, 1.41-1.58) were identified as independent predictors of HHC referral. HHC utilization was associated with longer median length of stay (4 days vs. 2 days, P < 0.001), higher rate of 30-day all-cause (15.5% vs. 10.6%, P < 0.001) and heart failure (2.1%vs. 1.1%, P < 0.001) readmission rates compared to those without HHC. CONCLUSIONS Our study identified a vulnerable group of TAVR patients that are at higher risk of 30-day readmission. Evidence-based interventions proven effective in reducing the burden of readmissions should be pursed in these patients to improve outcomes and quality of life.
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Affiliation(s)
- Salik Nazir
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keerat Rai Ahuja
- Department of Cardiology, Reading Hospital-Tower Health System, West Reading, PA, USA
| | - Robert W Ariss
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Khalid Changal
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Sadik A Khuder
- Department of Medicine and Public Health, University of Toledo, Toledo, OH, USA
| | - George V Moukarbel
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA.
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22
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Baik D, Leung PB, Sterling MR, Russell D, Jordan L, Silva AF, Masterson Creber RM. Eliciting the educational needs and priorities of home care workers on end-of-life care for patients with heart failure using nominal group technique. Palliat Med 2021; 35:977-982. [PMID: 33729053 PMCID: PMC8106634 DOI: 10.1177/0269216321999963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Home care workers, as paid caregivers, assist with many aspects of home-based heart failure care. However, most home care workers do not receive systematic training on end-of-life care for heart failure patients. AIM To elicit the educational needs and priorities of home care workers caring for community- dwelling adults with heart failure at the end-of-life. DESIGN Nominal group technique involving a semi-quantitative structured group process and point rating system was used to designate the importance of priorities elicited from home care workers. Individual responses to the question, "If you have ever cared for a heart failure patient who was dying (or receiving end-of-life care on hospice), what are some of the challenges you faced?", were aggregated into categories using directed content analysis methods. SETTING/PARTICIPANTS Forty-one home care workers were recruited from a non-profit training and education organization in New York City. RESULTS Individual responses to the question were aggregated into five categories: (1) how to cope and grieve; (2) assisting patients with behavior changes, (3) supporting patients to improve their quality of life, (4) assisting patients with physical symptom management, and (5) symptom recognition and assessment. CONCLUSIONS Our findings confirm the need for the formal development and evaluation of an educational program for home care workers to improve the care of heart failure patients at the end-of-life. There is also a need for research on integrating home care workers into the interprofessional healthcare team to support optimal health outcomes for patients with heart failure.
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Affiliation(s)
- Dawon Baik
- College of Nursing, University of Colorado, Aurora, CO, USA
| | - Peggy B Leung
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Madeline R Sterling
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - David Russell
- Department of Sociology, Appalachian State University, Boone, NC, USA.,Visiting Nurse Service of New York, New York, NY, USA
| | | | - Ariel F Silva
- Internal Medicine/Coumadin Practice, Weill Cornell Medicine, New York, NY, USA
| | - Ruth M Masterson Creber
- Department of Healthcare Policy & Research, Division of Health Informatics, Weill Cornell Medicine, New York, NY, USA
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