Determinants of home health visit length: results of a multisite prospective study

[Proposing a workload indicator for hospital at home patients in Osakidetza - Basque Public Health Service]

INTRODUCTION AND OBJECTIVES

The Hospital at Home (HaH) setting currently lacks adequate workload indicators. This study suggests an indicator that can help in improving professional resources allocation.

MATERIALS AND METHODS

Prospective data was collected during May 2021 from patients treated in nine HaH units of Osakidetza-Basque Health Service (North of Spain). Direct care and travel times of healthcare staff was recorded. Data on inpatient days, number of visits, sociodemographic variables, health status, and patient pathologies, among others, were collected. The proposed indicator encompasses both the average visit time and the visit rates. It is called intensity and represents the average daily workload time per patient.

RESULTS

A total of n = 1,171 users were included in the analyses. Their mean age was 69.8 years, 45.5% were women and 25% lived more than 12 km away from the corresponding HaH unit. Workload variations were observed for nursing-only and medical-nursing teams, depending on the type of day and patient classification group. The average nursing-only teams workload time on working days was 10.82 min and on non-working days it was 14.78 min. The average workload time for medical-nursing teams, during the same days, was 20.40 min and 4.59 min, respectively. It was observed that certain patient types, like those in palliative care, represented a high workload for medical-nursing teams on working days.

CONCLUSIONS

The intensity indicator can help answering the question of how many patients can be assigned to a professional. It can also be used to adjust the staffing needs of the HaH units.

[Factors associated with the hospital at home workload: A Delphi consensus study]

OBJECTIVES

To identify and prioritize a list of factors that contribute to the workload of the hospital at home (HaH) professionals.

MATERIAL AND METHODS

A qualitative methodology study performed between January and December 2019 in the 10 HAH units of the Basque Country. The data were obtained in 4phases: 1. Systematic literature search and review; 2. Expert group meeting; 3. Consensus method: Delphi technique (2 survey rounds) and nominal group meeting; 4. Meeting of the research team.

RESULTS

In the systematic literature search and review 85 factors were initially identified. These were reduced to 38 after the 8-person expert group meeting, in which 10 new factors were added. After the 2 Delphi rounds (106 and 57 professionals, respectively), 17 factors were maintained and 12 remained in doubt. The latter were evaluated at the nominal group meeting, consisting of 13 professionals who decided to eliminate 5 factors, include 3, and keep 3 as doubt. After the 8-person research team meeting, 14 potential factors were finally selected. They are related to the place of residence, the health state and social situation of the patients, as well as the health care provided at home.

CONCLUSIONS

The identified factors could serve for improving the organization and optimize the daily word of the HaH professionals.

Factors associated with the workload of health professionals in hospital at home: a systematic review

BACKGROUND

Understanding the factors related to workload, could help hospital at home (HaH) managers to make decisions on the most appropriate and efficient use of the HaH services. Published studies on this topic are scarce, so we have conducted a systematic review to identify such factors according to published evidence.

METHODS

Due to the heterogeneity of HaH models, HaH was defined as a care that provides a set of medical and nursing care and attention of hospital rank to patients at home, when they no longer require hospital infrastructure but still need active monitoring and complex care. The electronic data base literature search was conducted in MEDLINE (Ovid), EMBASE (Ovid), and Cinahl (EBSCOhost) from inception to December 2021, including grey literature. Search terms related to `hospital at home´, `workload´ and `care time´ were used. There was no restriction on language, type of study or year of publication. Quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist and certainty in the body of evidence was assessed using the GRADE Pro Tool. Results were summarised in a tabulated format.

RESULTS

Eighteen studies with 56,706 patients were included. Workload was measured as time, number of visits or both. The predictive factors of the workload included variables related to patient characteristics and other valid and reliable patient classification systems, as well as characteristics of the institutions where the studies were conducted. The factors associated with higher workloads were: being older, male, living in a rural environment, presenting a higher number of diagnoses, having worse functional status and being unable to assume self-care.

CONCLUSIONS

The identified predictors of workload are mostly associated with home nursing care. The results could be useful and applicable to different organisational models of HaH health systems. More studies that include physicians and proxy measures of workload are needed.

A Pilot Study of Palliative Medicine Fellows’ Hospice Home Visits

This was a prospective descriptive study of hospice physician home visits (HVs) conducted by Hospice and Palliative Medicine Fellows. Our objectives were 1) to improve our knowledge of hospice care at home by describing physician HVs 2) to identify the indications for physician HVs and the problems addressed during the HV. Data was collected on 58 consecutive patients using a standardized form completed before and after the home visit. More than half of the persons were women. Most were Caucasian. Median age was 75 years; 57% had cancer; 77% were do-not-resuscitate. 76% HV occurred in the home. The median visit duration was 60 minutes; median travel distance and time 25 miles and 42 minutes, respectively. A hospice nurse case manager was present in 95%. The most common issues addressed during HVs were: health education, symptom management, and psychosocial support. Medication review was prominent. Physicians identified previously unreported issues. Symptom control was usually pain, although 27 symptoms were identified. Medications were important; all home visits included drug review and two thirds drug change. Physicians had unique responsibilities and identified important issues in the HV. Physicians provided both education and symptom management. Physician HVs are an important intervention. HVs were important in continuity of care, however, time-consuming, and incurred considerable travel, and professional time and costs.

Articulating the role of relationships in access to home care nursing at the end of life

In this article, we draw on data collected from two samples of home care nurses to examine how relationships between nurses and family caregivers intersected with access to palliative home care nursing services. Participants referred to relationships as important for their practical benefits and for access to care: good relationships enhanced the nurse's ability to assess clients and families and fostered the family's trust in the nurse's care. Although emphasizing the need to build and maintain relationships (often requiring time), participants simultaneously referred to beliefs about the need to control the personal emotions invoked in relationships so as to ensure appropriate access for clients and families. Future research should further explore how the organizational and resource context, and the culture of palliative care, shape nurses' beliefs about relationships in their practice, the nature and types of relationships that can develop, and both client and family caregivers' access to care.

Home care nurses' decisions about the need for and amount of service at the end of life

AIMS

We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice.

BACKGROUND

Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care.

METHODS

Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison.

FINDINGS

Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care.

CONCLUSION

Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

Measuring the workload of community nurses in Ireland: a review of workload measurement systems

BACKGROUND

The primary community nursing service in Ireland is public health nursing and this unique healthcare role incorporates activities and responsibilities undertaken by a variety of health professionals in other countries. Capturing and comparing a measure of the work of any community nurse is complicated due to the difficulty in standardizing the nature of community nursing across care settings.

AIM

The aim of this paper was to review the varied approaches to measuring the workload/caseload of community nurses to evaluate how they may be applied to measure the workload of the public health nurse in the Irish Republic.

CONCLUSION

Many of the systems designed to measure nursing workload are reliant on measuring tasks and fail to capture the less tangible but core aspects of the public health nursing role like decision-making, assessment and case management.

IMPLICATIONS

There is a need to develop a workload measurement system for use by public health nurses in Ireland that is capable of measuring the uniqueness of the role.

Nurse Dose as a Concept

PURPOSE

To describe the concept of Nurse Dose.

METHODS

The concept of nurse dose has been identified from decades of clinical research as a concept essential in the delivery of safe and high quality health care. The components of nurse dose were conceptualized through review of the literature from nursing, medicine, and health services research.

FINDINGS

Nurse dose is conceptualized as having three equally essential components: dose, nurse, and host and host response. Dose in the macro view includes the number of nurses per patient or per population in cities, states, regions, or countries. Dose in a micro view includes the amount of nurse time and the number of contacts. The nurse component consists of the education, expertise, and experience of the nurse. Host is represented by an organization and its characteristics (culture, autonomy, practice control) in a macro view and by the patient and characteristics (beliefs, values, culture) in a micro view. Host response includes response to the autonomy and acceptability of the nurse.

CONCLUSIONS

Greater nurse dose has been associated with decreases in patient mortality, morbidity, and healthcare costs.

Are all children equal? An analysis of the predictive value of selected pediatric characteristics of the referral of children to pediatric home health services

ISSUES AND PURPOSE

To examine the predictive value of selected pediatric characteristics of the referral of children to pediatric home health services (PHHS). No empirical studies to date have evaluated the criteria used to determine the need for PHHS or if disparities in the referral of children to PHHS occur.

DESIGN AND METHODS

Randomly selected hospital records of 557 children discharged from one pediatric hospital between October 1999 and September 2000 were examined. Sequential logistic regression was used to calculate the odds of being referred to PHHS based on age, race or ethnicity, number of legal guardians in the household, and the number of technological devices at discharge. Insurance was excluded as a predictor because 97% of the study sample was insured.

RESULTS

Only the number of technological devices at discharge added predictive value (chi(2)[DF = 3, N= 557]= 42.023, P<0.001) to the SLR model. There was no evidence of disparities in referral.

IMPLICATIONS FOR PRACTICE

To ensure availability and equitable access to PHHS, nurses must actively participate in the discharge planning process for all children.

Measuring Relative Work Values for Home Care Nursing Services in Japan

BACKGROUND

Japan's system of Home Visit Nursing Care Stations (Station) began in 1991. To maintain the quality of services in home health nursing provided by Stations, reimbursement needs to account not only for the number of home visits, but also for the time and intensity of nursing services.

OBJECTIVES

This study aimed primarily to investigate the total work value and the three dimensions (time, mental effort, and physical effort) of actual visiting nursing services for the aged, and to quantify the contribution made by the three dimensions of nursing services to total work. The secondary purpose was to determine whether patient characteristics, nurse characteristics, and types of nursing services contributed to the variance in total work. Total work is defined as comprehensive work input of nursing services, with careful consideration given to both the intensity and duration of work.

METHODS

Self-report questionnaires about actual visiting nursing services, based on the Resource-Based Relative Value Scale, were answered by 32 nurses from three Stations in urban Yokohama, Japan.

RESULTS

Regression analysis showed that time and intensity (physical effort and mental effort) explained 96% the variance in total work. Time alone accounted for only 39% of the variance in total work. Patient characteristics, nurse characteristics, and service type accounted for less variance in total work than did time and intensity.

CONCLUSIONS

The study findings indicate that reimbursement of nursing services should reflect not only the time required for each visit, but also the intensity of nursing services provided, including mental effort and physical effort.

Home healthcare and client outcomes

This study examined the outcome measures of readmission to the hospital and change in functional status/quality of life. Patients were admitted to the hospital most commonly by the 15th visit indicating complications arise soon after home care initiation. Implications for more specific data related to acuity, family support, and outcomes are suggested to develop and evaluate strategies for cost-effective care. The potential for preventing hospitalizations may be diminished due to the cost containment strategies currently used by agencies in response to PPS.