Communication Openings: A Novel Approach for Serious Illness Communication in Homecare

Serious illness communication in homecare about hospice and/or palliative care transitions is lacking due to clinical culture. The purpose of the current study was to understand communication openings using COMFORT™, a palliative care communication model used to train nurses. Qualitative, focus group interviews with 31 homecare nurses were conducted. Data were transcribed verbatim and thematically analyzed using NVivo software, followed by hand-sorting. Four themes for communication openings for initiating discussions about potential hospice and/or palliative care transitions were identified: Organizational Openings (homecare appropriateness, eligibility requirements, and staffing); Patient Openings (patient physical decline, psychosocial changes, safety concerns, and denying/stopping care); Caregiver Openings (caregiver physical changes and patient readiness); and Nurse Openings (need for hospice, checking for prognosis understanding, increasing interprofessional care needs, and providing end-of-life care). This study extends the concept of communication openings in the COMFORT model. Further development of communication openings as part of COMFORT communication is needed in educational and intervention research. [Journal of Gerontological Nursing, 49(11), 33-41.].

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+.

"Second set of eyes:" Family caregivers and post-acute home health care during the COVID-19 pandemic

OBJECTIVES

This study aimed to explore how the COVID-19 pandemic shaped the experiences of family caregivers of older adults who were hospitalized with COVID-19 and discharged to post-acute, skilled home health care (HHC) services.

METHODS

Thirty semi-structured interviews with family caregivers of older adults who received services from a large, not-for-profit HHC agency following hospitalization with COVID-19 infection were conducted between March-July 2021 and analyzed using thematic analysis.

RESULTS

During the pandemic, family caregivers encountered societal and institutional barriers to assisting older adults across post-acute care transitions. These barriers included hospital visitation restrictions as well as difficulties accessing community-based resources and medical equipment. Despite limitations and delays in HHC services, many family caregivers identified post-acute HHC, delivered in-person or via telehealth, as important to addressing care gaps for older adults, as well as their own needs for training and support during the pandemic.

CONCLUSIONS

Policies intended to reduce the spread of COVID-19 introduced new challenges for caregivers during HHC. However, HHC agencies and their staff adapted within this context to provide a needed bridge of support.

Effect of different patterns of home- and community-based services in Taiwan on the changes in physical function

Our study aimed to explore the impact of different home- and community-based service (HCBS) use patterns on older adults' physical function. The cohort data were drawn from two national datasets, the National Ten-Year Long-Term Care Plan 1.0 database and the National Health Insurance Program claims data. Participants were care recipients ages 65 and over, first evaluated and prescribed HCBS from 2010 through 2013 and evaluated again after 6 months (n = 32,392). Latent class analysis was used to identify subgroups with different HCBS use patterns. Multiple regression was used to examine the impact of different HCBS use patterns on change over time in disability related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The analysis was stratified by respondents' levels of disability. Four subgroups of HCBS recipients were identified, with patterns of home-based personal care, home-based personal care and medical care, home-based medical care and community care services. Older adults in the Home-based MpC had significantly more improvement in both ADL (p < 0.05) and IADL (p < 0.001) scores compared with adults in the other three groups, while the community care group regressed the most. In the stratified analysis of the severely disabled, the IADL outcome of the Home-based MC group was better than the home-based PC group (p < 0.001). Study findings shed light on the benefits of promoting the use of integrated HCBS that combines personal and medical care, especially for community care services.

Transforming Direct Care Jobs, Reimagining Long-Term Services and Supports

The diverse array of individuals who receive long-term services and supports share one common experience, which is the need for assistance with personal care and/or other daily activities. The direct care workers (including nursing assistants, home health aides, and personal care aides) who provide this assistance play a critical role in keeping individuals safe, supporting their health and well-being, and helping prevent adverse outcomes. Yet despite decades of research, advocacy, and incremental policy and practice reform, direct care workers remain inadequately compensated, supported, and respected. Long-standing direct care job quality concerns are linked to high turnover and job vacancy rates in this workforce, which in turn compromise the availability and quality of essential care for older adults and people with disabilities-which has never been more evident than during the COVID-19 pandemic. This special article makes the case for transforming direct care jobs and stabilizing this workforce as a centerpiece of efforts to reimagine long-term services and supports system in the United States, as a public health priority, and as a social justice imperative. Drawing on research evidence and examples from the field, the article demonstrates that a strong, stable direct care workforce requires: a competitive wage and adequate employment benefits for direct care workers; updated training standards and delivery systems that prepare these workers to meet increasingly complex care needs across settings, while also enhancing career mobility and workforce flexibility; investment in well-trained frontline supervisors and peer mentors to help direct care workers navigate their challenging roles; and an elevated position for direct care workers in relation to the interdisciplinary care team. The article concludes by highlighting federal and state policy opportunities to achieve direct care job transformation, as well as discussing research and practice implications.

Medicaid Long-term Care Workforce Training Intervention and Value-Based Payment Metrics

OBJECTIVE

To examine the impact of a scaled implementation of workforce training intervention on value-based payment measures in a large home-based Medicaid managed long-term care plan population in New York.

DATA SOURCES

Managed long-term care clients' health assessments from the Uniform Assessment System of New York merged with paid claims, home health aide operational visit data, and workforce training rosters between 2018 and early-2020.

STUDY DESIGN

A quasi-experimental design was used. Exposure and control groups were constructed using the proportion of service hours delivered by trained aides between clients' baseline and follow-up/outcome assessments. Multivariate logistic generalized linear and additive models were estimated to examine associations between exposure to trained aides and value-based payment measures.

DATA COLLECTION/EXTRACTION METHODS

The analytic sample consisted of 19,212 pairs of assessments from 13,320 long-term care clients continuously enrolled in the plan between baseline and follow-up/outcome assessments. Matched assessment pairs were six to ten months apart.

PRINCIPAL FINDINGS

Over 27% of the study population (n = 3656 clients) received services from one or more of 8683 trained aides. Statistically significant associations were observed for four of seven value-based payment measures; however, presence and magnitudes of positive training effects differed by client service needs. With covariate adjustment, workforce training had the largest estimated positive impacts on rates of flu vaccination among average-need clients (1.60%, standard error [SE] = 0.01), not experiencing uncontrolled pain among above-average-need clients (0.69%, SE = 0.001), stable/improved pain intensity among heavy-need clients (1.25%, SE = 0.01), and stable/improved shortness of breath among light-need clients (0.88%, SE = 0.003).

CONCLUSION

Although we found mixed associations between scaled workforce training implementation and value-based payment metrics, we noted workforce training could benefit high-need long-term care recipients. Health indicators more sensitive to the daily support provided by direct care workers should be integrated into value-based healthcare models.

It Is Time to Resolve the Direct Care Workforce Crisis in Long-Term Care

Nearly 4.6 million direct care workers-including personal care aides, home health aides, and nursing assistants-provide daily support to older adults and people with disabilities across a range of settings in the United States, predominantly in long-term care (LTC). Even as the population grows older and drives up demand for LTC, the sector continues its decades-long struggle to fill direct care positions and stabilize this essential workforce. Recent events and emerging trends have converged, however, to produce new opportunities to address this longstanding workforce crisis, including the unprecedented attention generated by the coronavirus disease 2019 (COVID-19) pandemic and the systemic shifts to managed care and value-based payment in LTC. This Forum article outlines the pressing direct care workforce challenges in LTC before describing these potential levers of change, emphasizing the importance of not just expanding the workforce but also maximizing direct care workers' contributions to the delivery of high-quality services for a growing and evolving population of LTC consumers.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care

BACKGROUND/OBJECTIVES

Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services.

DESIGN

Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File.

SETTING

AL facilities and Medicare HH agencies in the United States.

PARTICIPANTS

741,926 Medicare HH admissions of AL residents in 2017.

MEASUREMENTS

Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission.

RESULTS

Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)).

CONCLUSION

For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Utilization and Functional Outcomes Among Medicare Home Health Recipients Varied Across Living Situations

BACKGROUND/OBJECTIVES

Home health (HH) is a major type of home-based skilled care available to Medicare beneficiaries. We examined the association between living situation (home alone, home with others, and assisted living (AL) residence) and utilization and functional outcomes among Medicare HH recipients.

DESIGN

Analysis of national data from the Outcome and Assessment Information Set, HH Compare, Medicare claims, and Area Health Resource Files.

SETTING

Medicare-certified HH agencies in the United States.

PARTICIPANTS

National population of Medicare beneficiaries ≥65 years old who received HH care in CY 2017 (N = 6,637,496).

MEASUREMENTS

Outcomes included time-to-event measures of hospitalization and emergency department (ED) visits, and improvement in activities of daily living (ADL) from the start to the end of the HH admission.

RESULTS

AL residents (12%) and patients living alone at home (24%) had longer survival time without hospitalization and ED visits than patients living with others at home (64%). Adjusting for covariates and HH agency-level random effects, and compared with patients living with others, AL residents had lower risk of hospitalization (hazard ratio (HR) = 0.85, P < .001) and ED visit (HR = 0.92, P < .001); however, less ADL improvement (β = 0.29 (29% less of total independence in one ADL)); and patients living alone had lower risk of hospitalization (HR = 0.94, P < .001) and ED visit (HR = 0.93, P < .001), yet more ADL improvement (β = -0.15 (15% more of total independence in one ADL)).

CONCLUSION

In the national population of Medicare HH recipients, patients living with others at home had the highest risk of hospitalization and ED visits, whereas AL residents had the lowest risk of hospitalization and patients living alone at home had the lowest risk of ED visits, meaning that combined support from HH and AL reduces acute care admissions. Evidence-based interventions are needed for HH patients living with others at home to avoid unnecessary acute care use.

Professional, friend or family?: How home care companies sell emotional care

While there is a growing literature on home care workers, less is known about how home care companies market their services. Through a content analysis of the 19 largest U.S. home care and home health providers' websites, we examined how companies describe services, desired outcomes of care, and job responsibilities and qualifications. Companies actively market family-like relationships as central to "good care". However, companies' emphasis on unmeasurable skills such as compassion and warmth may also create exploitative work environments. Supporting "good care" requires improved data collection, industry oversight, and policy change to recognize socio-emotional care and protect a marginalized workforce.

Functional outcome in home health: Do racial and ethnic minority patients with dementia fare worse?

Objectives

Evaluate the independent and interactive effects of dementia and racial/ethnic minority status on functional outcomes during a home health (HH) admission among Medicare beneficiaries.

Methods

Secondary analysis of data from the Outcome and Assessment Information Set [OASIS] and billing records in a non-profit HH agency in New York. Participants were adults ≥ 65 years old who received HH in CY 2017 with OASIS records at HH admission and HH discharge. Dementia was identified by diagnosis (ICD-10 codes) and cognitive impairment (OASIS: M1700, M1710, M1740). We used OASIS records to assess race/ethnicity (M0140) and functional status (M1800-M1870 on activities of daily living [ADL]). Functional outcome was measured as change in the composite ADL score from HH admission to HH discharge, where a negative score means improvement and a positive score means decline.

Results

The sample included 4,783 patients, among whom 93.9% improved in ADLs at HH discharge. In multivariable linear regression that adjusted for HH service use and covariates (R² = 0.23), being African American (β = 0.21, 95% confidence interval [CI]: 0.06, 0.35, p = 0.005) and having dementia (β = 0.51, 95% CI: 0.41, 0.62, p<0.001) were independently related to less ADL improvement at HH discharge, with significant interaction related to further decrease in ADL improvement. Relative to white patients without dementia, African American patients with dementia (β = 1.08, 95% CI: 0.81, 1.35, p<0.001), Hispanics with dementia (β = 0.92, 95% CI: 0.38, 1.47, p = 0.001) and Asian Americans with dementia (β = 1.47, 95% CI: 0.81, 2.13, p<0.001) showed the least ADL improvement at HH discharge.

Conclusion

Racial/ethnic minority status and dementia were associated with less ADL improvement in HH with independent and interactive effects. Policies should ensure that these patients have equitable access to appropriate, adequate community-based services to meet their needs in ADLs and disease management for improved outcomes.

"Who's Caring for Us?": Understanding and Addressing the Effects of Emotional Labor on Home Health Aides' Well-being

BACKGROUND AND OBJECTIVES

Interventions to strengthen the home care workforce focus on workers' economic and physical well-being, without acknowledging the caring labor affecting emotional well-being. Our study examined workers' perceptions of the emotional effects of caring work, coping mechanisms, and desired support.

RESEARCH DESIGN AND METHODS

We conducted 4 worker focus groups (n = 27). Moderators cross-checked codes and themes, and aides provided input through report-backs.

RESULTS

Building close, trusting relationships with clients was central to aides' emotional well-being. Well-being was also influenced by relationships with client families and agency supervisors, work-life balance, and the level to which aides felt their work was valued. Aides were largely alone in managing job stressors and desired more communication, connection, and support from supervisors and peers.

DISCUSSION AND IMPLICATIONS

Recognizing and supporting the emotional demands of caring work is crucial to strengthening the workforce. Policy makers and agencies must realign reimbursement systems, job descriptions, and care plans to include measures of emotional labor, improve communication between workers and supervisors, and provide training, mental health benefits, and peer support.

Changing home care aides: Differences between family and non-family care in California Medicaid home and community-based services

In California Medicaid home-and-community-based services (HCBS), recipients' family members receive payment as home care aides (HCAs). We analyzed data on first-time HCBS recipients to examine factors associated with the likelihood of switching HCAs within the first year of services. Those with family HCAs were less than half as likely to change than those with non-family HCAs and racial/ethnic minorities with non-family HCAs had the highest switching rates. Lower wages and local unemployment were associated with switching of non-family HCAs but not family HCAs. Policymakers can foster continuity of home care by paying family members for home care and raising worker wages.

Home Health Aides' Perceptions of Quality Care: Goals, Challenges, and Implications for a Rapidly Changing Industry

Home care payment models, quality measures, and care plans are based on physical tasks workers perform, ignoring relational care that supports clients' cognitive, emotional, and social well-being. As states seek to rein in costs and improve the efficiency and quality of care, they will need to consider how to measure and support relational care. In four focus groups ( n = 27) of unionized, agency-based New York City home health aides, workers reported aide-client relationships were a cornerstone of high-quality care, and building them required communication, respect, and going the extra mile. Since much of this care was invisible outside the worker-client relationship, aides received little supervisory support and felt excluded from the formal care team. Aligning payment models with quality requires understanding the full scope of services aides provide and a quality work environment that offers support and supervision, engages aides in patient care, and gives them a voice in policy decisions.

Older Patients’ and Next of Kin’s Perspectives on Continuity in Long-Term Home Health Care

The study explored how 125 older patients and 92 next of kin experienced and assessed continuity in long-term home health care. Data were collected by means of structured interviews. A majority of the patients indicated that having a high number of health care personnel involved in their care was not problematic. For patients, informed and skilled health personnel along with knowing the visiting personnel may compensate for a high number of personnel. For next of kin, accepting a high number of personnel was related to the carers being informed about the patient’s situation. This study indicates that, in terms of patient satisfaction, the overall quality of care is more important than the number of people providing the care.

Continuity in Visiting Nurse Personnel Has Important Implications for the Patient Experience

Continuity in health care personnel is an important component of high-quality care delivery. This study examines the extent to which continuity in nursing personnel is associated with Home Health Care Consumer Assessment of Healthcare Providers and Systems survey patient experience ratings. We examined the survey responses and administrative records of 7,196 patients served by a large home health agency between 2009 and 2014. Multivariate models were used to estimate associations between nursing continuity, measured with the Bice-Boxerman index, and five domains of patient experience ratings. Results indicated that patients’ overall ratings of care, willingness to recommend the agency to family/friends, perceived care coordination, and levels of communication with providers were positively associated with nursing continuity. No relationship was observed between continuity in nursing personnel and patients’ perceptions of safety, comfort, and education.

Measuring interpersonal continuity in high-frequency home healthcare services

AIM

To provide a method for assessing the degree of interpersonal continuity adapted to context and to measure and assess the degree of interpersonal continuity for long-term recipients dependent on daily home health care.

BACKGROUND

Interpersonal continuity is important to the quality of care for long-term dependents. In high-frequency home healthcare services where patients receive daily care from many nurses or other health personnel over time, interpersonal continuity may be difficult to attain.

DESIGN

A cross-sectional study with a descriptive design.

METHODS

Information concerning 79 patients receiving long-term frequent care was collected during four weeks in a maximum variation sample of Norwegian municipalities, from January 2009-May 2010. We measured interpersonal continuity objectively using indices of dispersion and the next-day sequence of health personnel. For each measure, we computed the highest feasible level of continuity that could be attained in this home healthcare context given a standard shift plan. This level was then used as benchmark against which the actual level of continuity was assessed.

RESULTS

Patients received on average 51 visits from a mean of 17 different carers during four weeks. The results revealed a low degree of interpersonal continuity in practice, far below what was feasible according to the benchmarks.

CONCLUSION

High-frequency home health care was characterized by interpersonal discontinuity, but with potential for improvement. Objective measures of interpersonal continuity, when the benchmark is adapted to the context, are useful tools for planning and surveying continuity of care.