Predictors of formal home health care use in elderly patients after hospitalization

Progressive Multicomponent Intervention for Older Adults in Home Health Settings Following Acute Hospitalization: Randomized Clinical Trial Protocol

BACKGROUND

Hospitalization is a profound contributor to functional loss for older adults. Many modifiable risk factors (ie, weakness) may persist after hospitalization, representing portents of poor health, re-hospitalization, or death. Older adults frequently receive home health (HH) care after hospitalization to manage functional deficits that have worsened during hospital stays. However, how best to manage these deficits in HH settings has yet to be determined.

OBJECTIVE

The objective is to determine if a higher intensity, progressive, multi-component (PMC) intervention, initiated upon admission to HH after an acute hospitalization, improves objectively measured and self-reported physical function more than usual care (UC) physical therapy.

DESIGN

This will be a 2-arm randomized controlled clinical trial.

SETTING

The setting will be participant homes.

PARTICIPANTS

A total of 200 older adults with deconditioning following acute hospitalization and referred for HH physical therapy will participate.

INTERVENTION

Participants will be randomized to either a PMC treatment group or a UC group and receive 12 therapy visits over a 60-day period. PMC participants will perform lower extremity resistance training at 80% of a 1-repetition maximum, task-specific activities of daily living training, along with advanced gait and balance training. PMC groups will also receive nutritional supplementation and nursing support during transition from hospital to home. The UC group will receive standard of care HH interventions.

MEASUREMENTS

Physical performance, self-reported function, fatigue, and health care utilization outcomes will be measured at baseline, 30 days, 60 days, 90 days, and 180 days. All measures will be assessed by blinded study personnel.

LIMITATIONS

The limitation is an inability to blind treating therapists to study allocation.

CONCLUSIONS

The authors hope to determine whether higher intensity, multi-component exercise interventions improve outcomes more than UC physical therapy for older adults recovering from acute hospitalization in HH settings.

Older Adults' Social Relationships and Health Care Utilization: A Systematic Review

BACKGROUND

Deficiencies in older people's social relationships (including loneliness, social isolation, and low social support) have been implicated as a cause of premature mortality and increased morbidity. Whether they affect service use is unclear.

OBJECTIVES

To determine whether social relationships are associated with older adults' use of health services, independently of health-related needs.

SEARCH METHODS

We searched 8 electronic databases (MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Scopus, the Cochrane Library, and the Centre for Reviews and Dissemination) for data published between 1983 and 2016. We also identified relevant sources from scanning the reference lists of included studies and review articles, contacting authors to identify additional studies, and searching the tables of contents of key journals.

SELECTION CRITERIA

Studies met inclusion criteria if more than 50% of participants were older than 60 years or mean age was older than 60 years; they included a measure of social networks, received social support, or perceived support; and they reported quantitative data on the association between social relationships and older adults' health service utilization.

DATA COLLECTION AND ANALYSIS

Two researchers independently screened studies for inclusion. They extracted data and appraised study quality by using standardized forms. In a narrative synthesis, we grouped the studies according to the outcome of interest (physician visits, hospital admissions, hospital readmissions, emergency department use, hospital length of stay, utilization of home- and community-based services, contact with general health services, and mental health service use) and the domain of social relationships covered (social networks, received social support, or perceived support). For each service type and social relationship domain, we assessed the strength of the evidence across studies according to the quantity and quality of studies and consistency of findings.

MAIN RESULTS

The literature search retrieved 26 077 citations, 126 of which met inclusion criteria. Data were reported across 226 678 participants from 19 countries. We identified strong evidence of an association between weaker social relationships and increased rates of readmission to hospital (75% of high-quality studies reported evidence of an association in the same direction). In evidence of moderate strength, according to 2 high-quality and 3 medium-quality studies, smaller social networks were associated with longer hospital stays. When we considered received and perceived social support separately, they were not linked to health care use. Overall, the evidence did not indicate that older patients with weaker social relationships place greater demands on ambulatory care (including physician visits and community- or home-based services) than warranted by their needs.

AUTHORS' CONCLUSIONS

Current evidence does not support the view that, independently of health status, older patients with lower levels of social support place greater demands on ambulatory care. Future research on social relationships would benefit from a consensus on clinically relevant concepts to measure. Public Health Implications. Our findings are important for public health because they challenge the notion that lonely older adults are a burden on all health and social care services. In high-income countries, interventions aimed at reducing social isolation and loneliness are promoted as a means of preventing inappropriate service use. Our review cautions against assuming that reductions in care utilization can be achieved by intervening to strengthen social relationships.

Factors associated with the use of home-visit nursing services covered by the long-term care insurance in rural Japan: a cross-sectional study

Background

In Japan, there is a large increase in the number of elderly persons who potentially need home-visit nursing services (VNS). However, the number of persons using the VNS has increased only little in comparison to the number of individuals who use home social services, which are also covered by the Long-Term Care Insurance (LTCI) system. This cross-sectional study investigated the predictors of the VNS used under the LTCI system in Japan.

Methods

We used 1,580 claim data from all the users of community-based services and 1,574 interview survey data collected in 2001 from the six municipal bodies in Japan. After we merged the two datasets, 1,276 users of community-based services under the LTCI were analyzed. Multiple logistic regression models stratified by care needs levels were used for analysis.

Results

Only 8.3% of the study subjects were VNS users. Even among study participants within the higher care-needs level, only 22.0% were VNS users. In the lower care level group, people with a higher care level (OR: 3.50, 95% CI: 1.50–8.93), those whose condition needed long term care due to respiratory or heart disease (OR: 4.31, 95% CI: 1.88–89.20), those whose period of needing care was two years or more (OR: 2.01, 95% CI: 1.14–3.48), those whose service plan was created by a medical care management agency (OR: 2.39, 95% CI: 1.31–4.33), those living with family (OR: 1.86, 95% CI: 1.00–3.42), and those who use home-help services (OR: 2.12, 95% CI: 1.17–3.83) were more likely to use the VNS. In the higher care level group, individuals with higher care level (OR: 3.63, 95% CI: 1.56–8.66), those with higher income (OR: 3.79, 95% CI: 1.01–14.25), and those who had regular hospital visits before entering the LTCI (OR: 2.36, 95% CI: 1.11–5.38) were more likely to use the VNS.

Conclusions

Our results suggested that VNS use is limited due to management by non-medical care management agencies, due to no caregivers being around or a low income household. The findings of this study provide valuable insight for LTCI policy makers: the present provision of VNS should be reconsidered.

Public reporting and market area exit decisions by home health agencies

OBJECTIVE

To examine whether home health agencies selectively discontinue services to areas with socio-economically disadvantaged people after the introduction of Home Health Compare (HHC), a public reporting program initiated by Medicare in 2003.

STUDY DESIGN /METHODS

We focused on agencies' initial responses to HHC and examined selective market-area exits by agencies between 2002 and 2004. We measured HHC effects by the percentage of quality indicators reported in public HHC data in 2003. Socio-economic status was measured by per capita income and percent college-educated at the market-area level.

DATA SOURCES

2002 and 2004 Outcome and Assessment Information Set (OASIS); 2000 US Census file; 2004 Area Resource File; and 2002 Provider of Service File.

PRINCIPAL FINDINGS

WE FOUND A SMALL AND WEAK EFFECT OF PUBLIC REPORTING ON SELECTIVE EXITS: a 10-percent increase in reporting (reporting one more indicator) increased the probability of leaving an area with less-educated people by 0.3 percentage points, compared with leaving an area with high education.

CONCLUSION

The small level of market-area exits under public reporting is unlikely to be practically meaningful, suggesting that HHC did not lead to a disruption in access to home health care through selective exits during the initial year of the program.

Life and living in advanced age: a cohort study in New Zealand--e Puāwaitanga o Nga Tapuwae Kia Ora Tonu, LiLACS NZ: study protocol

BACKGROUND

The number of people of advanced age (85 years and older) is increasing and health systems may be challenged by increasing health-related needs. Recent overseas evidence suggests relatively high levels of wellbeing in this group, however little is known about people of advanced age, particularly the indigenous Māori, in Aotearoa, New Zealand. This paper outlines the methods of the study Life and Living in Advanced Age: A Cohort Study in New Zealand. The study aimed to establish predictors of successful advanced ageing and understand the relative importance of health, frailty, cultural, social & economic factors to successful ageing for Māori and non-Māori in New Zealand.

METHODS/DESIGN

A total population cohort study of those of advanced age. Two cohorts of equal size, Māori aged 80-90 and non-Māori aged 85, oversampling to enable sufficient power, were enrolled. A defined geographic region, living in the Bay of Plenty and Lakes District Health Board areas of New Zealand, defined the sampling frame. Rūnanga (Māori tribal organisations) and Primary Health Organisations were subcontracted to recruit on behalf of the University. Measures--a comprehensive interview schedule was piloted and administered by a trained interviewer using standardised techniques. Socio-demographic and personal history included tribal affiliation for Māori and participation in cultural practices; physical and psychological health status used standardised validated research tools; health behaviours included smoking, alcohol use and nutrition risk; and environmental data included local amenities, type of housing and neighbourhood. Social network structures and social support exchanges are recorded. Measures of physical function; gait speed, leg strength and balance, were completed. Everyday interests and activities, views on ageing and financial interests complete the interview. A physical assessment by a trained nurse included electrocardiograph, blood pressure, hearing and vision, anthropometric measures, respiratory function testing and blood samples.

DISCUSSION

A longitudinal study of people of advanced age is underway in New Zealand. The health status of a population based sample of older people will be established and predictors of successful ageing determined.

Comparison of public and private care management agencies under public long-term care insurance in Japan: a cross-sectional study

AIM

Long-Term Care Insurance (LTCI), which started in April 2000, allowed private business corporations to provide long-term care services which had been provided by social welfare corporations or public agencies in the previous long-term care scheme. This study compared differences in care management plans for community-dwelling frail elderly people between public care management agencies and private care management agencies.

METHODS

The subjects were 309 community-dwelling frail elderly people living in a suburban city with a population of approximately 55,000 and who had been using community-based long-term care services of the LTCI for 6 months from April 2000. The characteristics of the care management agencies (public/private) were identified using a claims database. After comparing profiles of users and their care mix between those managed by public agencies and by private agencies, the effect of the characteristics of care management agencies on LTCI service use was examined.

RESULTS

Public care management agencies favored younger subjects (P = 0.003), male subjects (P = 0.006) and people with a higher need for care (P = 0.02) than private agencies. The number of service items used was significantly larger in public agencies than in their private counterparts. In multivariate regression analysis, the utilization of community-based long-term care service was significantly greater among beneficiaries managed by private agencies than those managed by public agencies (P = 0.02).

CONCLUSION

Private care management agencies play an important role in promoting the use of care services, but their quality of care plans might be questionable.

Inhome Service Use by Caregivers and Their Elders: Does Cognitive Status Make a Difference?

The intent of this study was to examine the effect of cognitive status on the use of inhome services by caregivers and their elders. Data from the screening, clinical and community-caregiver phases of the Manitoba Study on Health and Aging (MSHA-1) were analysed utilizing a modified Andersen-Newman model. The findings indicated that those with dementia were more likely to use personal care services and use two or more inhome services than caregivers and their elders with no cognitive impairment and those with cognitive impairment but no dementia. Functional status of the elder and living arrangement of the caregiver and elder were strongly associated with the use of specific inhome services and with overall use. Policy and research implications of the findings including other significant factors such as caregiver employment, are presented.

Homecare referrals and 12-week outcomes following surgery for cancer

PURPOSE/OBJECTIVES

To determine characteristics of patients undergoing cancer surgery who do and do not receive homecare referral after hospitalization, relative to poor discharge outcomes.

DESIGN

Secondary analysis of a randomized clinical trial.

SETTING

Urban, academic cancer center in the northeastern United States.

SAMPLE

375 patients 60 years and older and admitted for solid tumor cancer surgery.

METHODS

Stepwise, multiple logistic regression using patient characteristics related to homecare referrals or those related to poor discharge outcomes.

MAIN RESEARCH VARIABLES

Homecare referral and poor discharge outcome.

FINDINGS

Patients 70 years or older, single, hospitalized for a week or more for a late-stage cancer, with greater than four comorbid conditions, and discharged with more than four daily activity impairments, depressive symptoms, and a need for skilled nursing care were more likely to require home care. Patients not referred to home care who received adjuvant cancer therapies were about three times more likely to have poor discharge outcomes.

CONCLUSIONS

Patients who were referred for home care had characteristics similar to medical or surgical patients documented in the literature. However, younger patients with lengthy hospital stays and recipients of adjuvant cancer therapy did poorly after discharge and may benefit from home care.

IMPLICATIONS FOR NURSING

Certain characteristics, such as age, single marital status, depression, and cognition, should trigger further assessment of patients' needs after discharge, including anticipating needs of patients who will receive adjuvant therapies.

DeLLITE depression in late life: an intervention trial of exercise. Design and recruitment of a randomised controlled trial

Background

Physical activity shows potential in combating the poor outcomes associated with depression in older people. Meta-analyses show gaps in the research with poor trial design compromising certainty in conclusions and few programmes showing sustained effects.

Methods/design

The Depression in Late Life: an Intervention Trial of Exercise (DeLLITE) is a 12 month randomised controlled trial of a physical activity intervention to increase functional status in people aged 75 years and older with depressive symptoms. The intervention involves an individualised activity programme based on goal setting and progression of difficulty of activities delivered by a trained nurse during 8 home visits over 6 months. The control group received time matched home visits to discuss social contacts and networks. Baseline, 6 and 12 months measures were assessed in face to face visits with the primary outcome being functional status (SPPB, NEADL). Secondary outcomes include depressive symptoms (Geriatric Depression Scale), quality of life (SF-36), physical activity (AHS Physical Activity Questionnaire) and falls (self report).

Discussion

Due to report in 2008 the DeLLITE study has recruited 70% of those eligible and tests the efficacy of a home based, goal setting physical activity programme in improving function, mood and quality of life in older people with depressive symptomatology. If successful in improving function and mood this trial could prove for the first time that there are long term health benefit of physical activity, independent of social activity, in this high risk group who consume excess health related costs.

Trial registration

Australian and New Zealand Clinical Trials Register ACTRN12605000475640

Difficult hospital discharges in internal medicine wards

OBJECTIVE

Investigate the prevalence of difficult hospital discharges (DHD), describe clinical and social patients' characteristics as potential reasons for discharge delays in an internal medicine ward and implement tailored post-discharge care.

METHODS

During the year 2005 we analysed, in a middle-sized country hospital, all the patients for which some delay for discharge, owing to their whole complexity, was presumable. Comprehensive multidimensional assessment, clinical-social risk score, specific needs of care, mean of stay and outcomes were evaluated.

RESULTS

68.5% of DHD patients were >/=80 years old, with 3.8 the mean number of diseases per patient; 57.5% presented a loss of autonomy (ADL) just before acute deterioration; 80% were functionally and/or cognitively impaired. Only 5% had suitable family support; 5.1% were living at a nursing home; 2% were living alone. The most frequent causes of admission were stroke, cognitive impairment-dementia, cardiovascular diseases, fractures and cancer. Mean length of stay was 12 days. Fifty-two percent of patients were discharged home, 30% were admitted to a long-term care facility, 1% to hospice and 17% died during their hospital stay.

CONCLUSIONS

The aim of "coordinated care" (i.e., targeting "at-risk" patients with assessment of medical, functional, social and emotional needs; provision of optimal medical treatment, self-care education, integrated services, monitoring of progress and early signs of problems) is to improve health outcomes and reduce costs. More than 80% of DHDs patients, with specific tailored programmes, may be discharged from hospital, with satisfactory solutions for them and their families.

Medicare and Medicaid Home Health and Medicaid Waiver Services for Dually Eligible Older Adults: Risk Factors for Use and Correlates of Expenditures

PURPOSE

The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures.

DESIGN AND METHODS

Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997.

RESULTS

In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures.

IMPLICATIONS

Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

Socioeconomic disparities in the use of home health services in a medicare managed care population

OBJECTIVE

To investigate socioeconomic disparities in access to home health visits and durable medical equipment by persons enrolled in two Medicare managed care health plans.

DATA SOURCES

A telephone survey of 4,613 Medicare managed care enrollees conducted between April and October of 2000 and linked to administrative claims for a subsequent 12-month period.

STUDY DESIGN

We estimated a series of logistic regression models to determine which socioeconomic factors were related to home health visits and the use of durable medical equipment (DME) among Medicare managed care enrollees.

PRINCIPAL FINDINGS

Controlling for health and demographic differences, Medicare managed care enrollees in the lowest tertile for nonhousing assets had 50 percent greater odds than those in the highest tertile of having one or more home health visits. All else equal, enrollees with less than a high school education had 30 percent lower odds than those who had graduated from high school of using durable medical equipment.

CONCLUSIONS

Medicare managed care enrollees of low socioeconomic status do not appear to have reduced access to home health visits; however, use of durable medical equipment is considerably lower for enrollees with less than a high school education. Physicians and therapists working with Medicare managed care enrollees may want to actively target DME prescriptions to those with educational disadvantages.

Risks for unplanned hospital readmission in a teaching hospital in southern Taiwan

The purpose of this study was to assess and analyse hospital readmission and its risk factors for patients who were visited by a discharge planning coordinator during hospitalization in a teaching hospital located in southern Taiwan. Results found that 67 patients (5.7%) were readmitted within 14 days of discharge during the data collection period. Twenty-eight patients (41.8%) were readmitted because of complications. Patients' previous diagnoses and complications were two major reasons for patients to be re-hospitalized within 14 days of discharge. In addition, significant predictors for unplanned hospital readmission within 14 days of discharge were patients who received care from home health care nurses or hospice home health care nurses.

Home care with regard to definition, care recipients, content and outcome: systematic literature review

In spite of the fact that home care has grown considerably during the last few years and will continue to grow even more in the future, home care as a phenomenon and a concept is not clearly defined. The aim of this study was to review the empirical literature for the description of home care as a phenomenon and as a concept, especially with regard to who the care recipients are, what actions and assessments are performed and what effects are achieved for the care recipient in terms of functional health status and quality of life (QoL). Twenty-six relevant studies meeting the inclusion criteria and requirements for methodological quality were identified. The phenomenon of home care is described through content, outcome and objectives. The content of home care involved a range of activities from actions preventing decreased functional abilities in old people to palliative care in advanced diseases. The outcome had two different underlying foci: (1). for the benefit of the patient based on the assumption that being cared at home increases their QoL, (2). in the interests of the society, to minimize hospital care by moving activities to the home of the patient. The objectives were found to be aiming at improving the QoL and/or maintaining independence, by means of actions and assessments, based on the patient's needs, undertaken to preserve and increase functional ability and make it possible for the person to remain at home. In conclusion, home care as a phenomenon was the care provided by professionals to people in their own homes with the ultimate goal of not only contributing to their life quality and functional health status, but also to replace hospital care with care in the home for societal reasons; home care covered a wide range of activities, from preventive visits to end-of-life care.

Measuring disability in Medicare home care patients: application of Rasch modeling to the outcome and assessment information set

BACKGROUND

The Outcome and Assessment Information Set (OASIS) is the universal clinical assessment tool for adult nonmaternity patients receiving skilled care at home from Medicare-certified home health agencies in the United States. Anticipating increased use of OASIS data for research purposes, this article explored the usefulness of Rasch modeling to address disability measurement challenges presented by the unique response category structure of the seven activities of daily living (ADL) and eight instrumental ADL (IADL) items in the OASIS.

OBJECTIVES

To illustrate how Rasch model statistics can be used to evaluate OASIS ADL and IADL item unidimensionality and model fit; to illustrate how Rasch modeling simultaneously estimates ADL and IADL item difficulty, thresholds between item response categories, and person disability; and to compare Rasch estimates of item difficulty and person disability scores to estimates based on more conventional Likert scoring techniques.

SUBJECTS

Medicare-eligible home health care patients (n = 583) served by one of 12 home care agencies in Ohio between November 1999 and September 2000.

MEASURES

ADL and IADL items were measured three ways: according to the original OASIS scoring (raw Likert); transformed raw Likert scores accounting for the nonuniform item structure (corrected Likert); and Rasch Partial Credit model scores.

RESULTS

The items bathing and telephone use showed evidence of unexpected response patterns; recoding of these items was necessary for good Rasch model fit. Partial Credit model results revealed that interval distances between response categories varied widely across the 15 ADL and IADL items. When ADL and IADL items were ranked by level of difficulty, results were similar between Rasch and corrected Likert measurement approaches; however, corrected Likert person scores were found to be nonlinear at highest and lowest disability levels when plotted against Rasch person scores.

CONCLUSIONS

Rasch modeling can help improve the precision of disability measurement in Medicare home care patients when using ADL and IADL items from the OASIS instrument.

Determinants of Medicare home healthcare service use among Medicare recipients

BACKGROUND

Medicare reimbursement for home healthcare (HHC) services has changed dramatically in recent years. A clear understanding of the determinants of Medicare HHC services use is needed so that HHC agencies can meet the demand for services from an aging population while remaining financially sound.

OBJECTIVES

The purpose of the study was to identify the determinants of Medicare HHC service within the framework of the Andersen Behavioral Model.

METHODS

This cross-sectional secondary analysis used data from the 1996 Medical Expenditures Panel Survey to examine characteristics of 239 subjects who had received Medicare reimbursed HHC services. Predisposing characteristics, enabling resources, and need characteristics were examined to explain Medicare HHC service use. Two criterion measures, annual Medicare expenditures and days of care, were employed in hierarchical regression analyses.

RESULTS

Variance in annual Medicare expenditures was explained by both the predisposing (R(2) =.16, <.001) and need characteristics (R(2) =.09, <.001). Variance in days of care was explained by predisposing characteristics (R(2) =.12, <.001) and need characteristics (R(2) =.15, <.001). The adjusted for the total model was.21 for annual Medicare expenditures and.25 for days of care.

CONCLUSIONS

While Andersen's Behavioral Model is useful in explaining Medicare HHC service use, it may be important to use multiple measures as criterion variables since the amount and proportion of variance explained differs with the variable used.

Use of home health services covered by new public long-term care insurance in Japan: impact of the presence and kinship of family caregivers

OBJECTIVE

In April 2000, the system for caring for the elderly in Japan was changed drastically with the launch of new long-term care insurance. Unlike the previous system, the maximum monthly amount of insured services is now decided solely by an applicant's physical condition, regardless of family support. We investigated whether the presence and kinship of a family caregiver still affect service use under the new system.

DESIGN

A cross-sectional, mailed, self-administered questionnaire survey and analysis using multiple logistic regression.

SETTING

One month after the introduction of long-term care insurance in Japan.

PARTICIPANTS

The main family caregivers of 237 applicants for long-term care insurance with a caregiver and 33 applicants without a caregiver, living in the community in one city.

OUTCOME MEASURES

The applicants' sex, age, and eligible care level, existence of a family caregiver, family caregiver's sex, age, and kinship, and service use for each service covered by long-term care insurance.

RESULTS

Caregiver factors significantly affected use of the main services. The most popular service, nursing-home daycare, was utilized most when a wife was caring for her husband. As the level of care increased, this service was utilized less. Home help, the second most popular service, was most utilized when a wife was caring for her husband or when there was no caregiver.

CONCLUSION

The use of major services may be decided more by the needs of caregivers than by the care level of the applicant. To successfully implement the new system, consideration of the caregiver situation should be included in policy making.

Patient characteristics at hospital discharge and a comparison of home care referral decisions

OBJECTIVES

Describe the characteristics of hospitalized older adults who were not referred for home care, compare the referral decisions of hospital clinicians with those of nurses with expertise in discharge planning and transitional care, and compare the characteristics of hospitalized older adults who did not receive a home care referral with patients who did receive a home care referral.

DESIGN

Secondary analysis, descriptive, case series.

SETTING

Subjects were discharged to home from one of two urban hospitals in Philadelphia, Pennsylvania.

PARTICIPANTS

Ninety-nine patients for this study were drawn from the control group (n = 186) of a prior randomized clinical trial of advanced practice nurse hospital discharge planning and home follow-up. These 99 patients, or 56 of the control group, did not receive a home care referral even though they were screened into the original study as meeting at least one of the risk criteria associated with poor postdischarge outcomes.

MEASUREMENTS

Case studies were generated from research records of the control group patients who did not receive a home care referral. They included patient sociodemographic and health characteristics. Nurses with expertise in discharge planning and transitional care, blinded to the actual decision, reviewed each case study and made a referral decision.

RESULTS

Case studies revealed that control group patients, discharged without home follow-up, had many characteristics associated with the need for a home care referral, with the likelihood of receiving a referral, or with developing poor postdischarge outcomes. Overall, compared with control group patients who did not receive home care, those who did were older, had a longer hospital stay, more often rated their health as fair or poor, and had worse functional status. However, transitional care nurses judged that 96 of 99 of the control group patients discharged without home care had unmet discharge needs that may have benefited from a postdischarge referral. In addition, the transitional care nurses identified 49 of these 99 patients as having a high-priority need for home care. These patients had at least three of the characteristics associated with the need for a home care referral, the likelihood of receiving a referral, or of developing poor postdischarge outcomes. High-priority patients were significantly different in many sociodemographic and health characteristics and were rehospitalized significantly more often than other control group patients who were discharged without home care (P = .032).

CONCLUSION

Study findings have demonstrated that the majority of older adults in this sample were discharged without postdischarge referrals despite the presence of several characteristics associated with the need for home care and risk of poor discharge outcomes. Findings suggest the need for improved methods to identify and synthesize patient characteristics associated with the need for postdischarge referral and to support clinical decision-making. Insurance or homebound status should also be explored as barriers to patients receiving the postdischarge care that they need.

Medication adherence in elderly patients receiving home health services following hospital discharge

OBJECTIVE

To assess prevalence and risk factors for medication under- and overadherence in a two-week period following hospital discharge in adults > or = 65 years.

DESIGN

Prospective, cohort study.

SETTING

Three home healthcare agencies in Madison, Wisconsin, and surrounding vicinity.

PARTICIPANTS

One hundred forty-seven older participants taking three or more medications who were hospitalized for medical illness, received home nursing after discharge, and completed the two-week interview.

MEASUREMENTS

The main outcome measures were having at least one medication with less than 70% adherence (underadherence) and having at least one medication with more than 120% adherence (overadherence) based on pill counts.

RESULTS

Forty-five (30.6%) participants were underadherent and 27 (18.4%) participants were overadherent with at least one medication> In a multivariate model, underadherence was predicted by poor cognition (OR 2.5; 95% CI 1.02 to 6.10) and higher medication use (OR 1.16; 95% CI 1.03 to 1.31, for each 1-unit increase in number of medications). Both poor cognition and low education were significantly associated with overadherence in univariate analysis; however, neither variable was significant once included in the multivariate model.

CONCLUSIONS

Under- and overadherence to medications is common after hospital discharge. Poor cognition and a greater number of medications were associated with underadherence. Poor and lower education were markers for overadherence; however, further study is needed to determined whether these are independent predictors. Patients who have impaired cognition or are taking a greater number of medications after hospitalization may benefit from targeted interventions to monitor and improve medication compliance.

Problems of older adults living alone after hospitalization

OBJECTIVE

To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization.

DESIGN

Secondary analysis of a prospective cohort study.

PARTICIPANTS

Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed.

MEASUREMENTS

One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization.

RESULTS

One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P =.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7. 6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11. 9) times more likely to be admitted to a nursing home in the month after hospitalization.

CONCLUSION

Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence.

Factors associated with referral of elderly individuals with cardiac and pulmonary disorders for home care services following hospital discharge

Referrals for home care services initiated prior to hospital discharge may prevent or delay readmission or nursing home placement, especially for elderly individuals with multiple, chronic health problems. While multiple factors could justify the need for home follow-up after hospital discharge, little is known about those patient factors associated with clinicians' decisions to refer older adults with cardiac or pulmonary disorders. Increased understanding of factors that contribute to initiating a home care referral could enhance clinicians' decision-making and thus improve post-discharge outcomes for these patient groups. This study examined patient factors associated with and predictive of the decision to refer for home follow-up, using a sample of older adults hospitalized with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Study findings suggest a model that includes patients diagnosed with both COPD and CHF, who are not married, need home health aides, and have a longer than average length of hospital stay may be helpful in predicting the need for home care referrals.

Adverse drug events in elderly patients receiving home health services following hospital discharge

OBJECTIVE

To assess incidence, healthcare consequences, and identify risk factors for adverse drug events (ADEs) in elderly patients receiving home health services during the month following hospital discharge.

METHOD

This was a prospective cohort study of three home health agencies in Madison, Wisconsin, and its surrounding area. The sample consisted of 256 participants aged > or =65 years who were hospitalized for medical illness, received home nursing after discharge, and completed the one-month interview. The main outcome measure was self-reported ADEs (possible, probable, or definite) during the month following hospital discharge.

RESULTS

Incidence of ADEs was 20%. Fifty-two participants (20.3%) reported 64 ADEs: 23 possible, 37 probable, and four definite. The most common ADEs involved the gastrointestinal tract (31.3%) and the central nervous system (31.3%). Of 53 ADEs reported to providers, 59% of the drugs were discontinued or altered. One ADE resulted in hospitalization. In logistic regression, female gender (OR = 2.26; 95% CI 1.06 to 4.77) and the interaction between number of new medications and cognition were significantly associated with ADEs. The risk of an event increased with the number of new medications at discharge; however, risk was elevated primarily for participants with lower cognition.

CONCLUSIONS

ADEs were common during the month following hospital discharge, were more frequent in women, and often resulted in medication changes. Individuals at particular risk were those with lower cognition who were discharged with several new medications.

A prediction rule for the use of postdischarge medical services

OBJECTIVE

To develop and validate a prediction rule screening instrument, easily incorporated into the routine hospital admission assessment, that could facilitate discharge planning by identifying patients at the time of admission who are most likely to need postdischarge medical services.

DESIGN

Prospective cohort study with separate phases for prediction rule development and validation.

SETTING

Urban teaching hospital.

PATIENTS/PARTICIPANTS

General medical service patients, 381 in the derivation phase and 323 in the validation phase, who provided self-reported medical history, health status, and demographic data as a part of their admission nursing assessment, and were subsequently discharged alive.

MEASUREMENTS AND MAIN RESULTS

Use of postdischarge medical services such as visiting nurse or physical therapy, medical equipment, or placement in a rehabilitation or long-term care facility was determined. A prediction rule based on a patient's age and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) physical function and social function scores stratified patients with regard to their risk of using postdischarge medical services. In the validation set, the rate of actual postdischarge medical service use was 15% (15 of 97), 36% (39 of 107), and 58% (57 of 98) among patients characterized by the prediction rule as being at "low", "intermediate," and "high" risk of using postdischarge medical services, respectively.

CONCLUSIONS

This prediction rule stratified general medical patients with regard to their likelihood of needing discharge planning to arrange for postdischarge medical services. Further research is necessary to determine whether prospective identification of patients likely to need discharge planning will make the hospital discharge planning process more efficient.

Older home health care patients and their physicians: assessment of functional ability

Assessment of a person's level of functional impairment is a key aspect of geriatric clinical practice. This study examines the agreement between functional assessments reported by 54 physician-patient dyads. Physicians were typical of those providing services to elderly patients in an urban area. Patients, all aged 65 or more years and community-living, had been referred by these physicians for in-home health care services. Generally, physicians reported less impairment than did their patients, functional assessments by both doctors and patients matching completely in only 15 of 54 (28%) dyads. Underestimation of patient impairment occurred most commonly with respect to stair climbing, control of the urinary bladder, and bathing, but was also substantial for dressing, walking, and toileting. Few patient or doctor characteristics predicted congruence or lack thereof in assessment of functional impairments. Some implications of these findings for clinical practice and medical education are examined.

Identification of needs of and utilization of resources by rural and urban elders after hospital discharge to the home

The recent reductions in lengths of hospital stays may particularly affect the elderly in rural communities where resources may be scarce. The purpose of this descriptive, comparative study was to assess and evaluate the match of formal and informal resources with individual functional, behavioral, knowledge, and skilled care needs of rural and urban elderly during a 21-day transition period following hospital discharge to the home. Eighty-one elderly patients discharged to one urban and two frontier rural counties were selected. There were no significant differences in demographic variables between rural and urban participants. The Comprehensive Health Care Needs Assessment (CHCNA) questionnaire was used to assess needs and utilization of resources at 3 days and 3 weeks after discharge. Using repeated measure analyses of variance, there were significantly fewer needs identified at 3 weeks than at 3 days after discharge. Rural dwellers identified significantly more skilled care needs than their urban counterparts; however, none were highly technical in nature. Unexpectedly, at 3 weeks after discharge, considerably more functional needs were met by families in the urban setting than in the rural setting. Although only a small number of participants reported unmet needs in multiple domains, the complexity of the unmet needs requires further exploration.

Home care resource consumption and patient outcomes: what are the relationships?

This study examined empirical relationships between measures of home care resource consumption and patient outcome measures in a sample of 201 patients who began new episodes of home care with one of ten Medicare-certified home care agencies in Ohio. We found that, while the total volume of home care resource consumption (i.e., total visits and costs) was similar for patients whose episodes ended with discharge at home vs. hospitalization, patients discharged to hospitals consumed home care resources in a much shorter period of time. We also found that resource consumption patterns were very similar regardless of whether patients improved or declined in clinical and functional health during the episode of home care. Results suggest that home care agencies should carefully project both resource consumption and patient outcome targets when negotiating service contracts with managed care organizations, especially for Medicare patients.

Prospective value of self-report and performance-based tests of functional status for 18-month outcomes in elderly patients

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28%) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed "Up and Go", Timed Test of Money Counting. Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed "Up and Go", Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.