Survey of primary care physicians and home care clinicians

Health Information Technology Adoption at U.S. Home Health Care Agencies: Results from a Multi-Methods Study

Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; (4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR; an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.

A qualitative analysis of communication workflows between adult day service centers and primary care providers

OBJECTIVES

Our study documented communication workflows across adult day care centers (ADCs) and primary care providers (PCPs) around complex needs of persons living with dementia (PLWD). We also identified barriers and facilitators to productive communication in clinical decision support and clinical information systems.

MATERIALS AND METHODS

We conducted 6 focus groups with ADC staff (N = 33) and individual semistructured interviews with PCPs (N = 22) in California. The eHealth Enhanced Chronic Care Model was used to frame the directed qualitative content analysis.

RESULTS

Our results captured cumbersome and ineffective workflows currently used to exchange information across PCPs and ADCs. Stakeholders characterized current communication as (1) infrequent, (2) delayed, (3) incomplete, (4) unreliable, (5) irrelevant, and (6) generic. Conversely, communication that was bidirectional, relevant, succinct, and interdisciplinary was needed to elevate the standard of care for PLWD.

DISCUSSION AND CONCLUSION

ADCs possess a wealth of information that can support clinical decision-making across community-based providers involved in the care of PLWD, especially PCPs. However, effective information exchange is mired by complicated workflows that rely on antiquated technologies (eg, facsimile) and standard templates. Current information exchange largely focuses on satisfying regulatory guidelines rather than supporting clinical decision-making. Integrating community-based services into the health care continuum is a necessary step in elevating the standard of care for PLWD. In the absence of interoperable electronic health records, which may not be financially viable for ADCs, other options, such as mobile health, should be explored to facilitate productive information exchange of personalized relevant information.

Skilled home healthcare clinicians' experiences in communicating with physicians: A national survey

BACKGROUND

Effective communication between skilled home healthcare (SHHC) clinicians and physicians is critical to care coordination. No studies have examined this from the point of view of SHHC clinicians at the national level. The objective is to determine in national sample issues related to how SHHC agency clinicians communicate with physicians.

DESIGN

Mailed survey.

METHODS

Mailed survey to a national representative random sample of SHHC agencies. The survey measured the experiences of SHHC clinicians in communicating with physicians. Multilevel logistic regression models examining odds of adverse patient outcomes associated with communication failures.

RESULTS

A total of 265 surveys from 168 SHHC agencies were returned for a response rate of 13.3% at the individual respondent level and 16.8% at the SHHC agency level. Agency-level characteristics were similar between responding and nonresponding agencies. The most common method of contacting physicians during routine SHHC visits was telephone; communication via the electronic health record was uncommon. Nearly 40% of SHHC clinicians report never or rarely being able to reach a physician. SHHC clinicians rate the Center for Medicare and Medicaid Services Home Health Certification and Plan of Care (CMS-485) as a useful means of communication 6.3 (SD, 2.5) scale of 1 (least useful) to 10 (most useful); only 14% could have SHHC orders signed electronically. In multilevel logistic models, compared to SHHC clinicians who could reach a physician nearly every time or always, the odds of an SHHC clinician sending someone to the emergency department were 3.66 (95% confidence interval 1.16-11.5) for SHHC clinicians who were sometimes or often able to reach a physician and 5.43 (95% CI 1.56-18.9) for those who never or rarely reached a physician.

CONCLUSIONS

In this exploratory study, SHHC clinicians experience significant communication barriers with physicians who order SHHC services. Strategies to enhance meaningful communication between SHHC clinicians and physicians must be developed.

Home healthcare patient, caregiver and provider perspectives on use of unscheduled acute care and the usability and acceptability of on-demand telehealth solutions

BACKGROUND/OBJECTIVES

Home health care (HHC) agencies provide an important role in helping to transition patients from acute care to independent residential living. Telehealth has the potential to transform care delivery in HHC, however the majority of studies in HHC have focused on the use of telemonitoring for patients with specific chronic conditions. The objective of this study was to examine reasons HHC patients use acute care services and assess the acceptability of on-demand telehealth services among HHC patients, caregivers and personnel to help alleviate the need for seeking in-person acute care. Design/Setting/Participants/Measures: This study was a secondary analysis of qualitative data from in-depth interviews of 30 HHC personnel, patients and caregivers from a Medicare-certified HHC agency affiliated with a large healthcare system from January through May 2020. A conventional content analysis approach was used to identify themes.

RESULTS

Themes associated with reasons for seeking acute care included: sense of urgency, behavioral and psychosocial factors, and access to care. Participants described their perceptions of the benefits, usability and acceptability and barriers to using telehealth. Patients and HHC personnel agreed that on-demand telehealth should not replace in-person visits but all identified roles that on-demand telehealth services could play in improving communication and access to care. The biggest barriers to use of telehealth identified by HHC personnel were cost, access and ability to use technology by HHC patients.

CONCLUSION

This study identified reasons HHC patients seek unscheduled acute care and the usability and acceptability of on-demand telehealth services to increase access to care among HHC patients. These findings underscore the need to improve communication and coordination between patients, HHC personnel, and primary care providers and the role that on-demand telehealth services can have in transforming HHC.

Skilled Home Healthcare Clinician and Staff Perspectives on Communication With Physicians: A Multisite Qualitative Study

Communication between physicians who order, and clinicians who provide skilled home healthcare (SHHC), is critical to well-coordinated care. The views of SHHC staff on communication with physicians have not been well studied. The objective of this study was to explore how SHHC staff view the communication processes with physicians who order SHHC services. Using purposive and snowball sampling, we conducted semistructured interviews with 22 SHHC staff across multiple regions of the United States. Qualitative thematic content analysis was used to analyze the data. SHHC staff experienced significant barriers to effective communication with physicians, including not being able to communicate in a timely manner when necessary for patient care, and challenges identifying the correct physician to coordinate care and sign SHHC orders. Key strategies to enhance communication focused on creating standardized processes to streamline communication, setting expectations for response times in communication, and improving the Centers for Medicare & Medicaid Services Home Health Certification and Plan of Care form (commonly referred to as the "CMS-485"/Plan of Care). SHHC staff experience significant communication challenges with physicians who order SHHC services that can compromise care coordination and delivery. Modifications to workflows are urgently needed to improve efficiency and quality of communication, care coordination, and quality of care.

Medication Discrepancies in Older Veterans Receiving Home Healthcare

In a prospective cohort study of Veterans and community health nurses, we enrolled hospitalized older Veterans referred to home care for skilled nursing and/or physical or occupational therapy for posthospitalization care. We assessed preadmission activities of daily living and instrumental activities of daily living, health literacy, numeracy, and cognition. Postdischarge phone calls identified medication errors and medication reconciliation efforts by home healthcare clinicians. Veterans Administration-based community health nurses completed surveys about content and timing of postdischarge interactions with home healthcare clinicians. We determined the types and frequency of medication errors among older Veterans receiving home healthcare, patient-provider communication patterns in this setting, and patient characteristics affecting medication error rates. Most Veterans (24/30, 80%) had at least one discordant medication, and only one noted that errors were identified and resolved. Veterans were asked about medications in the home healthcare setting, but far fewer were questioned about medication-taking details, adherence, and as-needed or nonoral medications. Higher numeracy was associated with fewer errors. Veterans Administration community health nurses reported contact by home healthcare clinicians in 41% of cases (7/17). Given the high rate of medication errors discovered, future work should focus on implementing best practices for medication review in this setting, as well as documenting barriers/facilitators of patient-provider communication.

The Experience of Family Physicians and Home Health Staff Involved in an Intervention to Increase Patient-Related Collaboration

Les médecins de famille (MF) et le personnel de soins de santé à domicile (PSD) canadiens rencontrent d'importants obstacles lorsqu'ils doivent collaborer pour la prestation de soins aux patients qu'ils ont en commun. Cette étude à méthodologie mixte visait à évaluer la qualité et la viabilité de l'utilisation de l'audioconférence sécurisée dans une optique d'amélioration de la planification des soins pour ces patients. Les données primaires incluaient les résultats d'un sondage réalisé avant et après l'intervention, ainsi que des entretiens semi-structurés et des groupes de discussion post-intervention. Des méthodes statistiques non paramétriques ont été utilisées pour analyser les résultats du sondage, et les données qualitatives ont fait l'objet d'une analyse thématique de contenu. Les résultats des analyses quantitatives et qualitatives ont ensuite été intégrés afin de faire ressortir les inférences reflétant les approches des MF et du PSD relatives aux obstacles et aux avantages de la planification interdisciplinaire des soins. Les MF et le PSD ont montré que des obstacles structurels limitent leur capacité à collaborer. Le PSD et les MF ont également convenu que les rencontres entre les intervenants des deux services étaient bénéfiques pour les patients et que l'utilisation de l'audioconférence constituait une méthode efficiente de planification collaborative des soins. Les limites comprenaient la petite taille de l'échantillon et la courte période d'intervention, compte tenu de l'ampleur des changements attendus.

Canadian family physicians (FPs) and home health staff (HHS) experience significant barriers to patient-related collaboration about patients they share. This mixed-methods study sought to determine the quality and sustainability of secure audio conferencing as a way to increase care planning about shared patients. Primary data sources included pre-and post-study administration of a published survey and post-study semi-structured interviews and focus groups. Non-parametric statistical procedures were used to analyze survey results and thematic content analysis was undertaken for qualitative data. Results from both quantitative and qualitative analysis were integrated into the overall analysis, in order to draw inferences reflecting both approaches to barriers and benefits of collaborative care planning for FPs and HHS. Both FPs and HHS provided evidence that structural barriers impede their ability to collaborate. HHS and FPs also agreed that joint conferences were beneficial for patients, and that the use of audio conferencing provided an efficient method of collaborative care planning. Limitations included a small sample size and short timeline for the intervention period, given the magnitude of the expected change.

Smartphone-Based Health Technologies for Dementia Care: Opportunities, Challenges, and Current Practices

Most of the 5.4 million people affected by Alzheimer’s disease and other forms of dementia (AD) are noninstitutionalized, receiving care by unpaid family caregivers and medically managed by a primary care provider (PCP). Health Information Technology has been recognized for its potential in improving efficiency and quality of AD care and support for AD caregivers. Simultaneously, smartphone technologies have become an increasingly common way to deliver physical and behavioral health care. However, little is known about how smartphone technologies have been used to support AD caregiving and care. This article highlights the current need for smartphone-based interventions for AD and systematically identified and appraised current smartphone apps targeting and available for AD caregivers. Findings indicate that individual available apps have limited functions (compared with the complex needs of caregivers) and little has been done to extend AD caregiving apps to Hispanic populations. Implications for research, practice, and policy are discussed.

Communication between office-based primary care providers and nurses working within patients' homes: an analysis of process data from CAPABLE

AIMS AND OBJECTIVES

To examine themes of communication between office-based primary care providers and nurses working in private residences; to assess which methods of communication elicit fruitful responses to nurses' concerns.

BACKGROUND

Lack of effective communication between home health care nurses and primary care providers contributes to clinical errors, inefficient care delivery and decreased patient safety. Few studies have described best practices related to frequency, methods and reasons for communication between community-based nurses and primary care providers.

DESIGN

Secondary analysis of process data from 'Community Aging in Place: Advancing Better Living for Elders (CAPABLE)'.

METHODS

Independent reviewers analysed nurse documentation of communication (phone calls, letters and client coaching) initiated for 70 patients and analysed 45 letters to primary care providers to identify common concerns and recommendations raised by CAPABLE nurses.

RESULTS

Primary care providers responded to 86% of phone calls, 56% of letters and 50% of client coaching efforts. Primary care providers addressed 86% of concerns communicated by phone, 34% of concerns communicated by letter and 41% of client-raised concerns. Nurses' letters addressed five key concerns: medication safety, pain, change in activities of daily living, fall safety and mental health. In letters, CAPABLE nurses recommended 58 interventions: medication change; referral to a specialist; patient education; and further diagnostic evaluation.

CONCLUSIONS

Effective communication between home-based nurses and primary care providers enhances care coordination and improves outcomes for home-dwelling elders. Various methods of contact show promise for addressing specific communication needs.

RELEVANCE TO CLINICAL PRACTICE

Nurses practicing within patients' homes can improve care coordination by using phone calls to address minor matters and written letters for detailed communication. Future research should explore implementation of Situation, Background, Assessment and Recommendation in home care to promote safe and efficient communication. Nurses should empower patients to address concerns directly with providers through use of devices including health passports.

Access to Ambulatory Medical and Long-Term Care Services Among Elderly Medicare and Medicaid Beneficiaries: Organizational, Financial, and Geographic Barriers

The comprehensive insurance coverage afforded low-income elders with both Medicare and Medicaid coverage (dual enrollees) has substantially reduced financial barriers to care. However, other studies show reduced and less appropriate utilization patterns among dual enrollees compared to Medicare beneficiaries with private supplemental insurance, suggesting access barriers remain. This study found that 59 percent of elderly dual enrollees needed an ambulatory medical or long-term care service in a 1-year period. One third of these individuals experienced barriers to access; organizational and geographic barriers were more prevalent than financial barriers. African American race, trouble paying basic living expenses, fair or poor health status, and an unfavorable assessment of physician information giving were significantly associated with an increased likelihood of organizational and geographic access barriers among elderly dual enrollees.

Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices

BACKGROUND

The unique needs of homebound adults receiving home-based medical care (HBMC) (ie, home-based primary care and home-based palliative care services) are ideally provided by interdisciplinary care teams (IDTs) that provide coordinated care. The composition of team members from an array of organizations and the unique dimension of providing care in the home present specific challenges to timely access and communication of patient care information. The objective of this work was to develop a conceptual framework and corresponding quality indicators (QIs) that assess how IDT members for HBMC practices access and communicate key patient information with each other.

METHODS

A systematic review of peer-reviewed and gray literature was performed to inform a framework for care coordination in the home and the development of candidate QIs to assess processes by which all IDT members optimally access and use patient information. A technical expert panel (TEP) participated in a modified Delphi process to assess the validity and feasibility of each QI and to identify which would be most suitable for testing in the field.

RESULTS

Thematic analysis of literature revealed 4 process themes for how HBMC practices might engage in high-quality care coordination: using electronic medical records, conducting interdisciplinary team meetings, sharing standardized patient assessments, and communicating via secure e-messaging. Based on these themes, 9 candidate QIs were developed to reflect these processes. Three candidate QIs were assessed by the TEP as valid and feasible to measure in an HBMC practice setting. These indicators focused on use of IDT meetings, standardized patient assessments, and secure e-messaging.

CONCLUSION

Translating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.

Improving home-based providers' communication to primary care providers to enhance care coordination

OBJECTIVES

Health care system fragmentation is a pervasive problem. Research has not delineated concrete behavioral strategies to guide providers to communicate with personnel in other organizations to coordinate care. We addressed this gap within a particular context: home-based providers delivering depression care management (DCM) to older adults requiring coordination with primary care personnel. Our objective was to pilot test a communication protocol ('BRIDGE - BRinging Inter-Disciplinary Guidelines to Elders') in conjunction with DCM.

METHOD

In an open pilot trial (N = 7), home-based providers delivered DCM to participants. Following the BRIDGE protocol, home-based providers made scripted telephone calls and sent structured progress reports to personnel in participants' primary care practices with concise information and requests for assistance. Home-based providers documented visits with participants, contacts to and responses from primary care personnel. A research interviewer assessed participant outcomes [Symptom Checklist-20 (depressive symptoms), World Health Organization Disability Assessment Schedule-12, satisfaction] at baseline, three months, and six months.

RESULTS

Over 12 months, home-based providers made 2.4 telephone calls and sent 6.3 faxes to other personnel, on average per participant. Primary care personnel responded to 18 of 22 requests (81.8%; 2 requests dropped, 2 ongoing), with at least one response per participant. Participants' depressive symptoms and disability improved significantly at both post-tests with large effect sizes (d ranged 0.73-2.3). Participants were satisfied.

CONCLUSION

Using BRIDGE, home-based providers expended a small amount of effort to communicate with primary care personnel, who responded to almost all requests. Larger scale research is needed to confirm findings and potentially extend BRIDGE to other client problems, professions, and service sectors.

Practices of Depression Care in Home Health Care: Home Health Clinician Perspectives

OBJECTIVE

The study assessed gaps between published best practices and real-world practices of treating depression in home health care (HHC) and barriers to closing gaps.

METHODS

The qualitative study used semistructured interviews with nurses and administrators (N=20) from five HHC agencies in five states. Audio-recorded interviews were transcribed and analyzed by a multidisciplinary team using grounded theory method to identify themes.

RESULTS

Routine HHC nursing overlapped with all functional areas of depression care. However, gaps were noted between best and real-world practices. Gaps were associated with perceived scope of practice by HHC nurses, knowledge gaps and low self-efficacy in depression treatment, stigma attached to depression, poor quality of antidepressant management in primary care, and poor communication between HHC and primary care clinicians.

CONCLUSIONS

Strategies to close gaps between typical and best practices include enhancing HHC clinicians' knowledge and self-efficacy with depression treatment and improving the quality of antidepressant management and communication with primary care.

Antidepressant Medication Management Among Older Patients Receiving Home Health Care

OBJECTIVE

Antidepressant management for older patients receiving home health care (HHC) may occur through two pathways: nurse-physician collaboration (without patient visits to the physician) and physician management through office visits. This study examines the relative contribution of the two pathways and how they interplay.

METHODS

Retrospective analysis was conducted using Medicare claims of 7,389 depressed patients aged 65 years or older who received HHC in 2006-2007 and who possessed antidepressants at the start of HHC. A change in antidepressant therapy (versus discontinuation or refill) was the main study outcome and could take the form of a change in dose, switch to a different antidepressant, or augmentation (addition of a new antidepressant). Logistic regressions were estimated to examine how use of home health nursing care, patient visits to physicians, and their interactions predict a change in antidepressant therapy.

RESULTS

About 30% of patients experienced a change in antidepressants versus 51% who refilled and 18% who discontinued. Receipt of mental health specialty care was associated with a statistically significant, 10- to 20-percentage-point increase in the probability of antidepressant change; receipt of primary care was associated with a small and statistically significant increase in the probability of antidepressant change among patients with no mental health specialty care and above-average utilization of nursing care. Increased home health nursing care in absence of physician visits was not associated with increased antidepressant change.

CONCLUSIONS

Active antidepressant management resulting in a change in medication occurred on a limited scale among older patients receiving HHC. Addressing knowledge and practice gaps in antidepressant management by primary care providers and home health nurses and improving nurse-physician collaboration will be promising areas for future interventions.

Primary Care Physicians’ Attitudes Regarding Collaborating With Home-Based Depression Care Managers

Home-based case managers face many challenges to collaborating with primary care physicians, including for management of depression. To obtain physicians’ perspectives regarding optimal collaboration strategies, we conducted a mail survey of randomly selected primary care physicians ( N = 74). The survey described a home-based depression care management program to be delivered by case managers and assessed physicians’ preferred collaboration strategies. Most respondents perceived the services described as useful, including having the case manager send a list of medications and send psychotropic medication recommendations per consulting psychiatrist. Most physicians reported being likely to read a written summary sent by the case manager, reply, and send it back to the case manager. Preferred communication procedures varied widely. By considering physicians’ preferences, case managers may enhance collaboration.

Person-centeredness in home- and community-based long-term care: current challenges and new directions

Person-centered care (PCC) has demonstrated to be a viable and preferred model of providing health and institutionalized long-term care services. However, the concept of PCC has not been fully extended to home- and community-based long-term care services (HCBS) for older adults with chronic conditions. This review highlights the need for PCC in HCBS and suggests that social workers may play a role in overcoming cultural and structural barriers to extending PCC to HCBS that include: the fragmentation of the industry, financial structures, regulation of services, and paternalism in policy and practice. Recommendations for practice, policy, and research are provided.

Need and Potential Use of Information Technology for Case Manager–Physician Communication in Home Care

Case management has become a popular model for providing home care services to nursing home-eligible older adults. To maximize collaborative decision making and patient outcomes, members of the case management team must engage in ongoing, open communication. However, little is known about the quality of communication between home care case managers and their clients’ physicians. This study examined geriatric home care case managers’ perceptions of their communication with their clients’ physicians. Participating case managers were employed at two large home care agencies located in the South Florida region. The findings suggest that communication between home care case managers and physicians is limited and inefficient. Implication for policy and practice are provided. Finally, we propose ways to leverage Information Technology to bridge this communication gap.

Inappropriate medication in a national sample of US elderly patients receiving home health care

BACKGROUND

With substantial morbidity and functional impairment, older patients receiving home health care are especially susceptible to the adverse effects of unsafe or ineffective medications. Home health agencies’ medication review and reconciliation services, however, provide an added mechanism of medication safety that could offset this risk.

OBJECTIVE

To estimate the prevalence of potentially inappropriate medications (PIMs) among current elderly home health patients in the US.

DESIGN

Cross-sectional analysis using data from the 2007 National Home and Hospice Care Survey.

SUBJECTS

3,124 home health patients 65 years of age or older on at least one medication.

MAIN MEASURES

Prevalence and classification of PIM use and the association between PIM use and patient and home health agency characteristics.Key Results In 2007, 38% (95% CI: 36-41) of elderly home health patients were taking at least one PIM. Polypharmacy was associated with an increased risk of PIM use; admission to home health care from a nursing home or other sub-acute facility (compared to admission from the community) and a payment source other than Medicare or Medicaid were associated with a decreased risk of PIM use.

CONCLUSIONS

The prevalence of PIM use in older home health patients is high despite potential mechanisms for improved safety. Policies to improve the review and reconciliation processes within home health agencies and to improve physician-home health clinician collaboration are likely needed to lower the prevalence of PIM use in older home health patients.

An intervention to improve nurse-physician communication in depression care

OBJECTIVES

Depression in older adult home care recipients is frequently undetected and inadequately treated. Failed communication between home healthcare personnel and the patient's physician has been identified as a barrier for depression care. The purpose of this pilot intervention study was to improve nurse competency for communicating depression-related information to the physician.

DESIGN

A single group pre-post experimental design.

SETTING

Two Medicare-certified home healthcare agencies serving an urban and suburban area in New York.

PARTICIPANTS

Twenty-eight home care nurses, all female Registered Nurses.

INTERVENTION

Two-hour skills training workshop.

MEASUREMENTS

To evaluate the intervention, pre-post changes in effective nurse communication using Objective Structured Clinical Examinations and nurse survey reports.

RESULTS

The intervention significantly improved the ability of the home care nurse to perform a case presentation in a complete and standard organized format pre versus postintervention. The intervention also increased nurse-reported certainty to communicate depression-related information to the physician.

CONCLUSIONS

Our findings provide support for the ability of a brief, depression-focused communication skills training intervention to improve home care nurse competency for effectively communicating depression-related information to the physician.

Information Deficits in Home Care: A Barrier to Evidence-Based Disease Management

A disease management study conducted in home care with 303 patients with diabetes, heart failure, or both revealed information deficits that make disease and quality management difficult. Nurses used a guideline checklist to indicate the amount and type of information available to them on admission and by the end of the episode of care. Nurses reported having data on 7% to 94% of the data elements. Whether a lipid profile had been done, the HbA1C (glycosolated hemoglobin test, also called a hemoglobin A1C) levels, or ejection fractions were known for 7%, 17%, and 18%, respectively. When nurses reported information related to ACE-I use (N = 183), they reported that 76% of patients were on ACE-I (angiotensin-converting enzyme inhibitor) or acceptable alternative for heart failure. But no information was reported on ACE-I use for 12% of the patients (N = 24). Potential solutions to these deficits in information and quality include increased use of guidelines in home care, guideline checklists, information transfer forms, nurse activism to request information, and the adoption of the electronic health record.

Measuring Integration of Cancer Services to Support Performance Improvement: The CSI Survey

OBJECTIVE

To develop a measure of cancer services integration (CSI) that can inform clinical and administrative decision-makers in their efforts to monitor and improve cancer system performance.

METHODS

We employed a systematic approach to measurement development, including review of existing cancer/health services integration measures, key-informant interviews and focus groups with cancer system leaders. The research team constructed a Web-based survey that was field- and pilot-tested, refined and then formally conducted on a sample of cancer care providers and administrators in Ontario, Canada. We then conducted exploratory factor analysis to identify key dimensions of CSI.

RESULTS

A total of 1,769 physicians, other clinicians and administrators participated in the survey, responding to a 67-item questionnaire. The exploratory factor analysis identified 12 factors that were linked to three broader dimensions: clinical, functional and vertical system integration.

CONCLUSIONS

The CSI Survey provides important insights on a range of typically unmeasured aspects of the coordination and integration of cancer services, representing a new tool to inform performance improvement efforts.

Family caregivers' satisfaction with home care for mental illness in Taiwan

In Taiwan, family caregivers play a crucial role in the treatment of patients with mental illness. Attention to family caregivers' satisfaction with home care for mental illness could have a significant impact on the well-being of family caregivers, as well as on the health of the patients with mental illness for whom they care. A descriptive, cross-sectional design has been used to assess the level of family caregivers' satisfaction with home care for mental illness since the implementation of the National Health Insurance (NHI) in Taiwan, and to identify the family caregivers' unmet needs for home care in cases of mental illness. Data were collected using the self-administrated questionnaire completed by a convenience sample of 75 primary family caregivers of the patients with mental illness from a psychiatric hospital in Taipei, Taiwan. The result showed that most family caregivers were highly satisfied with home care provided to them and their relative with mental illness. Timeliness of home care provided in an emergency was the most prevalent unmet need. The implementation of the NHI has improved family caregivers' perceptions of costs of home care services. There is a need to improve NHI policy and home care programmes to provide more holistic services for the patients with mental illness and their family.

Communication among levels of care for stroke patients

Stroke patients in the United States frequently progress through several different locations of care and groups of providers during the course of their recovery. Consistently effective communication from one level of care and one set of providers to the next is a basic expectation, but one that is often not fully met. New concepts and promising technologies offer opportunities to improve hand-off processes at all levels.