National Trends and Geographic Variation in Availability of Home Health Care: 2002-2015

Rural-urban and regional variations in aspects of caregiving, support services and caregiver health in the USA: evidence from a national survey

OBJECTIVES

Due to substantial regional variability in available caregiving services and supports, culture and health status among informal caregivers in the USA, the study objective was to explore how rural-urban differences in aspects of caregiving-caregiving intensity, distance to care recipient, caregiver burden, caregiver health and caregiving support-vary by US Census region (Northeast, South, Midwest and West) after accounting for other social determinants of health.

DESIGN

This study was a secondary analysis of multiwave, cross-sectional study data.

SETTING

The data were collected on a representative sample of informal, unpaid caregivers to older adults.

PARTICIPANTS

A sample of n=3551 informal caregivers from the National Study of Caregiving identified by older adult care recipients from waves 1 (2011) and 5 (2015) of the National Health and Aging Trends Study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were caregiving intensity (provided support for/with the number of activities of daily living (ADLs) and instrumental ADL (IADLs)) caregiver assisted with, hours of caregiving per month), caregiver burden (physical, emotional and financial), support services sought (types and total number), caregivers' self-reported health and health status (individual comorbidities and a total number of comorbidities). Analyses were stratified by US Census region and rural-urban status, as defined by the US Census Bureau, of census tract of caregiver residence.

RESULTS

Urban caregivers provided higher levels of ADL support in the Northeast (beta=0.19, 95% CI 0.03, 0.35) and West (beta=0.15, 95% CI 0.05,0.26) regions. Urban caregivers provided significantly higher levels of ADL support (p=0.020), IADL support (p=0.033) and total ADLs plus IADLs (p=0.013) than rural caregivers. Caregivers living in the South had higher amounts of monthly hours spent caregiving, ADL support, IADL support and combined ADLs plus IADLs and were more likely to have obesity, report poor or fair health, have heart conditions and experience emotional difficulty from caregiving (all p<0.001).

CONCLUSIONS

Study findings underscore caregiving's multifaceted and complex nature and identify important urban-rural and regional differences in caregiving in the USA. Healthcare providers and healthcare organisations can have an important role in identifying and mitigating the negative impacts of caregiving on caregivers' overall health. Interventions and support should be tailored to caregivers' demographic backgrounds, addressing regional differences.

Outcomes and Issues Addressed by Palliative Care in the Neurology Clinic

Patients with neurological illnesses have many palliative care needs that need to be addressed in the outpatient clinical setting. This review discusses existing models of care delivery, including services delivered by neurology teams, palliative care specialists, telehealth, and home-based programs. We review the existing literature that supports these services and ongoing limitations that continue to create barriers to necessary clinical care for this vulnerable patient population.

Physical and Cognitive Function Trends in Post-acute Care after Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018

OBJECTIVES

Physical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018.

DESIGN

Observational study using Medicare enrollment, claims, and assessment data from 2013-2018.

SETTING AND PARTICIPANTS

1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018.

METHODS

Medicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013-2018) by estimating multivariable models that controlled for patient- and hospital-level covariates.

RESULTS

Multivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)-21.57% (2018), P < .001], HHA increased (46.72%-72.47%, P < .001), and IRF decreased (9.13%-5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)-14.23 (2018), P < .001] and cognitive impairment (13.25%-12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09-3.94, P < .001) and cognitive impairment (13.95%-16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81-37.78, P < .001) and cognitive dependence increased (39.08%-46.36%, P < .001), indicating greater dependence.

CONCLUSIONS AND IMPLICATIONS

From 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries

BACKGROUND

Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting.

METHODS

Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers.

RESULTS

A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge.

CONCLUSIONS

A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.

Association Between States' Certificate of Need Laws and Home Health Care Access in the US

Home health care has a significant role in the care of Medicare beneficiaries. Certificate of Need (CON) laws for home health agencies limit their number in affected states. This study's objective was to evaluate the association of CON laws with the availability and service utilization of urban and rural home health agencies in CON states and non-CON states using the generalized estimating equations (GEE) method. The results from this study indicated that CON states have fewer home health agencies for their Medicare population than non-CON states, regardless of urbanicity or rurality. Home health agencies in CON states also have less service utilization in terms of care episodes and visits per patient. This study provides an understanding of the effects of CON laws on Medicare beneficiaries' home health access and experiences.

A suggested mortality benefit with integrated health care versus conventional home health care in Taiwan

In Taiwan, the Integrated Home Care (IHC) project was introduced for medically compromised patients living at home receiving Home Health Care (HHC) in 2016. The focus of the project was on organizing care teams and managing care for patients. The aim of this study was to investigate the benefits and impacts of IHC in Taiwan. The primary outcome measure was the mortality rate of patients who received IHC versus those who did not receive IHC (non-IHC). The secondary outcomes were medical utilization and expenditure. The results showed that IHC was associated with a statistically significant reduction in mortality compared to non-IHC for home-dwelling patients over 90-, 180-, and 365-days periods. Additionally, IHC users were less likely to be hospitalized and had shorter hospitalization times compared to non-IHC users. Furthermore, IHC was found to reduce medical expenditure compared to non-IHC.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home

OBJECTIVES

Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients.

DESIGN

Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing.

SETTING AND PARTICIPANT

Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews.

MEASURES

Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders.

RESULTS

We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing.

CONCLUSIONS AND IMPLICATIONS

Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.

Implementation of US Post-Acute Care Payment Reform and COVID-19 Policies: Examining Experiences of Health System Leaders, Staff, Patients, and Family Caregivers-A Protocol

In fiscal year 2020, new national Medicare payment models were implemented in the two most common post-acute care settings (i.e., skilled nursing facilities (SNFs) and home health agencies (HHAs)), which were followed by the emergence of COVID-19. Given concerns about the unintended consequence of these events, this study protocol will examine how organizations responded to these policies and whether there were changes in SNF and HHA access, care delivery, and outcomes from the perspectives of leadership, staff, patients, and families. We will conduct a two-phase multiple case study guided by the Institute of Medicine's Model of Healthcare Systems. Phase I will include three cases for each setting and a maximum of fifty administrators per case. Phase II will include a subset of Phase I organizations, which are grouped into three setting-specific cases. Each Phase II case will include a maximum of four organizations. Semi-structured interviews will explore the perspectives of frontline staff, patients, and family caregivers (Phase II). Thematic analysis will be used to examine the impact of payment policy and COVID-19 on organizational operations, care delivery, and patient outcomes. The results of this study intend to develop evidence addressing concerns about the unintended consequences of the PAC payment policy during the COVID-19 pandemic.

How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks

PURPOSE

Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC.

METHODS

A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping.

FINDINGS

Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication.

IMPLICATIONS

Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

The Effects of Increasing State Minimum Wage on Family and Paid Caregiving

Older adults may receive either or a combination of unpaid family/friend and paid caregiving. The consumption of family/friend and paid caregiving may be sensitive to minimum wage policies. We used data (n = 11,698 unique respondents) from the Health and Retirement Study and a difference-in-differences design to evaluate associations between increases in state minimum wage between 2010 and 2014 and family/friend and paid caregiving consumed by adults age 65+ years. We also examined responses to increases in minimum wage for respondents with dementia or Medicaid beneficiaries. People living in states that increased their minimum wage did not consume substantially different hours of family/friend, paid, or any family/friend or paid caregiving. We did not observe differential responses between increases in minimum wage and hours of family/friend or paid caregiving among people with dementia or Medicaid beneficiaries. Increases in state minimum wage were not associated with changes in caregiving consumed by adults age 65+.

Trends in 1-Year Recurrent Ischemic Stroke in the US Medicare Fee-for-Service Population

BACKGROUND

There have been important advances in secondary stroke prevention and a focus on healthcare delivery over the past decades. Yet, data on US trends in recurrent stroke are limited. We examined national and regional patterns in 1-year recurrence among Medicare beneficiaries hospitalized for ischemic stroke from 2001 to 2017.

METHODS

This cohort study included all fee-for-service Medicare beneficiaries aged ≥65 years who were discharged alive with a principal diagnosis of ischemic stroke from 2001 to 2017. Follow-up was up to 1 year through 2018. Cox models were used to assess temporal trends in 1-year recurrent ischemic stroke, adjusting for demographic and clinical characteristics. We mapped recurrence rates and identified persistently high-recurrence counties as those with rates in the highest sextile for stroke recurrence in ≥5 of the following periods: 2001-2003, 2004-2006, 2007-2009, 2010-2012, 2013-2015, and 2016-2017.

RESULTS

There were 3 638 346 unique beneficiaries discharged with stroke (mean age 79.0±8.1 years, 55.2% women, 85.3% White). The national 1-year recurrent stroke rate decreased from 11.3% in 2001-2003 to 7.6% in 2016-2017 (relative reduction, 33.5% [95% CI, 32.5%-34.5%]). There was a 2.3% (95% CI, 2.2%-2.4%) adjusted annual decrease in recurrence from 2001 to 2017 that included reductions in all age, sex, and race subgroups. County-level recurrence rates ranged from 5.5% to 14.0% in 2001-2003 and from 0.2% to 8.9% in 2016-2017. There were 76 counties, concentrated in the South-Central United States, that had the highest recurrence throughout the study. These counties had populations with a higher proportion of Black residents and uninsured adults, greater wealth inequity, poorer general health, and reduced preventive testing rates as compared with other counties.

CONCLUSIONS

Recurrent ischemic strokes decreased over time overall and across demographic subgroups; however, there were geographic areas with persistently higher recurrence rates. These findings can inform secondary prevention intervention opportunities for high-risk populations and communities.

Rural-urban differences in family and paid caregiving utilization in the United States: Findings from the Cornell National Social Survey

PURPOSE

While rates of family caregiving and paid caregiving are increasing, how often they occur together ("shared care") and whether utilization varies geographically are unknown. We examined differences in family and paid caregiving utilization by rurality and region in the United States.

METHODS

The 2020 Cornell National Social Survey is an annual cross-sectional telephone-based survey of a random sample of 1,000 US adults. Participants were asked if they have been a family caregiver, including if they provided care alongside a paid caregiver. Rural-Urban Commuting Area Codes and Census areas classified rurality and region. The association between residence and the prevalence of caregiving was determined with multivariable Poisson regression.

FINDINGS

Among 857 participants with geographic and caregiving data, 11.8% (n = 101) were rural dwellers and 34.2% were family caregivers. Rural residence (vs urban) was associated with a higher prevalence of family caregiving (PR: 1.59 [1.22, 2.06]), and Western residence (vs Northeast) was associated with a lower prevalence of family caregiving (PR: 0.63 [0.46, 0.87], P = .01). Forty percent of family caregivers shared care with a paid caregiver. There was no significant difference in shared care by rural residence in unadjusted (31.8% rural vs 43.1% urban, P = .22) or adjusted models (PR: 0.85 [0.51, 1.41], P = .53).

CONCLUSIONS

Although family caregiving was more prevalent in rural areas and certain regions, shared care did not differ by rurality or region. Studies are needed to understand why rural residents do more family caregiving without additional support from paid caregivers, and what the implications are for caregivers and care recipients.

Home-Based Care for Children with Serious Illness: Ecological Framework and Research Implications

Care for U.S. children living with serious illness and their families at home is a complex and patchwork system. Improving home-based care for children and families requires a comprehensive, multilevel approach that accounts for and examines relationships across home environments, communities, and social contexts in which children and families live and receive care. We propose a multilevel conceptual framework, guided by Bronfenbrenner’s ecological model, that conceptualizes the complex system of home-based care into five levels. Levels 1 and 2 contain patient and family characteristics. Level 3 contains factors that influence family health, well-being, and experience with care in the home. Level 4 includes the community, including community groups, schools, and providers. Level 5 includes the broader regional system of care that impacts the care of children and families across communities. Finally, care coordination and care disparities transcend levels, impacting care at each level. A multilevel ecological framework of home-based care for children with serious illness and families can be used in future multilevel research to describe and test hypotheses about aspects of this system of care, as well as to inform interventions across levels to improve patient and family outcomes.

Exploring Barriers to the Development of Home Health Care in Iran: A Qualitative Study

Changes in society’s needs have increased individuals’ desire to be independent and receive health care at home. Home health care (HHC) is one of the main components of realizing these ambitions. However, there is a serious concern about the state of development of the HHC industry in Iran and the quality of its services. This study aims to explore the barriers to the development of HHC in Iran. This qualitative study with a conventional content analysis approach was conducted in Tabriz, Iran, from October 2019 to March 2020. Twenty-one key stakeholders including nurses, home health directors, physicians, policy-makers, patients, and their families participated in the study. Participants were selected using purposive sampling. Data were collected using a focus group discussion (FGD) and 18 semi-structured in-depth interviews and analyzed using Graneheim and Lundman’s techniques. Data collection continued until saturation was reached. Three main themes emerged from the analysis: quality management challenges, insufficient infrastructure and policy, and political issues. The findings show that applying standard strategies to monitor the quality of services, paying attention to infrastructure, and having a clear framework for policy-making are beneficial for the development of the HHC industry. Health managers can monitor and upgrade the quality of HHC services by defining standards and assessment indicators, as well as providing comprehensive data. It is suggested that legislators consider the principles of community-based accountability, justice, and accessibility their top priority. Moreover, policymakers need to develop a roadmap to reform policies to create the conditions for the development of this industry.

Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism

BACKGROUND

Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access.

METHODS

Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia.

RESULTS

Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas.

CONCLUSION

Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.

An Examination of Washington State Workers’ Compensation Claims for Home-Based Health Care Workers, 2006 to 2016: Part 2. Injury Rates and Trends

Research of home-based health care (HBHC) has shown that care providers suffer from a high rate of injuries. Analysis of workers’ compensation records, a reliable source for injury and illness data, enables the identification of trends within a specific working population. HBHC workers’ compensation compensable claims in Washington State from 2006 to 2016 were compared to clinical health care (CHC) claims. Injury event and source attributed to HBHC claims were also analyzed, with a focus on work-related musculoskeletal disorders (WMSDs). Though CHC had 5 times the number of full-time employees during the study period, HBHC grew by 61.1%, compared to 28.7% in CHC. Claim rates for all compensable claims and WMSD claims consistently decreased year-over-year for both HBHC and CHC. WMSD claims experienced a year-over-year decline of 5.3%; for all compensable claims the decline was 4.5%. Analysis of HBHC claim rates by injury event found WMSD had the highest rates, followed by falls from the same level. However, the largest annual change was for the injury event overexertion (−10.1%, 95%CI: −13.4, −6.8). HBHC injuries attributable to the health care patient were the most common. Claims with this injury source declined annually by 6.0%. Claim rates for injuries to the back region, and specifically back WMSDs, were consistently higher year-over-year compared to other body regions and WMSD types. Claims for injuries to the back declined by an annual rate of 6.6% (95% CI: −7.9, −5.3), while back WMSD claims decreased by 6.4% (94% CI: −7.8, −4.9).

Out Of Reach: Inequities In The Use Of High-Quality Home Health Agencies

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation.

Long-Term Care Market Trend and Patterns of Caregiving in the U.S

Informal care is a major source of long-term services and supports (LTSS) for older adults in the U.S. However, the increasing gap between available family caregivers and those needing LTSS in coming years warrants better understanding of the balance between informal and formal home or community-based LTSS to meet the growing demand. The current study aimed to 1) identify patterns of informal and formal LTSS use among community-dwelling individuals, and 2) examine if the supply of formal LTSS predicts the use of informal care. These aims were investigated by linking the market supply of formal LTSS at the state-level to the Health and Retirement Survey data (N = 7,781). Results provide important empirical evidence that patterns of informal and formal LTSS use among older adults are heterogeneous and market supply of formal home and community-based services (HCBS) significantly predicts the use of informal care. Most older adults rely on informal care in combination with some formal supports, suggesting that the two systems work in tandem to meet the growing needs of LTSS. This offers important implications for states allocating resources to meet the LTSS needs of older adults and individuals with disabilities since states play key roles in U.S. long-term care policies.

The Impact Of Medicare's Rural Add-On Payments On Supply Of Home Health Agencies Serving Rural Counties

Intermittently since 2001, Medicare has provided a percentage increase over standard payments to home health agencies that serve rural beneficiaries. Yet the effect of rural add-on payments on the supply of home health agencies that serve rural communities is unknown. Taking advantage of the pseudo-natural experiment created by varying rural add-on payment amounts over time, we used data from Home Health Compare to examine how the payments affected the number of home health agencies serving rural counties. Our results suggest that while supply changes are similar in rural counties adjacent to urban areas and in urban counties regardless of add-on payments, only higher add-on payments (of 5 percent or 10 percent) keep supply changes in rural counties not adjacent to urban areas on pace with those in urban counties. Our findings support the recent shift from broadly applied to targeted rural add-on payments but raise questions about the effects of the amount and eventual sunset of these payments on the supply of home health agencies serving remote rural communities.

Home healthcare in Iran: A hybrid concept analysis

BACKGROUND

Healthcare is changing from a focus on acute care health issues to one of managing chronic conditions. This change has resulted in the development of home health-care systems as a way of managing chronic conditions outside the hospital. The aim of this study was to analyze the concept of home healthcare using a hybrid model.

MATERIALS AND METHODS

This hybrid concept analysis consisted of three phases: theoretical, fieldwork, and analytical. Science Direct, PubMed, ProQuest, and Scopus were searched with related terms in the theoretical phase. In the fieldwork phase, six professionals with experience in home healthcare were interviewed and after each interview, qualitative content analysis was conducted. During the final phase, descriptions and themes from the first two phases were combined.

RESULTS

In the theoretical phase, the definition of home healthcare included descriptions answering the Who, What, When, Where, and Why questions. In the fieldwork phase, the results were divided into three areas: 1-comprehensive care; 2-extent of services; and 3-outcomes. The final analysis phase of this study indicated that the home health-care concept is a comprehensive, professional, and holistic care system accompanied by medical services and professionals whose goals are to support an individual's health and provide care in their home. Healthcare provided in one's home was found to preserve a patient's dignity and reduce health-care costs.

CONCLUSIONS

The definition of the home healthcare concept establishes a foundation for developing a comprehensive home health-care system. This concept analysis for home healthcare could be a guide for future studies.

Comparison of the caregivers' and community health professionals' views on home health care services for disabled older adults: a cross-sectional study in Beijing, China

Background

In an era of an increasingly ageing society, part of healthcare for older adults can be provided in patients’ homes, and the need for home health care services (HHCSs) is increasing. This study sought to determine whether a gap exists between the views of community health professionals and the caregivers of disabled older adults towards HHCSs in Beijing, China.

Methods

A cross-sectional study with two comparative questionnaire surveys was conducted in Beijing, China. One survey was administered to the caregivers of disabled older adults, and the other was administered to health professionals in community health service institutions (CHSIs). T-tests and Wilcoxon signed-rank tests were used to explore potential differences between the views of caregivers and community health professionals towards HHCSs.

Results

We received 370 valid questionnaires from caregivers and 224 questionnaires from health professionals. Of the 370 caregivers, 314 (84.9%) were willing to apply for HHCSs for the older adults, but only 20.5% (N = 76) received HHCSs. Over 80% of the caregivers accepted out-of-pocket costs less than 100 yuan per visit. Caregivers’ demands on home nursing services were significantly higher than those of health guidance services (Z = − 7.725, P < 0.001). Most of the 224 health professionals chose “health professionals’ personal safety cannot be guaranteed” as a problem limiting the provision of HHCSs (N = 151, 40.8%). The health professionals’ attitudes towards home nursing services were significantly less positive than those towards health guidance services (Z = − 10.081, P < 0.001). For home nursing services, health professionals’ attitude scores were lower than the caregivers’ demand scores (Z = − 4.960, P < 0.001), while for health guidance services, health professionals’ attitude scores were higher than the caregivers’ demand scores (Z = − 8.373, P < 0.001).

Conclusions

Gaps exist between the views of caregivers and health professionals on HHCSs. Compared to health professionals with a higher willingness to provide health guidance services, caregivers need home nursing services. Feasible policies should be implemented to safeguard the rights and interests of health professionals, and qualified health professionals should be trained for HHCSs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06400-9.

Urban Neighborhood Characteristics and the Spatial Distribution of Home and Community-Based Service Organizations in Michigan Metropolitan Statistical Areas

Living in a neighborhood with dense HCBS organizations can promote older adults' health and well-being and may mitigate health disparities generated by living in materially deprived urban neighborhoods. Using 2016 US County Business Patterns and the American Community Survey (2013-2017), focused on 516 ZIP Codes in Michigan Metropolitan Statistical Areas, this study examines the association between neighborhood characteristics and the relative density of businesses offering services for older adults and persons with disabilities (e.g., senior centers, adult day service centers, personal care) and businesses offering home health care. Results from a series of spatial econometric models show that social care organization density tends to be high in neighborhoods with a greater number of residents who have a bachelor's degree, who are older, and who are in poverty. Home health care density was not explained by neighborhood factors. Multiple neighborhood socio-demographic indicators explain the spatial distribution of social care organizations.

HOme-based Longitudinal Investigation of the multidiSciplinary Team Integrated Care (HOLISTIC): protocol of a prospective nationwide cohort study

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.

State Variation in Posthospital Home Nursing for Commercially Insured Medically Complex Children

BACKGROUND AND OBJECTIVES

Home nursing is essential for children with medical complexity (CMC), but provision varies substantially across states. Our objectives were to quantify state-to-state variability in distribution of posthospitalization home nursing to commercially insured CMC and to rank-order states.

METHODS

Retrospective cohort study of hospitalized commercially insured children with ≥1 complex chronic condition from birth to 18 years of age in the Truven MarketScan database. Cohort eligibility criteria were hospital discharge between January 2013 and November 2016 and at least 30 days of follow-up after discharge. Two primary outcome measures were used: receipt of any home nursing within 30 days of hospital discharge (yes or no) and number of days of posthospitalization home nursing (1-30 days). A composite metric encompassing both receipt and quantity was created by evaluating the 95th percentile of days of home nursing (0-30 days).

RESULTS

Overall, 9.9% of the sample received home nursing. After we adjusted for patient characteristics, the probability of receiving home nursing varied across states, ranging from 3.4% to 19.2%. Among home nursing recipients, the adjusted median home nursing days across states ranged from 6.6 to 24.5 days. The adjusted 95th percentile of days of home nursing (across the entire of sample, including recipients and nonrecipients of home nursing) ranged from 6.8 to 22.6 days.

CONCLUSIONS

We observed striking state-to-state variability in receipt of home nursing and mean number of days of posthospitalization home nursing among commercially insured CMC after adjustment for demographic and clinical differences. This suggests opportunities for state-level improvement.

Understanding the Workflow of Home Health Care for Patients with Heart Failure: Challenges and Opportunities

BACKGROUND

Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal.

OBJECTIVE

We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist.

DESIGN AND PARTICIPANTS

In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018.

APPROACH

Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image.

KEY RESULTS

Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step.

CONCLUSIONS

Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

Homebound Status and the Critical Role of Caregiving Support

The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.

Persistent geographic variations in availability and quality of nursing home care in the United States: 1996 to 2016

BACKGROUND

Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care.

METHODS

Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996-2016. Outcomes were 1) availability of all nursing home care (1996-2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged ≥65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds.

RESULTS

From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged ≥65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77-0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged ≥65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51-0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30-0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division.

CONCLUSION

We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated.

Functional Status Is Associated With 30-Day Potentially Preventable Readmissions Following Home Health Care

BACKGROUND

Beginning in 2019, home health agencies' rates of potentially preventable hospital readmissions over the 30 days following discharge will be publicly reported.

OBJECTIVES

Our primary objective was to determine the association between patients' functional status at discharge from home health care and 30-day potentially preventable readmissions. A secondary objective was to identify the most common conditions resulting in potentially preventable readmissions.

DESIGN

This was a retrospective cohort study.

PARTICIPANTS

A total of 1,510,297 Medicare fee-for-service beneficiaries discharged from home health care in 2013-2015. Average age was 75.9 (SD, 10.9) years, 60.0% were female, and 84.2% non-Hispanic white.

MEASUREMENTS

Thirty-day potentially preventable readmissions following home health discharge. Functional status measures included mobility, self-care, and impaired cognition.

RESULTS

The overall rate of 30-day potentially preventable readmissions was 2.6% (N=39,452), which accounted for 40% of all 30-day readmissions. After adjusting for sociodemographic and clinical characteristics, the odds ratios for the most dependent score quartile versus the most independent was 1.58 [95% confidence interval (CI), 1.53-1.63] for mobility and 1.65 (95% CI, 1.59-1.69) for self-care. The odds ratios for impaired versus intact cognition was 1.21 (95% CI, 1.18-1.24). The 5 most common conditions resulting in a potentially preventable readmission were congestive heart failure (23.6%), septicemia (16.7%), bacterial pneumonia (9.8%), chronic obstructive pulmonary disease (9.4%), and renal failure (7.5%).

CONCLUSIONS

Functional limitations at discharge from home health are associated with increased risk for potentially preventable readmissions. Future research is needed to determine whether improving functional independence decreases the risk for potentially preventable readmissions following home health care.

Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty

BACKGROUND

Home-health-care utilization after total knee arthroplasty (TKA) is increasing. Recent publications have suggested that supervised rehabilitation is not needed to optimize functional recovery after TKA; however, few studies have evaluated patients in home-health-care settings. The objectives of this study were to (1) determine whether physical therapy (PT) utilization is associated with functional improvements for patients in home-health-care settings after TKA and (2) determine which factors are related to utilization of PT.

METHODS

This study was an analysis of Medicare home-health-care claims data for patients treated with a TKA in 2012 who received home-health-care services for postoperative rehabilitation. Multivariable linear regression models were used to evaluate relationships between PT utilization and recovery in activities of daily living (ADLs). Negative binomial regression models were used to determine factors associated with PT utilization.

RESULTS

Records from 5,967 Medicare beneficiaries were evaluated. Low home-health-care PT utilization (≤5 visits) was associated with less improvement in ADLs compared with 6 to 9 visits, 10 to 13 visits, or ≥14 visits. Compared with low home-health-care utilization, utilization of 6 to 9 visits was associated with a 25% greater improvement in ADLs over the home-health-care episode (p < 0.0001); 10 to 13 visits, with a 40% greater improvement (p < 0.0001); and ≥14 visits, with a 50% greater improvement (p < 0.0001). The findings remained robust following adjustments for medical complexity, baseline functional status, and home-health-care episode duration. After adjustment, lower PT utilization was observed for patients receiving home health care from rural agencies (10.7% fewer visits, 95% confidence interval [CI] = 7.9% to 13.7%), those with depressive symptoms (4.8% fewer visits, 95% CI = 1.3% to 8.3%), and those with any baseline dyspnea (5.3% fewer visits, 95% CI = 3.1% to 7.5%).

CONCLUSIONS

Low home-health-care PT utilization was significantly associated with worse recovery in ADLs after TKA for Medicare beneficiaries, after controlling for medical complexity, baseline function, and home-health-care episode duration. Patients who are served by rural agencies or who have higher medical complexity receive fewer PT visits after TKA and may need closer monitoring to ensure optimal functional recovery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Home Health Agency Performance in the United States: 2011-15

OBJECTIVES

To evaluate home health agency quality performance.

DESIGN

Observational study.

SETTING

Home health agencies.

PARTICIPANTS

All Medicare-certified agencies with at least 6 months of data from 2011 to 2015.

MEASUREMENTS

Twenty-two quality indicators, five patient survey indicators, and their composite scores.

RESULTS

The study included 11,462 Medicare-certified home health agencies that served 92.4% of all ZIP codes nationwide, accounting for 315.2 million people. The mean composite scores were 409.1 ± 22.7 out of 500 with the patient survey indicators and 492.3 ± 21.7 out of 600 without the patient survey indicators. Home health agency performance on 27 quality indicators varied, with the coefficients of dispersion ranging from 4.9 to 62.8. Categorization of agencies into performance quartiles revealed that 3,179 (27.7%) were in the low-performing group (below 25th percentile) at least one time during the period from 2011-12 to 2014-15 and that 493 were in the low-performing group throughout the study period. Geographic variation in agency performance was observed. Agencies with longer Medicare-certified years were more likely to have high-performing scores; agencies providing partial services, with proprietary ownership, and those with long travel distances to reach patients had lower performance. Agencies serving low-income counties and counties with lower proportions of women and senior residences and greater proportions of Hispanic residents were more likely to attain lower performance scores.

CONCLUSION

Home health agency performance on several quality indicators varied, and many agencies were persistently in the lowest quartile of performance. Still, there is a need to improve the quality of care of all agencies. Many parts of the United States, particularly lower-income areas and areas with more Hispanic residents, are more likely to receive lower quality home health care.