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Ho YC, Wang CT, Weng TC, Ho CH, Tsai KT, Hsu CC, Lin HJ, Chen HC, Huang CC. Impact of the Home-Based Medical Integrated Program on Health Outcomes and Medical Resource Utilization in Home Healthcare Patients in Taiwan. Clin Interv Aging 2024; 19:1437-1444. [PMID: 39165906 PMCID: PMC11333557 DOI: 10.2147/cia.s457281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 08/01/2024] [Indexed: 08/22/2024] Open
Abstract
Purpose The home-based medical integrated program (HMIP) is a novel model for home healthcare (HHC) in Taiwan, initiated in 2016 to enhance care quality. However, the outcomes of this program on health outcomes and medical resource utilization in HHC patients remain unclear. Thus, we conducted this study to clarify it. Patients and Methods The authors utilized the Taiwan National Health Insurance Research Database to identify HHC patients who received HMIP and those who did not between January 2015 and December 2017. A retrospective cohort study design was used. Convenience sampling was employed to select patients who met the inclusion criteria: being part of the HHC program and having complete data for analysis. Results A total of 4982 HHC patients in the HMIP group and 10,447 patients in the non-HMIP group were identified for this study. The mean age in the HMIP group and non-HMIP group was 77.6 years and 76.1 years, respectively. Compared with the non-HMIP group, the HMIP group had lower total medical costs for HHC, fewer outpatient department visits and lower medical costs, lower medical costs for emergency department visits, fewer hospitalizations, and a lower mortality rate (34.6% vs 41.2%, p<0.001). Conclusion The HMIP is a promising model for improving care quality and reducing medical resource utilization in HHC patients. While this suggests that the non-HMIP model should be replaced, it's important to note that both non-HMIP and HMIP models currently coexist. The HMIP may serve as an important reference for other nations seeking to improve care quality and reduce medical resource utilization in their own HHC systems.
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Affiliation(s)
- Yu-Chieh Ho
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Ti Wang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Tzu-Chieh Weng
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Kang-Ting Tsai
- Department of Senior Welfare and Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- Division of Geriatrics and Gerontology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Chin Chen
- Department of Senior Welfare and Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- Department of Nursing, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Rao K, Goldstein NE, Peikes DN, Polt L, Kornitzer B. Effects of Primary Care-Led, Integrated Palliative Care for Medicare Patients in a Value-Based Model. J Pain Symptom Manage 2024; 67:195-203. [PMID: 37972717 DOI: 10.1016/j.jpainsymman.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
CONTEXT Faced with a projected shortage of specialized palliative care physicians, scalable palliative solutions are required to better meet the aging population's needs. OBJECTIVES To determine whether a multi-site, primary care-led, integrated palliative care model improves clinical, utilization, and economic outcomes. METHODS Propensity score-matched comparison group formed from participants who were Medicare beneficiaries, died January 1, 2021-January 31, 2023, were patients of eight primary care practices that partner with agilon health, and enrolled in palliative care for at least seven days. Each practice operates in a value-based model, where primary care providers (PCPs) take on full-risk for the cost and quality of patient outcomes. Each program includes symptom management, defining goals of care/advance directives, PCP care coordination, and assistance with care transitions if patients enroll in hospice. RESULTS Final sample included 1778 decedents, with 889 in both enrolled and matched cohorts, average age 83. Palliative care is associated with improved patient outcomes from palliative care enrollment until death, including 5.4 more days at home (p < 0.001), 0.4 fewer hospitalizations (p < 0.001), 17% fewer deaths in a hospital (p < 0.001), and $10,393 lower overall healthcare costs (p < 0.001). CONCLUSION A primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the healthcare needs of an aging population by impacting patient outcomes and reducing avoidable utilization and cost at the end of life. These findings demonstrate that PCPs in a scaled, full-risk model can simultaneously improve care for patients while reducing costs to the healthcare system.
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Affiliation(s)
- Karthik Rao
- agilon health (K.R., B.K.), Boston, Massachusetts, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (N.E.G.), Icahn School of Medicine, New York City, New York USA
| | - Deborah N Peikes
- Blue Cross Blue Shield of Massachusetts (D.N.P.), Princeton, New Jersey, USA
| | - Lauren Polt
- agilon health (L.P.), St. Petersburg, Florida, USA
| | - Benjamin Kornitzer
- agilon health (K.R., B.K.), Boston, Massachusetts, USA; Department of Medicine (B.K.), Icahn School of Medicine, New York City, New York, USA.
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Akiya K, Palacios S, Silver D. Mental Health Referrals Among Medicare Advantage Enrollees Receiving Home-Based Annual Wellness Visits in Puerto Rico During the COVID-19 Pandemic. J Appl Gerontol 2024; 43:287-292. [PMID: 38018418 DOI: 10.1177/07334648231205983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Annual Wellness Visits (AWV) promote preventive care for older adults, yet uptake remains low. To increase AWVs, a Medicare Advantage (MA) plan in Puerto Rico contracted a medical group to provide home-based AWVs during the last quarter of 2020. Using data from 464 visits, we conducted descriptive and multivariable analysis to profile patient characteristics and identify predictors of mental health referrals. We found that 87% of patients had multiple chronic conditions, 75% were taking more than 5 medications, and the odds of a mental health referral were higher for those who also had a nutrition-related condition (AOR = 5.05, CI95: 1.76-11.88), diabetes (AOR = 3.34, CI95: 1.18-7.58), or an additional reported uncontrolled health issue (AOR = 28.18, CI95: 8.96-70.59). This strategy helped one MA plan reach high-need patients, but coordination of follow-up care is needed to ensure patients receive recommended services.
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Affiliation(s)
- Kelley Akiya
- School of Global Public Health, New York University, New York, NY, USA
| | - Sofia Palacios
- School of Global Public Health, New York University, New York, NY, USA
| | - Diana Silver
- School of Global Public Health, New York University, New York, NY, USA
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4
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Edwards ST, O'Neill A, Niederhausen M, Salvi A, Laliberte A, Saha S, Hynes DM, Pizer S, Kinosian B. Trajectories of care and outcomes of Veterans receiving home-based primary care. J Am Geriatr Soc 2024; 72:80-90. [PMID: 37772617 DOI: 10.1111/jgs.18607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described. METHODS We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps. RESULTS We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care. CONCLUSIONS HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.
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Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Allison O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University - Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Apoorva Salvi
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Avery Laliberte
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Somnath Saha
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Health Management and Policy Program, School of Public Health and Nutrition, College of Health, Oregon State University, Corvallis, Oregon, USA
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Steven Pizer
- Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Partnered Evidence-Based Policy Resource Center, Department of Veterans Affairs, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Division of Geriatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Geriatrics and Extended Care Data Analysis Center, Cpl Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Scholz SW, Moroz BE, Saez-Atienzar S, Chia R, Cahoon EK, Dalgard CL, Freedman DM, Pfeiffer RM. Association of cardiovascular disease management drugs with Lewy body dementia: a case-control study. Brain Commun 2023; 6:fcad346. [PMID: 38162907 PMCID: PMC10754316 DOI: 10.1093/braincomms/fcad346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/04/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Lewy body dementia is the second most common neurodegenerative dementia after Alzheimer's disease. Disease-modifying therapies for this disabling neuropsychiatric condition are critically needed. To identify drugs associated with the risk of developing Lewy body dementia, we performed a population-based case-control study of 148 170 US Medicare participants diagnosed with Lewy body dementia between 1 January 2008 and 31 December 2014 and of 1 253 043 frequency-matched controls. We estimated odds ratios and 95% confidence intervals for the association of Lewy body dementia risk with 1017 prescription drugs overall and separately for the three major racial groups (Black, Hispanic and White Americans). We identified significantly reduced Lewy body dementia risk associated with drugs used to treat cardiovascular diseases (anti-hypertensives: odds ratio = 0.72, 95% confidence interval = 0.70-0.74, P-value = 0; cholesterol-lowering agents: odds ratio = 0.85, 95% confidence interval = 0.83-0.87, P-value = 0; anti-diabetics: odds ratio = 0.83, 95% confidence interval = 0.62-0.72, P-value = 0). Notably, anti-diabetic medications were associated with a larger risk reduction among Black Lewy body dementia patients compared with other racial groups (Black: odds ratio = 0.67, 95% confidence interval = 0.62-0.72, P-value = 0; Hispanic: odds ratio = 0.86, 95% = 0.80-0.92, P-value = 5.16 × 10-5; White: odds ratio = 0.85, 95% confidence interval = 0.82-0.88, P-value = 0). To independently confirm the epidemiological findings, we looked for evidence of genetic overlap between Lewy body dementia and cardiovascular traits using whole-genome sequence data generated for 2591 Lewy body dementia patients and 4027 controls. Bivariate mixed modelling identified shared genetic risk between Lewy body dementia and low-density lipoprotein cholesterol levels, Type 2 diabetes and hypertension. By combining epidemiological and genomic data, we demonstrated that drugs treating cardiovascular diseases are associated with reduced Lewy body dementia risk, and these associations varied across racial groups. Future randomized clinical trials need to confirm our findings, but our data suggest that assiduous management of cardiovascular diseases may be beneficial in this understudied form of dementia.
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Affiliation(s)
- Sonja W Scholz
- Department of Neurology, Johns Hopkins University Medical Center, Baltimore, MD 21287, USA
- Neurodegenerative Diseases Research Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA
| | - Brian E Moroz
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sara Saez-Atienzar
- Laboratory of Neurogenetics, National Institute on Aging, National Institutes of Health, Bethesda, MD 20814, USA
| | - Ruth Chia
- Laboratory of Neurogenetics, National Institute on Aging, National Institutes of Health, Bethesda, MD 20814, USA
| | - Elizabeth K Cahoon
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Clifton L Dalgard
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- The American Genome Center, Collaborative Health Initiative Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Daryl Michal Freedman
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ruth M Pfeiffer
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Augustine MR, Intrator O, Li J, Lubetsky S, Ornstein KA, DeCherrie LV, Leff B, Siu AL. Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis. Med Care 2023; 61:805-812. [PMID: 37733394 DOI: 10.1097/mlr.0000000000001925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes. DESIGN Comparative effectiveness analysis. SETTING AND PARTICIPANTS Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535). METHODS We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community. RESULTS The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different. CONCLUSIONS AND IMPLICATIONS RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.
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Affiliation(s)
- Matthew R Augustine
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
- Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester, Rochester
- Geriatrics & Extended Care Data Analysis Center, Canandaigua VA Medical Center, Canandaigua
| | - Jiejin Li
- Department of Public Health Sciences, University of Rochester, Rochester
| | - Sara Lubetsky
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Katherine A Ornstein
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Linda V DeCherrie
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bruce Leff
- Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Albert L Siu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
- Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Bharadwaj P, Dyjack N, Gill G, Solomon A, Schafer M, Simpson E, DeVito R, Merz G, Switzer L, Gillette M, Fahnestock L, Somaiya CK, Randhawa M. Preliminary Analysis of an Advanced Health Care Practitioner-Led Home-Visit Primary Care Program for High-Risk Patients Reduced Health Care Costs and Utilization. J Palliat Med 2023; 26:1395-1397. [PMID: 37459163 DOI: 10.1089/jpm.2023.0351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background: MemorialCare Medical Group (MCMG) designed and implemented an advanced health care practitioner (AHP)-led home-visit primary care program to address the needs of a frail older adult population, who struggled with arriving for in-office care. We sought to perform a preliminary analysis to determine the program's efficacy. Methods: We conducted a retrospective review of patients enrolled in the program through tabulation of total costs of care, inpatient visits (IPVs), emergency department visits (EDVs), and 30-day readmissions (30DRs) 1-year pre-enrollment and postenrollment. Results: For the prior year and postyear windows, per-member per-month total cost of care decreased 21.4% ($5,883.44-$4,622.31), reflecting a gross savings of $2,693,480.32. Mean IPVs (2.42-1.56), EDVs (1.53-0.93), and 30DRs (0.27-0.13) were reduced. Conclusions: Initial analysis of an AHP-led in-home primary care program for frail seniors shows promise for improved outcomes with a clear decrease in the total cost of care.
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Affiliation(s)
| | - Nathan Dyjack
- MemorialCare Medical Group, Long Beach, California, USA
| | | | - Adam Solomon
- MemorialCare Medical Group, Long Beach, California, USA
| | - Mark Schafer
- MemorialCare Medical Group, Long Beach, California, USA
| | | | - Roseann DeVito
- National Environmental Health Association, Denver, Colorado, USA
| | - Gwyn Merz
- MemorialCare Medical Group, Long Beach, California, USA
| | - Lysa Switzer
- MemorialCare Medical Group, Long Beach, California, USA
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Osakwe ZT, Liu B, Ankuda CK, Ritchie CS, Leff B, Ornstein KA. The role of restrictive scope-of-practice regulations on the delivery of nurse practitioner-delivered home-based primary care. J Am Geriatr Soc 2023; 71:2256-2263. [PMID: 36855242 PMCID: PMC10363209 DOI: 10.1111/jgs.18300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Nurse practitioners (NPs) are the largest group of providers delivering home-based primary care (HBPC) in the U.S. We examined the association of scope-of-practice regulations and NP-HBPC rates. METHODS Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state-level analysis to examine the impact of scope-of-practice regulations on the utilization of NP-HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341-99,345, 99,347-99,350) and domiciliary settings (99324-99,328, 99,334-99,337). We used linear regression to compare NP-HBPC utilization rates between states of either restricted or reduced scope-of-practice laws to states with full scope-of-practice, adjusting for a number of NP-HBPC providers, state ranking of total assisted living, the proportion of fee-for-service (FFS) Medicare beneficiaries and neighborhood-level socio-economic status and race and ethnicity. RESULTS Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope-of-practice, states with restricted or reduced scope-of-practice had higher adjusted rates of NP-HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP-HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full- scope-of-practice laws, respectively. The rate of NP-HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13-1.72; p = 0.023) and reduced scope-of-practice laws (Beta coefficient = 0.91; 95%CI 0.03-1.79; p = 0.043) compared to states with full scope-of-practice laws. CONCLUSION Restricted state NP scope-of-practice regulations were associated with higher rates of FFS Medicare NP-HBPC care delivery compared with full or reduced scope-of-practice. Understanding underlying mechanisms of how scope-of-practice affects NP-HBPC delivery could help to develop scope-of-practice regulations that improve access to HBPC for the underserved homebound population.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claire K. Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine A. Ornstein
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, MD, USA
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9
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Salahub C, Kiran T, Na Y, Sinha SK, Stall NM, Ivers NM, Costa AP, Jones A, Lapointe-Shaw L. Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study. CMAJ Open 2023; 11:E282-E290. [PMID: 36944429 PMCID: PMC10035667 DOI: 10.9778/cmajo.20220124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits. METHODS This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%). RESULTS A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home. INTERPRETATION A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.
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Affiliation(s)
- Christine Salahub
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Tara Kiran
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Yingbo Na
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Samir K Sinha
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Nathan M Stall
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Noah M Ivers
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Andrew P Costa
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Aaron Jones
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.
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10
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Oseroff BH, Ankuda CK, Bollens-Lund E, Garrido MM, Ornstein KA. Patterns of Healthcare Utilization and Spending Among Homebound Older Adults in the USA: an Observational Study. J Gen Intern Med 2023; 38:1001-1007. [PMID: 35945471 PMCID: PMC9362988 DOI: 10.1007/s11606-022-07742-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/13/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Homebound older adults have complex social, medical, and financial needs, but little is known about their healthcare utilization and spending. OBJECTIVE To characterize healthcare utilization and spending among homebound older adults. DESIGN Cohort study using National Health and Aging Trends Study data linked to Medicare Fee-for-Service (FFS) claims data. PARTICIPANTS Adults aged 70 years and older with Medicare FFS coverage (n = 6468). MAIN MEASURES In a person-year analysis, survey-weighted rates and adjusted marginal differences in inpatient, outpatient, and emergency department utilization and spending 12 months post-interview were calculated by homebound status, defined as reporting never or rarely (no more than 1 day/week) leaving home in the last month. KEY RESULTS Compared to the non-homebound, homebound observations had lower annual unadjusted rates of accessing primary care (60.9% vs 71.9%, p < 0.001) and specialist care (61.0% vs 74.9%, p < 0.001) and higher annual rates of emergency department use (54.0% vs 32.6%, p < 0.001) and hospitalization (39.8% vs 19.8%, p < 0.001). Total annual Medicare spending was $11,346 higher among the homebound compared to the non-homebound (p < 0.001). In a single year analysis (2015), homebound older adults accounted for 11.0% of Medicare spending among those over 70 despite making up only 5.7% of this population. 13.6% of the homebound were in the 95th percentile or above of Medicare spending in 2015. In models adjusting for demographic, clinical, and geographic characteristics, homebound status was associated with a decreased likelihood of having an annual primary care or specialist visit and $2226 additional total annual Medicare spending. CONCLUSIONS Homebound older adults use more hospital-based care and less outpatient care than the non-homebound, contributing to higher levels of overall Medicare spending.
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Affiliation(s)
- Benjamin H Oseroff
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melissa M Garrido
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System Research & Development, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Bowers A, Drake C, Makarkin AE, Monzyk R, Maity B, Telle A. Predicting Patient Mortality for Earlier Palliative Care Identification in Medicare Advantage Plans: Features of a Machine Learning Model. JMIR AI 2023; 2:e42253. [PMID: 38875557 PMCID: PMC11041411 DOI: 10.2196/42253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/21/2022] [Accepted: 12/20/2022] [Indexed: 06/16/2024]
Abstract
BACKGROUND Machine learning (ML) can offer greater precision and sensitivity in predicting Medicare patient end of life and potential need for palliative services compared to provider recommendations alone. However, earlier ML research on older community dwelling Medicare beneficiaries has provided insufficient exploration of key model feature impacts and the role of the social determinants of health. OBJECTIVE This study describes the development of a binary classification ML model predicting 1-year mortality among Medicare Advantage plan members aged ≥65 years (N=318,774) and further examines the top features of the predictive model. METHODS A light gradient-boosted trees model configuration was selected based on 5-fold cross-validation. The model was trained with 80% of cases (n=255,020) using randomized feature generation periods, with 20% (n=63,754) reserved as a holdout for validation. The final algorithm used 907 feature inputs extracted primarily from claims and administrative data capturing patient diagnoses, service utilization, demographics, and census tract-based social determinants index measures. RESULTS The total sample had an actual mortality prevalence of 3.9% in the 2018 outcome period. The final model correctly predicted 44.2% of patient expirations among the top 1% of highest risk members (AUC=0.84; 95% CI 0.83-0.85) versus 24.0% predicted by the model iteration using only age, gender, and select high-risk utilization features (AUC=0.74; 95% CI 0.73-0.74). The most important algorithm features included patient demographics, diagnoses, pharmacy utilization, mean costs, and certain social determinants of health. CONCLUSIONS The final ML model better predicts Medicare Advantage member end of life using a variety of routinely collected data and supports earlier patient identification for palliative care.
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Affiliation(s)
- Anne Bowers
- Evernorth Health, Inc, St. Louis, MO, United States
| | | | | | | | | | - Andrew Telle
- Evernorth Health, Inc, St. Louis, MO, United States
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12
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Boling PA, Kinosian B. The challenge of proving the value of medical care in the home. J Am Geriatr Soc 2023; 71:362-364. [PMID: 36562648 DOI: 10.1111/jgs.18153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/26/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Peter A Boling
- Department of Internal Medicine, Division of Geriatric Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bruce Kinosian
- Division of Geriatrics, Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Federman AD, Brody A, Ritchie CS, Egorova N, Arora A, Lubetsky S, Goswami R, Peralta M, Reckrey JM, Boockvar K, Shah S, Ornstein KA, Leff B, DeCherrie L, Siu AL. Outcomes of home-based primary care for homebound older adults: A randomized clinical trial. J Am Geriatr Soc 2023; 71:443-454. [PMID: 36054295 PMCID: PMC9939556 DOI: 10.1111/jgs.17999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 07/13/2022] [Accepted: 07/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited. METHODS We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients. RESULTS The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p = 0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p = 0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p = 0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001). CONCLUSION HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination.
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Affiliation(s)
- Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abraham Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA
| | - Christine S. Ritchie
- The Mongan Institute and Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Arushi Arora
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Lubetsky
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruchir Goswami
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria Peralta
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jenny M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenneth Boockvar
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
- The New Jewish Home, New York, NY, USA
| | - Shivani Shah
- Visiting Nurse Service of New York, New York, NY, USA
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Linda DeCherrie
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Albert L. Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
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Shih CY, Chen YM, Huang SJ. Survival and characteristics of older adults receiving home-based medical care: A nationwide analysis in Taiwan. J Am Geriatr Soc 2023; 71:1526-1535. [PMID: 36705340 DOI: 10.1111/jgs.18232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/08/2022] [Accepted: 12/18/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND In Taiwan, the National Health Insurance Administration initiated the integrated home-based medical care (iHBMC) program in 2016 to improve accessibility to health care for homebound patients. This study aimed to describe the characteristics of older people receiving iHBMC services in Taiwan as well as the relationship between patient characteristics and survival. METHODS All older adults registered in the iHBMC application dataset were enrolled between March 1, 2016, and December 31, 2018. Data on social determinants of health (income level, residential area), functional status, consciousness status, nasogastric tube or urinary catheter placement, and major diseases were retrieved from the database. Data on the frequency of multidisciplinary team members' visits were collected. The survival rate was investigated using the Kaplan-Meier method. A Cox proportional hazards univariate regression was conducted to analyze factors influencing survival rates. RESULTS A total of 41,079 patients aged ≥65 years were enrolled in iHBMC services. The results showed that the one-year survival rates were 72.1%, 67.4%, and 14.7% in the home-based primary care (HBPC), home-based primary care plus (HBPC-Plus), and home-based palliative care (HBPalC), respectively. Nearly two-thirds of the HBPC-Plus patients underwent nasogastric tube placement. The Cox proportional hazards univariate regression analysis showed that a low urbanization level, a low income level, a low functional status, and an impaired consciousness status were significant predictors of poor survival after adjustment for confounding variables. CONCLUSIONS Older adults receiving iHBMC services had a high mortality rate. The high rate of feeding tube use indicated that education and support for both clinical practitioners and family caregivers regarding careful hand feeding are warranted. There was a relationship between low income levels and poor survival in rural areas. Further research on whether social care could impact prognosis should be considered.
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Affiliation(s)
- Chih-Yuan Shih
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Ya-Mei Chen
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Sheng-Jean Huang
- Department of Surgery, Medical College, National Taiwan University, Taipei, Taiwan
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15
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Scacchi A, Savatteri A, Politano G, Conti A, Dalmasso M, Campagna S, Gianino MM. Impact of the Timing of Integrated Home Palliative Care Enrolment on Emergency Department Visits. Int J Health Policy Manag 2022; 11:2964-2971. [PMID: 35596272 PMCID: PMC10105184 DOI: 10.34172/ijhpm.2022.5783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/30/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The association between timing of integrated home palliative care (IHPC) enrolment and emergency department (ED) visits is still under debate, and no studies investigated the effect of the timing of IHPC enrolment on ED visits, according to their level of emergency. This study aimed to investigate the impact of the timing of IHPC enrolment on different acuity ED visits. METHODS A retrospective, pre-/post-intervention study was conducted from 2013 to 2019 in Italy. Analyses were stratified by IHPC duration (short ≤30 days; medium 31-90 days; long >90 days) and triage tags (white/green: low level of emergency visit; yellow/red: medium-to-high level). The impact of the timing of IHPC enrolment was evaluated in two ways: incidence rate ratios (IRRs) of ED visits were determined (1) before and after IHPC enrolment in each group and (2) post-IHPC among groups. RESULTS A cohort of 17 983 patients was analysed. Patients enrolled early in the IHPC programme had a significantly lower incidence rate of ED visits than the pre-enrolment period (IRR=0.65). The incidence rates of white/green and yellow/red ED visits were significantly lower post-IHPC enrolment for patients enrolled early (IRR=0.63 and 0.67, respectively). All results were statistically significant (P<.001). Comparing the IHPC groups after enrolment versus the short group, medium and long IHPC groups had a significant reduction of ED visits (IRR=0.37, IRR=0.14 respectively), showing a relation between the timing of IHPC enrolment and the incidence of ED visits. A similar trend was observed after accounting for triage tags of ED visits. CONCLUSION The timing of IHPC enrolment is related with a variation of the incidence of ED visits. Early IHPC enrolment is related to a high significant reduction of ED visits when compared to the 90-day pre-IHPC enrolment period and to late IHPC enrolment, accounting for both low-level and medium-to-high level emergency ED visits.
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Affiliation(s)
- Alessandro Scacchi
- Department of Public Health and Paediatrics, University of Turin, Torino, Italy
| | - Armando Savatteri
- Department of Public Health and Paediatrics, University of Turin, Torino, Italy
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Torino, Italy
| | - Alessio Conti
- Department of Public Health and Paediatrics, University of Turin, Torino, Italy
| | - Marco Dalmasso
- Epidemiology Unit, Local Health Unit TO3, Grugliasco, Italy
| | - Sara Campagna
- Department of Public Health and Paediatrics, University of Turin, Torino, Italy
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Bolsoni L, Garcia LP, Calderón DBDL. Predição de visitas domiciliares na atenção primária. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2022. [DOI: 10.5712/rbmfc17(44)3012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Introdução: Espera-se, nos próximos anos, um novo perfil de demanda para o Sistema Único de Saúde em consequência do envelhecimento populacional e do aumento da prevalência de doenças crônicas. Diante disso, faz-se necessário o uso de ferramentas para estimar a demanda futura por serviços. Modelos para a análise de séries temporais como o Autoregressive Integrated Moving Average (ARIMA) podem auxiliar. Objetivo: Estimar a demanda por visitas domiciliares na Atenção Primária à Saúde (APS) do Sistema Único de Saúde, em Florianópolis (SC). Métodos: Estudo ecológico de séries temporais que utilizou o ARIMA para projeções. Adotaram-se as visitas domiciliares realizadas pela APS, registradas do prontuário eletrônico da Secretaria de Saúde do município, de janeiro de 2015 a fevereiro de 2019. As projeções dos 20 meses seguintes foram realizadas para o município e para cada um de seus 49 Centros de Saúde. Resultados: A previsão aponta, em agosto de 2019, a máxima de 702 visitas, seguida de queda para 573 visitas em dezembro de 2019 e posterior recuperação, com estimativa de 632 para outubro de 2020. A previsão para cada Centro de Saúde indicou variações na demanda entre unidades com o mesmo número de equipes de Saúde da Família (ESF), entre 11,3 e 1,3 visitas/ESF, no 20o mês. Conclusões: O ARIMA possibilitou a realização das projeções de visitas domiciliares no município, indicando queda na demanda de visitas domiciliares. O método pode ser de grande valia para a projeção de outras demandas no mesmo município ou em outros que possuam dados de série histórica. Estudos futuros podem expandir a análise nesse sentido, bem como comparar o ARIMA com modelos como a suavização exponencial.
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Quinlan C, McKibbin C, Cuffney C, Brownson R, Brownson C, Clark J, Osvold L. Barriers to Aging in Place for Rural, Institutionalized Older Adults: A Qualitative Exploration. Clin Gerontol 2022; 45:1167-1179. [PMID: 32981469 DOI: 10.1080/07317115.2020.1820651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Although the majority of older adults wish to "age in place" in their communities, rural contexts pose challenges to maintaining long-term independence. The purpose of this study was to develop an understanding of the experiences of rural older adults who live in Skilled Nursing Facilities (SNFs) and thus have not aged in place. By retrospectively analyzing their pre-institution care situation, we aim to generate foundational knowledge on the barriers to aging in place in rural settings. METHODS A series of individual and group interviews was conducted in SNFs across seven rural communities. A grounded, thematic analysis was used to interpret interview findings, and coding was informed by the socio-ecological model (SEM). RESULTS Participants were 32 adults with a mean age of 72 years (SD = 5.7 years) and an average SNF residence of 3.9 years. Two themes emerged as primary barriers to successful aging in place: (1) Caregiver-related support issues and (2) Present focus, or lack of advanced care-planning. CONCLUSIONS Findings suggest the importance of specifically supporting caregivers, to ease burden and allow for increased agency for rural older adults. A lack of access to caregiver supports and other services limits the ability of community-dwelling rural older adults to age in place or plan for the future. CLINICAL IMPLICATIONS Existing networks of rural community resources and innovative solutions should be leveraged to improve access to services for older adults and their informal caregivers.
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Affiliation(s)
- Claire Quinlan
- Aging Division, Department of Health, Cheyenne, Wyoming, USA
| | | | - Cari Cuffney
- Wyoming Department of Family Services, Cheyenne, Wyoming, USA
| | - Ross Brownson
- Division of Public Health Sciences and Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carol Brownson
- Division of Public Health Sciences and Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeff Clark
- Aging Division, Department of Health, Cheyenne, Wyoming, USA
| | - Lisa Osvold
- Aging Division, Department of Health, Cheyenne, Wyoming, USA
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18
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Carlson LC, Pu CT, Mark E, Gao Y, Nussbaum L, Vogeli C. Applying embedded program evaluation for care delivery transformation: An analysis of a home-based urgent care program. Health Sci Rep 2022; 5:e643. [PMID: 36051625 PMCID: PMC9412970 DOI: 10.1002/hsr2.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 04/09/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background In 2014, Mass General Brigham, formerly Partners HealthCare, launched a novel urgent home-based medical care program to provide rapid medical evaluation and treatment to homebound patients and older adults with frailty or limited mobility named the partners mobile observation unit (PMOU) program. Methods We conducted a pragmatic, embedded evaluation assessing the impact of PMOU on postreferral utilization and total medical expenditure (TME). We used propensity weighting and logistic regression to estimate the 30-day adjusted odds ratios (ORs) of emergency department (ED) utilization and inpatient medical hospitalization for patients enrolled in PMOU (891 episodes of care) relative to those who were referred but not enrolled in the program (57 episodes of care) during the period of April 2017 to June 2018. We additionally conducted a difference-in-differences analysis assessing program impact on TME, comparing claims data 30 days pre/post referral. Results Despite positive trends, there were no statistically significant differences between the two groups with regard to postreferral ED visits or hospitalizations, with an OR of 0.83 (p = 0.56) and OR of 0.64 (p = 0.21), respectively. There was no statistically significant difference in pre/post referral TME for intervention relative to control episodes (p = 0.64). In post hoc analysis of control episodes, 75% received care elsewhere within 14 days of referral. Conclusion Although the results suggested positive trends, this analysis of this relatively mature program was unable to identify statistically significant reductions in ED visits, hospitalizations, or TME associated with the PMOU program. Future efforts to build home-based urgent care programs or related programs targeting older adults with frailty or limited mobility should aim to improve patient targeting and identify opportunities to improve program operations and generate meaningful reductions in healthcare utilization and spending.
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Affiliation(s)
- Lucas C. Carlson
- Population Health Management, Mass General BrighamBostonMassachusettsUSA
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Charles T. Pu
- Population Health Management, Mass General BrighamBostonMassachusettsUSA
- Department of MedicineDivision of Palliative Care and Geriatric Medicine, Massachusetts General HospitalBostonMassachusettsUSA
| | - Eden Mark
- Population Health Management, Mass General BrighamBostonMassachusettsUSA
| | - Ya Gao
- Population Health Management, Mass General BrighamBostonMassachusettsUSA
| | - Lisa Nussbaum
- Population Health Management, Mass General BrighamBostonMassachusettsUSA
| | - Christine Vogeli
- Population Health Management, Mass General BrighamBostonMassachusettsUSA
- The Mongan Institute, Massachusetts General HospitalBostonMassachusettsUSA
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19
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Han YH, Yoo SH, Lee SY, Hwang IY, Kim KH, Cho B, Kim MS, Choi W, Kim Y. The Medical Needs and Characteristics of Cancer and Progressive Neurologic Disease Patients Who Use Home-Based Medical Care in Korea: A Retrospective Study for 2011-2020. J Am Med Dir Assoc 2022; 23:1634-1641.e2. [PMID: 35926572 DOI: 10.1016/j.jamda.2022.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/08/2022] [Accepted: 06/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the needs and characteristics of patients with cancer and neurologic disorders requiring home-based medical care (HBMC). DESIGN Retrospective observational study. SETTING AND PARTICIPANTS Patients receiving HBMC on discharge from a tertiary hospital in Korea during 2011-2020. METHODS Patients were classified into 3 disease groups: cancer, progressive neurologic disorders (NR), and others. Characteristics and medical needs were assessed in each disease group. Medical needs were categorized based on functional items requiring support or management at the time of registration: respiratory, feeding, urinary system, drain tube, central catheter, wound, medication, and other. Patients with multiple medical needs were assigned to multiple categories. Patients who used HBMC for more than 3 months were defined as long-term users; their characteristics were evaluated in the same way. RESULTS Of the total 655 patients, 47.0% (308) had cancer and 17.3% (113) were NR patients. Among all patients, 78.8% were partially dependent (44.0%) or completely dependent (34.8%) in daily activities, and there were more dependent patients in the NR group (80.5%) than cancer (26.6%). Patients with cancer needed central catheter management the most (43.5%), followed by wound care (36.7%), feeding support (35.1%), and drain tube management (22.1%). NR patients required feeding support the most (80.5%), followed by respiratory support (43.4%), wound care (41.6%), and urinary system support (19.5%). Of all patients, 30.2% (198) were long-term users (NR, 37.9%; cancer, 35.4%). Long-term users were common among patients who needed respiratory support (59.4%), feeding support (48.75), and urinary system support (34.6%). CONCLUSIONS AND IMPLICATIONS Homebound patients with cancer and progressive neurologic disorders need medical services at home after discharge. Patients who need feeding and respiratory support usually use HBMC for more than 3 months. Further studies are needed to design an optimal HBMC that continuously provides medical services to patients with serious illnesses living at home.
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Affiliation(s)
- Yo Han Han
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - In Young Hwang
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyae Hyung Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Belong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Sun Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Wonho Choi
- Center for Palliative care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yejin Kim
- Center for Palliative care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
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20
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Miller RK, Morgan-Gouveia MD, DeCherrie LV. Medical Training in Home Care Medicine: The Time is Now. J Gen Intern Med 2022; 37:2302-2305. [PMID: 35710677 PMCID: PMC9202974 DOI: 10.1007/s11606-022-07514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/25/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Rachel K Miller
- Division of Geriatric Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, and Geriatrics and Extended Care Program, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
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21
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Sakr-Ashour FA, Wambogo E, Sahyoun NR. Social Relationships, Food Security, Protein Intake, and Hospitalization in Homebound Older Adults: A PATH Analysis. J Nutr Gerontol Geriatr 2022; 41:201-216. [PMID: 35703450 DOI: 10.1080/21551197.2022.2084203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The objective of this study was to measure direct and indirect relationships between food insecurity (FI), protein intake, social relationships, depressive symptoms, and their impact on hospitalization among home-delivered meal (HDM) recipients, compared to controls, using structural equation modeling. The analysis used data from the National Outcomes Evaluation Study (2015-2017) of the OAANSP. HDM recipients' mean usual protein intake was significantly higher than controls, but both groups had mean intakes below recommendations. Eating alone was inversely associated with lower protein intake and greater hospitalizations in controls. FI, prevalent in 25.1% of HDM recipient and 16% of controls, was associated with lower protein intake in both groups. Receiving instrumental social support was directly associated with lesser severity of FI in recipients. and more depressive symptoms only in controls. HDM recipients and controls may be at high risk for protein insufficiency, underscored by high prevalence of FI.
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Affiliation(s)
- Fayrouz A Sakr-Ashour
- School of Sciences & Engineering, Institute of Global Health and Human Ecology, The American University in Cairo, New Cairo, Egypt
| | - Edwina Wambogo
- Department of Nutrition and Food Science, University of Maryland, College Park, Maryland, USA
| | - Nadine R Sahyoun
- Department of Nutrition and Food Science, University of Maryland, College Park, Maryland, USA
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22
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Sun CA, Parslow C, Gray J, Koyfman I, deCardi Hladek M, Han HR. Home-based primary care visits by nurse practitioners. J Am Assoc Nurse Pract 2022; 34:802-812. [PMID: 35439205 PMCID: PMC9175775 DOI: 10.1097/jxx.0000000000000706] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND With rapidly growing numbers of homebound older adults, the need for effective home-based health interventions is increasingly recognized. Advanced practice registered nurses (NPs) are one of the most common providers of home-based primary care. Limited information is available to address the scope and nature of NP-led home-based primary care and associated outcomes. OBJECTIVE To synthesize research evidence of NP visits in home-based primary care. DATA SOURCES Six electronic databases-PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Web of Science, and Scopus-were searched to identify peer-reviewed research articles addressing home-based primary care interventions led by NPs. Independent screening resulted in 17 relevant articles from 14 unique studies to include in the review. CONCLUSIONS Nurse practitioners provided health assessments, education, care planning and coordination primarily by face-to-face home visits. Despite a variability in terms of study design, setting, and sample, NP-led home-based primary care was in general associated with less hospitalization and fewer emergency department visits. Evidence was mixed in relation to patient-reported outcomes such as subjective health, functional status, and symptoms. Costs and patient or caregiver satisfaction were additional outcomes addressed, but the findings were inconsistent. IMPLICATIONS FOR PRACTICE Recent policy changes to authorize NPs to independently assess, diagnose, and order home care services directly affect how NPs approach home-based primary care programs. Our findings support NP-led home-based primary care to decrease consequential health utilization and suggest the need for further evaluating the care models in diverse populations with more patient-reported and caregiver outcomes.
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Affiliation(s)
- Chun-An Sun
- The Johns Hopkins University, School of Nursing, Baltimore, MD
| | - Chad Parslow
- The Johns Hopkins University, School of Nursing, Baltimore, MD
| | - Ja’Lynn Gray
- The Johns Hopkins University, School of Nursing, Baltimore, MD
| | | | | | - Hae-Ra Han
- The Johns Hopkins University, School of Nursing, Baltimore, MD
- The Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
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23
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McNabney MK, Green AR, Burke M, Le ST, Butler D, Chun AK, Elliott DP, Fulton AT, Hyer K, Setters B, Shega JW. Complexities of care: Common components of models of care in geriatrics. J Am Geriatr Soc 2022; 70:1960-1972. [PMID: 35485287 PMCID: PMC9540486 DOI: 10.1111/jgs.17811] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 12/29/2022]
Abstract
As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this “care complexity.” Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.
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Affiliation(s)
| | - Ariel R Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Meg Burke
- Geriatric Medicine Associates, Westminster, Colorado, USA
| | - Stephanie T Le
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dawn Butler
- Indiana University, Indianapolis, Indiana, USA
| | - Audrey K Chun
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Kathryn Hyer
- University of South Florida, Tampa, Florida, USA
| | | | - Joseph W Shega
- University of Central Florida, Gotha, Florida, USA.,VITAS Healthcare, Gotha, Florida, USA
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24
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Nguyen HQ, Haupt EC, Duan L, Hou AC, Wang SE, Mariano JD, Lee JA, McMullen C. Hospital utilisation in home palliative care: caregiver health, preparedness and burden associations. BMJ Support Palliat Care 2022:bmjspcare-2021-003455. [PMID: 35078873 DOI: 10.1136/bmjspcare-2021-003455] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Prior studies show that family caregiver factors influence patient outcomes. The purpose of this analysis was to determine the association between family caregiver self-rated health, perception of preparedness and burden at the time of patient admission to home palliative care (HomePal) with downstream patient hospital utilisation and time to hospice enrolment and death. METHODS Data for this cohort study (n=441) were drawn from a trial testing two models of HomePal. Caregiver self-rated health, preparedness (Preparedness for Caregiving Scale, CPS) and burden (Zarit-12) were measured at admission to HomePal. Caregivers were categorised as having good/very good/excellent or fair/poor health, scoring above or below the CPS median score (23), or having no/mild (0-10), moderate (11-20) or high (>20) burden. Proportional hazard competing risk models assessed the association between caregiver factors with hospital utilisation (emergency department visits, observation and inpatient stays). RESULTS Patients whose caregivers reported poor health and low preparedness received more visits by home health aides and social workers, respectively (both, p<0.05). Adjusted models showed that worse caregiver health (HR: 0.69 (95% CI 0.52 to 0.92), p=0.01), low preparedness (HR: 0.73 (95% CI 0.57 to 0.94), p=0.01) and high burden (HR: 0.77 (95% CI 0.56 to 1.06), p=0.10) were associated with lower risk for hospital utilisation. There were no significant associations between caregiver factors with time to patient enrolment in hospice or death in adjusted models (both, p>0.05). CONCLUSION Prospective studies are needed to understand how greater in-home supports for family caregivers with poor health could help achieve quality palliative care that aligns with families' priorities. TRIAL REGISTRATION NUMBER NCT03694431; ClinicalTrials.gov.
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Affiliation(s)
- Huong Q Nguyen
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Eric C Haupt
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lewei Duan
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Anthony C Hou
- Geriatrics, Palliative and Continuing Care, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Susan E Wang
- Geriatrics, Palliative and Continuing Care, Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
| | - Jeffrey D Mariano
- Geriatrics, Palliative and Continuing Care, Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
| | - Jung-Ah Lee
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
| | - Carmit McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
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25
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Nguyen HQ, Vallejo JD, Macias M, Shiffman MG, Rosen R, Mowry V, Omotunde O, Hong B, Liu ILA, Borson S. A mixed-methods evaluation of home-based primary care in dementia within an integrated system. J Am Geriatr Soc 2021; 70:1136-1146. [PMID: 34936090 DOI: 10.1111/jgs.17627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/07/2021] [Accepted: 12/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND No prior studies have examined the effects of home-based primary care (HBPC) in persons living with dementia (PLWD), within an ecosystem of serious illness care in an integrated healthcare system. Our objectives were to compare the characteristics of PLWD receiving HBPC and their hospital utilization and end-of-life care, with those of a matched comparison group, and to understand the experiences of family caregivers of PLWD receiving HBPC. METHODS This mixed-methods study used a retrospective observational cohort design with PLWD receiving HBPC (n = 287) from 2015 to 2020 and a strata-matched comparison group (n = 861), and qualitative phone interviews with 16 HBPC family caregivers in 2020. Inverse probability of treatment weighting propensity score-adjusted models were used to compare time-to-first hospital-based utilization and, for decedents, home palliative and hospice care and place of death. Care experience was captured through caregiver interviews. RESULTS Patients receiving HBPC had a similar risk of hospital utilization [adjusted hazard ratio, 1.06 (95% CI: 0.89-1.26), p = 0.51] as a matched non-HBPC comparison group after a median follow-up of 199 days. However, HBPC decedents (n = 159) were more likely to receive home palliative care or hospice [rate ratio, RR: 1.23 (95% CI: 1.07-1.42), p < 0.01] and to die at home [RR: 1.66 (95% CI: 1.35-2.05), p < 0.001] than were non-HBPC decedents (n = 423). Caregivers reported that HBPC provided coordinated, continuous, and convenient care that was aligned with families' priorities and goals; however, some expressed unmet needs, especially for help paying for personal care and medical supplies/equipment, and a desire for clearer communication about program operations and more quality oversight for contract services. CONCLUSIONS Although HBPC for PLWD was associated with a similar risk of hospital utilization compared to a matched non-HBPC comparison group, HBPC resulted in more patient-centered end-of-life care for decedents. Prospective studies of HBPC that further elicit and address unmet needs are warranted.
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Affiliation(s)
- Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jessica D Vallejo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Mayra Macias
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Romina Rosen
- Woodland Hills Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Velda Mowry
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Omotayo Omotunde
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Benjamin Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Family Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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26
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Chen T, Zhou R, Yao NA, Wang S. Mental health of homebound older adults in China. Geriatr Nurs 2021; 43:124-129. [PMID: 34864541 DOI: 10.1016/j.gerinurse.2021.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/13/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022]
Abstract
The mental health status of the homebound population in China is relatively overlooked. A sample of 1,301 older adults from Shandong Province was used to compare the mental health status among homebound, semi-homebound, and non-homebound older adults in China, and examine the moderation effects of loneliness and gender. This study found that, controlling for demographic and physical health status, the homebound population was more likely to have worse mental health status than non-homebound older adults. Experiencing loneliness intensified the adverse effects of being homebound on older adults' mental health. The negative effects of being semi-homebound on mental health were more pronounced among older males than females. Findings from this study suggested that homebound older adults in China experienced psychological challenges. Social programs and interventions may be designed to improve this population's mental health.
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Affiliation(s)
- Tao Chen
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Rui Zhou
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Nengliang Aaron Yao
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China; University of Virginia, School of Medicine, Section of Geriatrics; Home Centered Care Institute
| | - Shuangshuang Wang
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China; University of Massachusetts Boston, Gerontology Institute.
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27
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Cooper SA, Szymanski BR, Karel MJ, Katz IR, McCarthy JF. Suicide among Veterans receiving Veterans Health Administration Home Based Primary Care and following discharge from Community Living Centers. Suicide Life Threat Behav 2021; 51:1055-1066. [PMID: 34333781 DOI: 10.1111/sltb.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/16/2020] [Accepted: 04/14/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Veterans who receive Veterans Health Administration (VHA) Home Based Primary Care (HBPC) services and those discharged from VHA Community Living Centers (CLC) may be at increased risk of suicide. No studies to date have assessed suicide risks among HBPC patients. This study examined suicide risks among recipients of VHA HBPC services and following discharge from VHA CLCs, as compared to other Veteran VHA users. METHODS We identified three cohorts of 2013 Veteran VHA patients: 47,842 HBPC users, 17,725 with live discharges from CLCs, and 5,554,635 other VHA users. Using proportional hazards regression, we assessed risk of suicide through 2016. RESULTS Overall, HBPC recipients did not differ from the other cohorts in suicide risk. Although in unadjusted analyses CLC discharged patients had greater suicide risk than the general VHA patient cohort (hazard ratio (HR) = 1.73, 95% confidence interval = 1.25-2.41), this became nonsignificant when controlling for diagnoses. CONCLUSIONS Overall findings did not identify differential suicide risk among VHA HBPC recipients in 2013, when compared to other Veteran VHA patient cohorts. Veterans discharged from VHA CLCs have increased mental health morbidity, which was associated with increased suicide risk.
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Affiliation(s)
- Samantha A Cooper
- US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA
| | - Benjamin R Szymanski
- US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA
| | - Michele J Karel
- US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Washington, DC, USA
| | - Ira R Katz
- US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - John F McCarthy
- US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA
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28
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Huded JM, Lee A, Song S, McQuown CM, Wilson BM, Smith TI, Bonomo RA. Association of a geriatric emergency department program with healthcare outcomes among veterans. J Am Geriatr Soc 2021; 70:601-608. [PMID: 34820827 DOI: 10.1111/jgs.17572] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. METHODS In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N = 725) and a matched control group (n = 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. RESULTS In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p < 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p < 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p < 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p < 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n = 57.5%], p = 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p = 0.004) without increasing ED length of stay (5.4 ± 2.2 vs. 5.4 ± 2.6 h, p = 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p = 0.25) in the GERI-VET group. CONCLUSIONS A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.
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Affiliation(s)
- Jill M Huded
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Albert Lee
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Sunah Song
- Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.,Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Colleen M McQuown
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Todd I Smith
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert A Bonomo
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Coleman Z. The value of pharmacists within and beyond value-based care. J Am Pharm Assoc (2003) 2021. [DOI: 10.1016/j.japh.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Osei-Poku G, Szczerepa O, Potter A, Malone M, Fain B, Prentice J. Safety Trade-Offs in Home Care During COVID-19: A Mixed Methods Study Capturing the Perspective of Frontline Workers. PATIENT SAFETY 2021. [DOI: 10.33940/infection/2021.9.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Home care workers help older individuals and those with disabilities with a variety of functional tasks. Despite their core role providing essential care to vulnerable populations, home care workers are often an invisible sector of the healthcare workforce. The transmission of COVID-19 and the nature of home care work raise several questions about the overall safety of these workers during the pandemic.
Objective: To examine the experiences of home care workers during COVID-19, particularly their access to information about infection status, to testing, and to personal protective equipment (PPE); their understanding of guidelines; and trade-offs associated with protecting workers’ safety.
Methods: A mixed methods study including qualitative analysis of guided discussion questions and quantitative analysis of multiple-choice survey questions was conducted. Eleven virtual focus groups in October and November 2020 involved 83 home care workers who care for clients/consumers in Massachusetts. Thirty-nine participants worked as personal care attendants (PCAs) employed directly by a consumer and 44 participants worked for an agency. Ninety percent self-identified as female and 54% had worked in home care for more than five years. Qualitative data was analyzed using thematic analysis, with identification of major and minor themes. Likert scale survey question data on perceptions of COVID-19 exposure, access to resources to prevent transmission, and perceptions of safety at work were dichotomized into agree or disagree.
Results: PCAs and agency-employed home care workers were regularly faced with trade-offs between meeting client/consumer needs and protecting themselves from COVID-19 exposure. Twenty-five percent of participants reported serving a client/consumer who had COVID-19, 75% reported worrying about getting COVID-19 at work, and 29% reported thinking about stopping their work in home care. Despite a low pay structure, participants reported opting to risk exposure rather than to leave their clients/consumers without essential care. However, workers often lacked the resources (e.g., PPE, testing) to feel truly protected. This scarcity of resources combined with insufficient guidance and policies specific to home care settings led many workers to informally collaborate with clients/consumers to assess exposure risks and agree upon safety protocols. Focus group participants expressed uncertainty as to whether workers were truly empowered to ask for changes if conditions seemed unsafe. The burden of determining safety protocols was felt more strongly by PCAs who operate more independently than agency-employed workers who have supervisors to consult.
Conclusions: Home care workers expressed deep commitment to continuing to care for their clients/consumers during COVID-19, but often had to operate with insufficient resources and under conditions that made their work environments feel unsafe. Their ability to identify exposure risks and make decisions on how to protect themselves often hinged on a transparent and trusting relationship with their clients/consumers. These relationships were particularly important for PCAs who did not have access to safety guidance from a home care agency.
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Gorbenko K, Franzosa E, Masse S, Brody AA, Sheehan O, Kinosian B, Ritchie CS, Leff B, Ripp J, Ornstein KA, Federman AD. "I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York. Home Health Care Serv Q 2021; 40:1-15. [PMID: 34301160 PMCID: PMC8783921 DOI: 10.1080/01621424.2021.1935383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.
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Affiliation(s)
- Ksenia Gorbenko
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute of Health Care Delivery Science, Mount Sinai Health System, New York, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
| | - Sybil Masse
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Orla Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Ripp
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Zimbroff RM, Ornstein KA, Sheehan OC. Home-based primary care: A systematic review of the literature, 2010-2020. J Am Geriatr Soc 2021; 69:2963-2972. [PMID: 34247383 DOI: 10.1111/jgs.17365] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although more than seven million older adults struggle or are unable to leave their homes independently, only a small minority access home-based primary care (HBPC). Despite substantial growth of HBPC, fueled by growing evidence supporting positive patient outcomes and cost savings, the population remains dramatically underserved and many evidence gaps still exist around scope of practice and key issues in care delivery and quality. Understanding the current state of the field is critical to the delivery of high-quality home-based care. METHODS We conducted a systematic search of the peer-reviewed literature on HBPC, published between January 2010 and January 2020, using Medline, CINAHL, Embase, Web of Science, and Scopus online libraries. All studies were evaluated by two members of the research team, and key findings were extracted. RESULTS The initial search yielded 1730 unique studies for screening. Of these initial results, 1322 were deemed not relevant to this review. Of the 408 studies deemed potentially relevant, 79 were included in the study. Researchers identified five overarching themes: the provision of HBPC, the composition of care teams, HBPC outcomes, the role of telehealth, and emergency preparedness efforts. CONCLUSION The need and desire for growth of HBPC has been highlighted by the recent COVID-19 pandemic. Current research on HBPC finds a diverse scope of practice, successful use of interdisciplinary teams, positive outcomes, and increasing interest in telehealth with many areas ripe for further research.
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Affiliation(s)
- Robert M Zimbroff
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Sheehan OC, Federman AD, Ornstein KA. "There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19. J Appl Gerontol 2021; 40:1417-1424. [PMID: 34210200 DOI: 10.1177/07334648211028393] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.
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Affiliation(s)
- Emily Franzosa
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters VA Medical Center, Bronx, NY, USA
| | | | | | - Bruce Leff
- Johns Hopkins University, Baltimore, MD, USA
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Pharmacist medication review: An integrated team approach to serve home-based primary care patients. PLoS One 2021; 16:e0252151. [PMID: 34033661 PMCID: PMC8148331 DOI: 10.1371/journal.pone.0252151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/11/2021] [Indexed: 11/19/2022] Open
Abstract
Background Comprehensive medication review is a patient-centered approach to optimize medication use and improve patient outcomes. This study outlines a pilot model of care in which a remote corporate-based clinical pharmacist implemented comprehensive medication reviews for a cohort of medically complex home-based primary care (HBPC) patients. Method Ninety-six medically complex patients were assessed for medication-related problems. Data collected on these patients were: number of chronic conditions, number of medications, appropriate indication for each medication, dose appropriateness, drug interactions, recommendations for medication optimization and deprescribing. The number of accepted recommendations by the HBPC practice was analyzed. Results On average, the patients were 82 years old and had 13 chronic conditions. They were taking a median of 17 medications. Over a four-month pilot period, 175 medication recommendations were made, and 53 (30.3%) of them were accepted, with most common being medication discontinuation, deprescribing, and dose adjustments. Sixty-four (66.7%) patients were on a medication listed as potentially inappropriate for use in older adults. The most common potentially inappropriate medication was a proton-pump inhibitor (38.5%), followed by aspirin (24%), tramadol (15.6%), a benzodiazepine (13.5%) or an opioid (8.3%). Eighty-one medications were recommended for deprescribing and 27 medications were discontinued (33.3%). There were 24 recommended dose adjustments and 11 medications were dose adjusted (45.8%). Thirty-four medications were suggested as an addition to the current patient regimen, 2 medications were added (5.9%). Conclusion Pharmacist comprehensive medication review is a necessary component of the HBPC healthcare continuum. Additional research is needed to examine whether aligning pharmacists to deliver support to HBPC improves clinical outcomes, reduces healthcare expenditures and improves the patient’s experience.
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Zhou R, Cheng J, Wang S, Yao N. A qualitative study of home health care experiences among Chinese homebound adults. BMC Geriatr 2021; 21:309. [PMID: 33985442 PMCID: PMC8117649 DOI: 10.1186/s12877-021-02258-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Home health care services (HHC) are emerging in China to meet increased healthcare needs among the homebound population, but there is a lack of research examining the efficiency and effectiveness of this new care model. This study aimed to investigate care recipients' experiences with HHC and areas for improvement in China. METHODS This research was a qualitative study based on semi-structured interviews. Qualitative data were collected from homebound adults living in Jinan, Zhangqiu, and Shanghai, China. A sample of 17 homebound participants aged 45 or older (mean age = 76) who have received home-based health care were recruited. Conceptual content analysis and Colaizzi's method was used to generate qualitative codes and identify themes. RESULTS The evaluations of participants' experiences with HHC yielded both positive and negative aspects. Positive experiences included: 1) the healthcare delivery method was convenient for homebound older adults; 2) health problems could be detected in a timely manner because clinicians visited regularly; 3) home care providers had better bedside manners and technical skills than did hospital-based providers; 4) medical insurance typically covered the cost of home care services. Areas that could potentially be improved included: 1) the scope of HHC services was too limited to meet all the needs of homebound older adults; 2) the visit time was too short; 3) healthcare providers' technical skills varied greatly. CONCLUSIONS Findings from this study suggested that the HHC model benefited Chinese older adults-primarily homebound adults-in terms of convenience and affordability. There are opportunities to expand the scope of home health care services and improve the quality of care. Policymakers should consider providing more resources and incentives to enhance HHC in China. Educational programs may be created to train more HHC providers and improve their technical skills.
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Affiliation(s)
- Rui Zhou
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Rd, Jinan, 250012, Shandong, China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012, China
| | - Joyce Cheng
- University of Virginia, College of Arts and Sciences, Charlottesville, VA, USA
| | - Shuangshuang Wang
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Rd, Jinan, 250012, Shandong, China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012, China.,Department of Gerontology, University of Massachusetts Boston, Boston, MA, USA
| | - Nengliang Yao
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Rd, Jinan, 250012, Shandong, China. .,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012, China. .,School of Medicine, University of Virginia, Charlottesville, VA, USA. .,Home Centered Care Institute, Schaumburg, Chicago, IL, USA.
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Chan CS, Davis D, Cooper D, Edes T, Phibbs CS, Intrator O, Kinosian B. VA home-based primary care interdisciplinary team structure varies with Veterans' needs, aligns with PACE regulation. J Am Geriatr Soc 2021; 69:1729-1737. [PMID: 33834504 DOI: 10.1111/jgs.17174] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically complex and functionally impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs. DESIGN Cross-sectional analysis. SETTING All 139 VA HBPC programs administered across 379 sites. PARTICIPANTS About 55,173 Veterans enrolled in HBPC during fiscal year 2018. MEASUREMENTS Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk. RESULTS HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X2 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p < 0.0001). CONCLUSION There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.
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Affiliation(s)
- Caitlin S Chan
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Economics Resource Center (HERC), Menlo Park, California, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Darlene Davis
- Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Dayna Cooper
- Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Thomas Edes
- Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Ciaran S Phibbs
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Economics Resource Center (HERC), Menlo Park, California, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA.,Stanford University, Stanford, California, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA.,University of Rochester, Rochester, New York, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA.,Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania, USA.,Cpl. Michael J Crescenz VA Medical Center (Philadelphia), Philadelphia, Pennsylvania, USA.,University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Reckrey JM, Yang M, Kinosian B, Bollens-Lund E, Leff B, Ritchie C, Ornstein K. Receipt Of Home-Based Medical Care Among Older Beneficiaries Enrolled In Fee-For-Service Medicare. Health Aff (Millwood) 2021; 39:1289-1296. [PMID: 32744949 DOI: 10.1377/hlthaff.2019.01537] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Millions of older Americans are homebound and may benefit from home-based medical care. We characterized the receipt of this care among community-dwelling, fee-for-service Medicare beneficiaries ages sixty-five and older surveyed in the National Health and Aging Trends Study between 2011 and 2017. Five percent of those surveyed received any home-based medical care between 2011 and 2017 (mean follow-up time per person was 3.4 years), and 75 percent of home-based medical care recipients were homebound. Only 11 percent of the total homebound population (approximately 4.4 million fee-for-service Medicare beneficiaries in 2017) received any home-based medical care between 2011 and 2017. Receipt of home-based medical care was more common among homebound beneficiaries living in metropolitan areas and assisted living facilities, which suggests that geographic factors create operational efficiencies for home-based medical care practices that may improve their financial sustainability within the fee-for-service reimbursement setting. The significant unmet needs of this high-need, high-cost population and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care.
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Affiliation(s)
- Jennifer M Reckrey
- Jennifer M. Reckrey is an associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, in New York, New York
| | - Mia Yang
- Mia Yang is an assistant professor of internal medicine and geriatrics and gerontology at the Wake Forest University School of Medicine, in Winston-Salem, North Carolina
| | - Bruce Kinosian
- Bruce Kinosian is an associate professor of geriatrics at the University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Evan Bollens-Lund
- Evan Bollens-Lund is a data analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Bruce Leff
- Bruce Leff is a professor of medicine in the Division of Geriatric Medicine at Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Christine Ritchie
- Christine Ritchie is a professor of palliative care and geriatric medicine at Massachusetts General Hospital, in Boston, Massachusetts
| | - Katherine Ornstein
- Katherine Ornstein is an associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai
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Osakwe ZT, Kim RS, Obioha CU, Osborne JC, Harun N, Saint Fleur-Calixte R. Impact of state scope-of-practice laws on nurse practitioner-provided home visits. Geriatr Nurs 2021; 42:674-680. [PMID: 33823425 DOI: 10.1016/j.gerinurse.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/01/2022]
Abstract
Millions of older Americans receive nurse practitioner (NP)-provided home based primary care (HBPC). Little is known about how state scope-of- practice (SOP) laws may impact use of NP-home visits. Using 2017 Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File (PUF), we examined the impact of state SOP laws on the use of NP-home visits. The PUF file was merged with the 2017 American Community Survey to assess area-level median income. Over 4.4 million home visits were provided to 1.6 million Medicare beneficiaries. NPs represented the largest share of providers (47.5%). In states with restricted SOP laws, compared to NPs, physicians and physician assistants had higher odds of providing HBPC. In states with reduced SOP laws, compared to NPs, physicians and PAs had decreased odds of providing HBPC. Our study provides evidence that SOP restrictions are associated with decreased utilization of NP-provided HBPC.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health at Adelphi University, 1 South Avenue, Garden City, NY, 11530, United States.
| | - Ryung S Kim
- Department of Epidemiology and Population, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States.
| | - Chinedu U Obioha
- College of Nursing and Public Health at Adelphi University, 1 South Avenue, Garden City, NY, 11530, United States.
| | - Jennel C Osborne
- Harriet Rothkopf Heilbrunn School of Nursing, Long Island University, 1 University Plaza, Brooklyn, NY 11201-5372, United States.
| | - Nafin Harun
- Center for Health workforce Studies, School of Public Health, University of Albany, SUNY, 1 University Place, Ste 220/Rensselaer, NY 12144, United States.
| | - Rose Saint Fleur-Calixte
- Department of Community Health and Social Medicine, CUNY School of Medicine, Townsend Harris Hall, Suite 313, 160 Covent Avenue, NY 10031, United States.
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Ankuda CK, Husain M, Bollens-Lund E, Leff B, Ritchie CS, Liu SH, Ornstein KA. The dynamics of being homebound over time: A prospective study of Medicare beneficiaries, 2012-2018. J Am Geriatr Soc 2021; 69:1609-1616. [PMID: 33683707 PMCID: PMC8192419 DOI: 10.1111/jgs.17086] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/01/2021] [Accepted: 02/06/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Approximately 2 million people, or 6% of older adults in the United States, are homebound. In cross-sectional studies, homebound older adults have high levels of morbidity and mortality, but there is little evidence of longitudinal outcomes after becoming homebound. The aim of this research is to prospectively assess over 6 years the dynamics of homebound status, ongoing community residence, and death in a population of community-dwelling older adults who are newly homebound. DESIGN/SETTING Prospective cohort study using 2011-2018 data from the National Health and Aging Trends Study (NHATS), an annual, nationally-representative longitudinal study of aging in the United States. PARTICIPANTS Two hundred and sixty seven newly homebound older adults in 2012. MEASUREMENTS Homebound status was defined via self-report as living in the community but rarely/never leaving home in the prior month. Semi-homebound was defined as leaving the house only with difficulty or help. RESULTS One year after becoming newly homebound, 33.1% remained homebound, 22.8% were completely independent, 23.8% were semi-homebound, 2.2% were in a nursing home, and 18.0% died. Homebound status is highly dynamic; 6 years after becoming homebound, 13.5% remained homebound and 65.0% had died. Recovering from being homebound at 1 year was associated with younger age and lower baseline rates of receiving help with activities of daily living, in particular, with bathing. CONCLUSION Homebound status is a dynamic state. Even if transient, becoming homebound is strongly associated with functional decline and death. Identifying newly homebound older adults and developing interventions to mitigate associated negative consequences needs to be prioritized.
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Affiliation(s)
- Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Mohammed Husain
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Bruce Leff
- The Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shelley H Liu
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
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Yao N, Mutter JB, Berry JD, Yamanaka T, Mohess DT, Cornwell T. In Traditional Medicare, Modest Growth In The Home Care Workforce Largely Driven By Nurse Practitioners. Health Aff (Millwood) 2021; 40:478-486. [PMID: 33646879 DOI: 10.1377/hlthaff.2020.00671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Little is known about the characteristics of the workforce providing home-based medical care for traditional (fee-for-service) Medicare beneficiaries. We found that the number of participating home care providers in traditional Medicare increased from about 14,100 in 2012 to around 16,600 in 2016. Approximately 4,000 providers joined or reentered that workforce annually, and 3,000 stopped or paused participation. The number of home visits that most participants provided each year remained below 200. Only 0.7 percent of physicians in Medicare provided fifty or more home visits annually, with little change over the course of five years. In contrast, the number of home-visiting nurse practitioners almost doubled, and the average number of home visits they made increased each year. Despite generally low overall participation of traditional Medicare providers in home-based care, the workforce has seen modest but steady growth, driven primarily by increasing nurse practitioner participation. Additional stimuli may be necessary to ensure workforce adequacy and stability.
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Affiliation(s)
- Nengliang Yao
- Nengliang (Aaron) Yao is the Cheeloo Scholar Professor in Healthcare Management and Nursing at Shandong University, in Jinan, Shandong, China. He is also the part-time research director of the Home Centered Care Institute, in Schaumburg, Illinois, and a part-time research scientist for the Section of Geriatric Medicine at the University of Virginia, in Charlottesville, Virginia
| | - Justin B Mutter
- Justin B. Mutter is section head of geriatric medicine at the University of Virginia School of Medicine and a fellow at the Institute for Advanced Studies in Culture, University of Virginia
| | - James D Berry
- James D. Berry is the chief of the Division of ALS and Motor Neuron Diseases and director of the Neurological Clinical Research Institute at Massachusetts General Hospital, in Boston, Massachusetts
| | - Takashi Yamanaka
- Takashi Yamanaka is the chair of the Department of Home Care Medicine at the University of Tokyo, in Bunkyo City, Tokyo, Japan
| | - Denise T Mohess
- Denise T. Mohess is the medical director and section chief of Geriatrics in the Inova Health System, in Fairfax, Virginia
| | - Thomas Cornwell
- Thomas Cornwell is the executive chairman of the Home Centered Care Institute and is the senior medical director of Village Medical at Home, in Chicago, Illinois
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41
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Mah JC, Stevens SJ, Keefe JM, Rockwood K, Andrew MK. Social factors influencing utilization of home care in community-dwelling older adults: a scoping review. BMC Geriatr 2021; 21:145. [PMID: 33639856 PMCID: PMC7912889 DOI: 10.1186/s12877-021-02069-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/01/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Older adults want to live at home as long as possible, even in the face of circumstances that limit their autonomy. Home care services reflect this emergent preference, allowing older adults to 'age in place' in familiar settings rather than receiving care for chronic health conditions or ageing needs in an institutionalized setting. Numerous social factors, generally studied in isolation, have been associated with home care utilization. Even so, social circumstances are complex and how these factors collectively influence home care use patterns remains unclear. OBJECTIVES To provide a broad and comprehensive overview of the social factors influencing home care utilization; and to evaluate the influence of discrete social factors on patterns of home care utilization in community-dwelling older adults in high-income countries. METHODS A scoping review was conducted of six electronic databases for records published between 2010 and 2020; additional records were obtained from hand searching review articles, reference lists of included studies and documents from international organisations. A narrative synthesis was presented, complemented by vote counting per social factor, harvest plots and an evaluation of aggregated findings to determine consistency across studies. RESULTS A total of 2,365 records were identified, of which 66 met inclusion criteria. There were 35 discrete social factors grouped into four levels of influence using a socio-ecological model (individual, relationship, community and societal levels) and grouped according to outcome of interest (home care propensity and intensity). Across all studies, social factors consistently showing any association (positive, negative, or equivocal in pattern) with home care propensity were: age, ethnicity/race, self-assessed health, insurance, housing ownership, housing problems, marital status, household income, children, informal caregiving, social networks and urban/rural area. Age, education, personal finances, living arrangements and housing ownership were associated with home care intensity, also with variable patterns in utilization. Additional community and societal level factors were identified as relevant but lacking consistency across the literature; these included rurality, availability of community services, methods of financing home care systems, and cultural determinants. CONCLUSION This is the first literature review bringing together a wide range of reported social factors that influence home care utilization. It confirms social factors do influence home care utilization in complex interactions, distinguishes level of influences at which these factors affect patterns of use and discusses policy implications for home care reform.
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Affiliation(s)
- Jasmine C Mah
- Department of Health Policy, London School of Economics and Political Sciences, London, UK.
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.
| | - Susan J Stevens
- Faculty of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada
- Continuing Care, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Janice M Keefe
- Faculty of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Melissa K Andrew
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
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Shrank WH, DeParle NA, Gottlieb S, Jain SH, Orszag P, Powers BW, Wilensky GR. Health Costs And Financing: Challenges And Strategies For A New Administration. Health Aff (Millwood) 2021; 40:235-242. [DOI: 10.1377/hlthaff.2020.01560] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- William H. Shrank
- William H. Shrank is chief medical and corporate affairs officer of Humana in Louisville, Kentucky
| | - Nancy-Ann DeParle
- Nancy-Ann DeParle is a managing partner and cofounder of Consonance Capital Partners, in New York, New York
| | - Scott Gottlieb
- Scott Gottlieb is a resident fellow at the American Enterprise Institute, in Washington, D.C
| | - Sachin H. Jain
- Sachin H. Jain is president and CEO of the SCAN Group and Health Plan and an adjunct professor of medicine, Stanford University School of Medicine, in Stanford, California
| | - Peter Orszag
- Peter Orszag is the CEO of Financial Advisory at Lazard Freres and Co., LLC, in New York, New York
| | - Brian W. Powers
- Brian W. Powers is deputy chief medical officer at Humana in Boston, Massachusetts
| | - Gail R. Wilensky
- Gail R. Wilensky is a senior fellow at Project HOPE, in Bethesda, Maryland
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43
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Manheim C, Haverhals L, Gilman C, Karuza J, Olsan T, Edwards S, Levy C, Gillespie S. VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans. Home Health Care Serv Q 2021; 40:1-15. [PMID: 33411588 DOI: 10.1080/01621424.2020.1869634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.
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Affiliation(s)
- C Manheim
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA
| | - L Haverhals
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA
| | - C Gilman
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA
| | - J Karuza
- Geriatrics, Extended Care and Rehabilitation, Canandaigua VA Medical Center , Canandaigua, New York, USA.,Division of Geriatrics/Aging, Department of Medicine, University of Rochester School of Medicine , Rochester, New York, USA.,Department of Psychology, S.U.N.Y at Buffalo State , Buffalo, New York, USA
| | - T Olsan
- Geriatrics, Extended Care and Rehabilitation, Canandaigua VA Medical Center , Canandaigua, New York, USA.,School of Nursing, University of Rochester , Rochester, New York, USA
| | - S Edwards
- Section of General Internal Medicine, Portland VA Medical Center , Portland, Oregon, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health and Science University , Portland, Oregon, USA
| | - C Levy
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA.,Department of Medicine, Division of Health Care Policy and Research, Anschutz Medical Campus, School of Medicine, University of Colorado , Aurora, Colorado, USA
| | - S Gillespie
- Geriatrics, Extended Care and Rehabilitation, Canandaigua VA Medical Center , Canandaigua, New York, USA.,Division of Geriatrics/Aging, Department of Medicine, University of Rochester School of Medicine , Rochester, New York, USA
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44
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Zimbroff RM, Ritchie CS, Leff B, Sheehan OC. Home-Based Primary and Palliative Care in the Medicaid Program: Systematic Review of the Literature. J Am Geriatr Soc 2021; 69:245-254. [PMID: 32959375 PMCID: PMC11208066 DOI: 10.1111/jgs.16837] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries. DESIGN A systematic review of the peer-reviewed and gray literature of home-based primary care and palliative care programs among Medicaid beneficiaries including dual eligibles. SETTING HBMC including home-based primary care and palliative care programs. PARTICIPANTS Studies describing Medicaid beneficiaries receiving HBMC. MEASUREMENTS Three groups of studies were included: those focused on HBMC specifically for Medicaid beneficiaries, studies that described the proportion of Medicaid patients receiving HBMC, and those that used Medicaid status as a dependent variable in studying HBMC. RESULTS The peer-reviewed and gray literature searches revealed 574 unique studies of which only 16 met inclusion criteria. Few publications described HBMC as an integral care delivery model for Medicaid programs. Data from the programs described suggest the use of HBMC for Medicaid beneficiaries can reduce healthcare costs. The addition of social supports to HBMC appears to convey additional savings and benefits. CONCLUSION This systematic literature review highlights the relative dearth of literature regarding the use and impact of HBMC in the Medicaid population. HBMC has great potential to reduce Medicaid costs, and innovative programs combining HBMC with social support systems need to be tested.
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Affiliation(s)
- Robert M. Zimbroff
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Orla C. Sheehan
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Geriatric Medicine and Gerontology, Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
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45
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Fessler EB, Soriano T, Whitehouse CR, Miller RK. Home-Based Medical Care: High-Value Health Care During Coronavirus Disease 2019 and Beyond. J Am Geriatr Soc 2020; 69:289-292. [PMID: 33283263 DOI: 10.1111/jgs.16967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/26/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
Ms. H is a 78-year-old woman with a history of congestive heart failure, chronic obstructive pulmonary disease, and recent stroke who was discharged 1 month ago from a subacute rehabilitation facility. She moved in with her son because she now requires a walker and cannot return to her third-floor apartment. One evening, Ms. H develops a low-grade fever and mild shortness of breath intermittently relieved by her albuterol inhaler. Her son is worried, but knows that his mom does not want to return to the hospital.
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Affiliation(s)
- Emily B Fessler
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Geriatrics and Extended Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Theresa Soriano
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina R Whitehouse
- Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania, USA
| | - Rachel K Miller
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Geriatrics and Extended Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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46
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Liao JY, Chen PJ, Wu YL, Cheng CH, Yu SJ, Huang CH, Li CM, Wang YW, Zhang KP, Liu IT, Umegaki H, Hamano J, Mori M, Petersen I, Sampson EL, Hsiung CA. HOme-based Longitudinal Investigation of the multidiSciplinary Team Integrated Care (HOLISTIC): protocol of a prospective nationwide cohort study. BMC Geriatr 2020; 20:511. [PMID: 33246407 PMCID: PMC7694342 DOI: 10.1186/s12877-020-01920-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/18/2020] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The use of home health care (HHC) is increasing worldwide. This may have an impact not only on patients and their caregivers' health but on care resource utilization and costs. We lack information on the impact of HHC on the broader dimensions of health status and care resource utilization. More understanding of the longitudinal HHC impact on HHC patients and caregivers is also needed. Moreover, we know little about the synergy between HHC and social care. Therefore, the present study aims to observe longitudinal changes in health, care resource utilization and costs and caregiving burden among HHC recipients and their caregivers in Taiwan. METHODS A prospective cohort study "Home-based Longitudinal Investigation of the Multidisciplinary Team Integrated Care (HOLISTIC)" will be conducted and 600 eligible patient-caregiver dyads will be recruited and followed with comprehensive quantitative assessments during six home investigations over two years. The measurements include physical function, psychological health, cognitive function, wellbeing, shared decision making and advance care planning, palliative care and quality of dying, caregiving burden, continuity and coordination of care, care resource utilization, and costs. DISCUSSION The HOLISTIC study offers the opportunity to comprehensively understand longitudinal changes in health conditions, care resource utilization and costs and caregiving burden among HHC patients and caregivers. It will provide new insights for clinical practitioners and policymakers. TRIAL REGISTRATION ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.
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Affiliation(s)
- Jung-Yu Liao
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, 350, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, 807, Taiwan.
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, 807, Taiwan.
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, W1T 7NF, UK.
| | - Yu-Lin Wu
- Department of Nursing, St. Mary's Junior College of Medicine, Nursing and Management, Yilan County, 266, Taiwan
| | - Ching-Hsia Cheng
- Department of Social Welfare, National Chung-Cheng University, Chiayi County, 621, Taiwan
| | - Sang-Ju Yu
- Home Clinic Dulan, Taitung County, 959, Taiwan
| | - Chi-Hsien Huang
- Department of Community Healthcare and Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Aichi Prefecture, 466-8550, Japan
- Department of Family Medicine, E-Da Hospital, Kaohsiung City, 824, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, 840, Taiwan
| | - Chia-Ming Li
- Department of Family Medicine, National Taiwan University Hospital, Beihu Branch, Taipei City, 108, Taiwan
| | - Ying-Wei Wang
- Health Promotion Administration, Ministry of Health and Welfare, Taipei City, 103, Taiwan
| | | | - I-Te Liu
- Taiwan Society of Home Health Care, Taipei City, 106, Taiwan
| | - Hiroyuki Umegaki
- Department of Community Healthcare and Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Aichi Prefecture, 466-8550, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Shizuoka, 433-8558, Japan
| | - Irene Petersen
- UCL Department of Primary Care and Population Sciences, University College London, London, NW3 2PF, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, W1T 7NF, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Chao A Hsiung
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, 350, Taiwan
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47
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Takahashi PY, Leppin AL, Hanson GJ. Hospital to Community Transitions for Older Adults: An Update for the Practicing Clinician. Mayo Clin Proc 2020; 95:2253-2262. [PMID: 32736941 DOI: 10.1016/j.mayocp.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 01/16/2020] [Accepted: 02/04/2020] [Indexed: 01/17/2023]
Abstract
Spurred by changes in both population demographics and health care reimbursement, health care providers are responding by using new models to more fully support the posthospital transition. This paper reviews common models for posthospital transition and also describes the Mayo Clinic model for care transition. Models are designed with the intent of managing the cost of health care by reducing 30-day hospital readmissions and improving management of chronic disease. Meta-analyses have proved helpful in identifying the most effective program elements designed to reduce 30-day hospital readmissions. These elements include a bundled and multidisciplinary approach to best meet the needs of patients. Successful care teams also emphasize self-empowerment for both patients and caregivers. There are 2 general types of practice. In 1 model, introduced by Mary Naylor, an advanced-practice provider cares for the patient for a set period of time, which includes home visits. In the second model, introduced by Eric Coleman, a transitions coach, who can be an RN, a social worker, or a trained volunteer, serves as the health care coach, while improving self-efficacy. Both models have been successful. At Mayo Clinic, the Mayo Clinic Care Transitions program has encompassed a 7-year experience, using the services of an advanced practice provider. In previous studies, this model demonstrated a 20.1% (95% confidence interval [CI], 15.8 to 24.1%) decrease in 30-day readmission in controls compared with 12.4% (95% CI, 8.9 to 15.7%) in the control group. Although this model was successful in reducing 30-day readmissions, there was no difference between groups at 180 days. In patients experiencing the highest deciles of cost (8th decile), enrollment in a care transitions program reduced their overall cost by $2700. This cost savings was statistically significant. Both patients and caregivers participating in the program appreciated the home visits and felt more comfortable communicating at home.
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Affiliation(s)
- Paul Y Takahashi
- Division of Community Internal Medicine and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN; Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN.
| | - Aaron L Leppin
- Division of Health Care Policy and Research, Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Gregory J Hanson
- Division of Community Internal Medicine and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN; Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN
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Johnston KJ, Joynt Maddox KE. The Role Of Social, Cognitive, And Functional Risk Factors In Medicare Spending For Dual And Nondual Enrollees. Health Aff (Millwood) 2020; 38:569-576. [PMID: 30933581 DOI: 10.1377/hlthaff.2018.05032] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Centers for Medicare and Medicaid Services is increasingly focused on value-based payment programs, which tie payment to performance on quality and cost measures. In this context, there is rising concern that such programs systematically disadvantage providers that care for vulnerable populations, such as the poor, by holding the providers accountable for factors beyond their control that influence patient outcomes and utilization. In this nationally representative study of Medicare beneficiaries, we found that dually enrolled Medicare beneficiaries (those also enrolled in Medicaid) had strikingly higher levels of medical, functional, and cognitive comorbidities, as well as social needs, compared to their non-dually enrolled counterparts. Dual enrollees also had significantly higher annual costs of care. Including functional, cognitive, and social factors in cost prediction, in addition to risk factors derived from medical claims, improved risk prediction and decreased differences between dual and nondual enrollees. Medicare could consider such adjustment to improve accuracy and fairness in value-based payment programs.
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Affiliation(s)
- Kenton J Johnston
- Kenton J. Johnston ( ) is an assistant professor of health management and policy at Saint Louis University, in Missouri
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in St. Louis
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49
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Lei L, Intrator O, Conwell Y, Fortinsky RH, Cai S. Continuity of care and health care cost among community-dwelling older adult veterans living with dementia. Health Serv Res 2020; 56:378-388. [PMID: 32812658 DOI: 10.1111/1475-6773.13541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia. DATA SOURCES Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015. STUDY DESIGN FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders. DATA COLLECTION Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073). PRINCIPAL FINDINGS Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost. CONCLUSIONS COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.
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Affiliation(s)
- Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York
| | - Orna Intrator
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Richard H Fortinsky
- Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Shubing Cai
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Cheng JM, Batten GP, Cornwell T, Yao N. A qualitative study of health-care experiences and challenges faced by ageing homebound adults. Health Expect 2020; 23:934-942. [PMID: 32476232 PMCID: PMC7495080 DOI: 10.1111/hex.13072] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The ageing of the global population is associated with an increasing prevalence of chronic diseases and functional impairments, resulting in a greater proportion of homebound individuals. OBJECTIVE To examine the health-care experiences of older homebound adults who have not previously received home-based primary care (HBPC). To explore their impressions of this method of care. DESIGN Cross-sectional qualitative study using semi-structured interviews. SETTING AND PARTICIPANTS 18 older homebound individuals in Central Virginia. RESULTS Our findings revealed that homebound individuals faced significant health challenges, including pain resulting from various comorbidities. They felt that their mobility was restricted by their physical conditions and transportation challenges. These were major barriers to social outings and health-care access. Participants left their homes infrequently and typically with assistance. Regarding office-based care, participants were concerned about long wait times and making timely appointments. Some thought that HBPC would be convenient and could result in better quality care; however, others believed that the structure of the health-care system and its focus on efficiency would not permit routine HBPC. DISCUSSION AND CONCLUSIONS Older homebound adults in this study faced high burdens of disease, a lack of mobility and difficulty accessing quality health care. Our observations may help researchers and clinicians better understand the health-care experiences and personal opinions of older homebound individuals, informing the development of effective and empathetic home-based care. Participant responses illuminated a need for education about HBPC. We must improve health-care delivery and develop comprehensive, patient-centered HBPC to meet the needs of homebound individuals.
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Affiliation(s)
- Joyce M. Cheng
- University of Virginia College of Arts and SciencesCharlottesvilleVAUnited States
- Shandong University School of Health Care Management (NHC Key Laboratory of Health Economics and Policy Research)JinanChina
| | - George P. Batten
- University of Virginia Cancer CenterCharlottesvilleVAUnited States
| | | | - Nengliang Yao
- Shandong University School of Health Care Management (NHC Key Laboratory of Health Economics and Policy Research)JinanChina
- Home Centered Care InstituteSchaumburgILUnited States
- University of Virginia School of MedicineCharlottesvilleVAUnited States
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