The Invisible Homebound: Setting Quality-Of-Care Standards For Home-Based Primary And Palliative Care

The quality of home-based primary care delivered by nurse practitioners: A national Medicare claims analysis

BACKGROUND

As the US population ages, there is an increasing demand for home-based primary care (HBPC) by those with Alzheimer's/dementia, multiple chronic conditions, severe physical limitations, or those facing end-of life. Nurse practitioners (NPs) are increasingly providing HBPC, yet little is known about their quality of care in this unique setting.

METHODS

This observational study uses Medicare claims data from 2018 to assess the quality of care for high-intensity HBPC users (5 or more visits/year) based on provider type (NP-only, physician (MD)-only, or both NP and MDs). We employ 12 quality measures from 3 care domains: access and prevention, acute care utilization, and end-of-life. Analysis includes bivariate comparisons and logistic regression models that adjust for demographic, clinical, and geographic characteristics.

RESULTS

Among the 574,567 beneficiaries with 5 or more HBPC visits, 37% saw an NP, 37% saw a MD, and 27% saw both NPs and MDs. In multivariate models, those receiving HBPC from an NP or both NP-MD are significantly more likely to receive a flu shot than the MD-only group, but less likely to access preventive care. NP-only care is associated with more acute care hospitalizations, avoidable ED visits, and fall-related injuries, but significantly fewer avoidable admissions. For end-of-life care, those with NP-only or both NP-MD care are significantly more likely to have an advanced directive, be in hospice in the last 3 days of life, and more likely to die in hospice. The NP group is also more likely to die in the next year.

CONCLUSIONS

HBPC patients are complex, with both palliative and curative needs. NPs provide almost half of HBPC in the Medicare program, to patients who are possibly sicker than those treated by physicians, with similar quality to MDs.

Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan

BACKGROUND

Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown.

OBJECTIVE

To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan.

DESIGN

Cross-sectional.

SETTING

National MA plan.

PARTICIPANTS

Humana MA beneficiaries in 2022 (n = 2 435 519).

MEASUREMENTS

Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status.

RESULTS

In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]).

LIMITATION

The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability.

CONCLUSION

Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries.

PRIMARY FUNDING SOURCE

Humana, under a collaborative research agreement with Johns Hopkins University.

Healthcare contact days among older adults living with dementia

BACKGROUND

For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population.

METHODS

We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days.

RESULTS

In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days.

CONCLUSIONS

Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.

Diagnostic uncertainty and decision-making in home-based primary care: A qualitative study of antibiotic prescribing

BACKGROUND

Evaluating infection in home-based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision-making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision-making by exploring the perspectives of clinicians in home-based primary care.

METHODS

Clinicians from the Department of Veterans Affairs Home-Based Primary Care Program were recruited. Semi-structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes.

RESULTS

Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home-based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow-up) and those that inhibited prescribing (perceptions of antibiotic-associated harms, willingness to trial non-pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms).

CONCLUSIONS

Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home-based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings.

Clinician Perceptions of Barriers and Facilitators for Delivering Early Integrated Palliative Care via Telehealth

Early integrated palliative care (EIPC) significantly improves clinical outcomes for patients with advanced cancer. Telehealth may be a useful tool to deliver EIPC sustainably and equitably. Palliative care clinicians completed a survey regarding their perceptions of the barriers, facilitators, and benefits of using telehealth video visits for delivering EIPC for patients with advanced lung cancer. Forty-eight clinicians across 22 cancer centers completed the survey between May and July 2022. Most (91.7%) agreed that telehealth increases access to EIPC and simplifies the process for patients to receive EIPC (79.2%). Clinicians noted that the elderly, those in rural areas, and those with less-resourced backgrounds have greater difficulty using telehealth. Perceived barriers were largely patient-based factors, including technological literacy, internet and device availability, and patient preferences. Clinicians agreed that several organizational factors facilitated telehealth EIPC delivery, including technological infrastructure (85.4%), training (83.3%), and support from study coordinators (81.3%). Other barriers included systems-based factors, such as insurance reimbursement and out-of-state coverage restrictions. Patient-, organization-, and systems-based factors are all important to providing and improving access to telehealth EIPC services. Further research is needed to investigate the efficacy of telehealth EIPC and how policies and interventions may improve access to and dissemination of this care modality.

Effects of interventions on life-space mobility for community-dwelling older adults: A systematic review and meta-analysis

AIM

The present study aimed to conduct a meta-analysis to evaluate the methods and effects of interventions to increase life-space mobility among community-dwelling older adults.

METHODS

Records were identified through nine databases. Eligible study designs for inclusion in the review were randomized controlled trials of interventions on life-space mobility for community-dwelling older adults. The risk of bias was assessed using the Risk of Bias 2 tool. We followed the Grading of Recommendations, Assessment, Development, and Evaluation approach to summarize the evidence.

RESULTS

Four studies (558 participants) identified via search strategies were included. Two studies involved individualized exercise and lifestyle interventions. In three out of the four studies, individual interventions were applied. Overall, when compared with a control group, the intervention group was more likely to positively affect increasing life-space mobility (standardized mean difference 0.47, 95% confidence interval [0.020 to 0.92]). The heterogeneity statistic indicated considerable heterogeneity (I2  = 84%). The evidence was downgraded one step owing to imprecision.

CONCLUSIONS

Interventions on increasing life-space mobility for community-dwelling older adults have a positive effect. Combination interventions may be more effective than single interventions, and individual interventions may be more effective than group interventions. However, owing to the limited number of studies, conducting further research to enhance the generalizability of results is crucial. Additionally, subgroup analysis should be conducted to clarify differences in intervention methods and effects. Geriatr Gerontol Int 2023; 23: 842-848.

Dysphagia in Older Adults is Associated With Food Insecurity and Being Homebound

Objective: Our aim was to evaluate relationships between swallowing difficulty (dysphagia) and social determinants of health (SDOH) in older adults ≥65 years. Method: Cross-sectional analyses were performed in community-dwelling Medicare beneficiaries from the National Health & Aging Trends Study (NHATS). The primary exposure was self-reported difficulty chewing/swallowing in the prior month. Dependent measures included a variety of SDOH outcomes (e.g., food insecurity [FI]). Weighted logistic regression models were estimated to determine associations between dysphagia and SDOH outcomes. Results: Of 4041 participants, 428 (10.6%) self-reported dysphagia. In the adjusted model, dysphagia was associated with significantly increased odds for FI (odds ratio [OR] = 1.48, 95% confidence interval [CI] = 1.06, 2.07, p = .023) and being homebound (OR = 1.32, 95% CI = 1.13, 1.55, p= < .001). Discussion: Older adults with dysphagia had increased odds of FI and being homebound. These associations have implications for health-promoting interventions at the individual and policy levels in older adults.

Patterns of Healthcare Utilization and Spending Among Homebound Older Adults in the USA: an Observational Study

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.

An Organizational Assessment of 34 Home Delivered Meals Programs that Engaged and Assisted Homebound Individuals With Obtaining the COVID-19 Vaccine During the Pandemic

Vaccinating homebound individuals during the COVID-19 pandemic presented several challenges, including time and cost of engaging this group. In Los Angeles County, the departments of Public Health and Aging and Disabilities turned to home delivered meals programs (HDMs) for help with this public health priority. A mixed-method organizational assessment of 34 HDMs was conducted during March-April 2022 to describe these efforts. Most HDMs were nonprofit (67.6%) and had <25 staff (58.8%). Overall, they served a large catchment area before and during COVID-19, providing services to an estimated total of 24,995 clients/week and delivering 19,511 meals/day. A majority (82.4%) reported engaging their clients to facilitate COVID-19 vaccinations. As of early 2022, <6% of these HDMs' homebound clients were unvaccinated. These programs' efforts to assist older individuals who were homebound during the pandemic represent a potentially underutilized model of public-nonprofit/not-for-profit partnership for improving vaccine delivery and uptake in this hard-to-reach population.

Care Disruptions and End-Of-Life Care Experiences Among Home-Based Primary Care Patients During the COVID-19 Pandemic in New York City: A Retrospective Chart Review

Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC's multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.

Growth of Fee-for-Service Medicare Home-Based Medical Care Within Private Residences and Domiciliary Care Settings in the U.S., 2012-2019

OBJECTIVES

Home-based medical care (HBMC) delivers physician or advanced practice provider-led medical services for patients in private residences and domiciliary settings (eg, assisted living facilities, group/boarding homes). We aimed to examine the time trends in HBMC utilization by care settings.

DESIGN

Analyses of HBMC utilization at the national and state levels during the years 2012-2019.

SETTING AND PARTICIPANTS

With Medicare public use files, we calculated the state-level utilization rate of HBMC among fee-for-service (FFS) Medicare beneficiaries, measured by visits per 1000 FFS enrollees, in private residences and domiciliary settings, both separately and combined.

METHODS

We assessed the trend of HBMC utilization over time via linear mixed models with random intercept for state, adjusting for the following state-level markers of HBMC supply and demand: number of HBMC providers, state ranking of total assisted living and residential care capacity, and the proportion of FFS beneficiaries with dementia, dual eligibility for Medicaid, receiving home health services, and Medicare Advantage.

RESULTS

Total HBMC visits in the United States increased from 3,911,778 in 2012 to 5,524,939 in 2019. The median (interquartile range) state-level HBMC utilization rate per 1000 FFS population was 67.6 (34.1-151.3) visits overall, 17.3 (7.9-41.9) visits in private residences, and 47.7 (23.1-86.6) visits in domiciliary settings. The annual percentage increase of utilization rates was significant for all care settings in crude models (3%-8%), and remained significant for overall visits and visits in domiciliary settings (2%-4%), but not in private residences.

CONCLUSIONS AND IMPLICATIONS

The national-level growth in HBMC from 2012-2019 was largely driven by a growth of HBMC occurring in domiciliary settings. To meet the needs of a growing aging population, future studies should focus efforts on policy and payment issues to address inequities in access to HBMC services for homebound older adults, and examine drivers of HBMC growth at regional and local levels.

National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship

Background

Over 7 million older Americans are homebound. Managing infections in homebound persons presents unique challenges that are magnified among persons living with dementia (PLWD). This work sought to characterize antibiotic use in a national cohort of PLWD who received home-based primary care (HBPC) through the Veterans Health Administration.

Methods

Administrative data identified veterans aged ≥65 years with ≥2 physician home visits in a year between 2014 and 2018 and a dementia diagnosis 3 years before through 1 year after their initial HBPC visit. Antibiotics prescribed orally, intravenously, intramuscularly, or by enema within 3 days of an HBPC visit were assessed from the initial HBPC visit to death or December 31, 2018. Prescription fills and days of therapy (DOT) per 1000 days of home care (DOHC) were calculated.

Results

Among 39 861 PLWD, the median age (interquartile range [IQR]) was 85 (78-90) years, and 15.0% were Black. Overall, 16 956 (42.5%) PLWD received 45 122 prescription fills. The antibiotic use rate was 20.7 DOT per 1000 DOHC. Telephone visits and advanced practice provider visits were associated with 30.9% and 42.0% of fills, respectively. Sixty-seven percent of fills were associated with diagnoses for conditions where antibiotics are not indicated. Quinolones were the most prescribed class (24.3% of fills). The overall median length of therapy (IQR) was 7 (7-10) days. Antibiotic use rates varied across regions. Within regions, the median annual antibiotic use rate decreased from 2014 to 2018.

Conclusions

Antibiotic prescriptions were prevalent in HBPC. The scope, appropriateness, and harms of antibiotic use in homebound PLWD need further investigation.

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

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.

Factors Associated with Having Home Care Physicians as an Integrated Source of Medications for Chronic Conditions Among Homebound Patients

BACKGROUND

Inappropriate management of medications is a major threat to homebound patients with chronic conditions. Despite many efforts in improving medication reconciliation in ambulatory and inpatient settings, little research has focused on home care settings. In 2016, Taiwan initiated the Integrated Home Health Care programme, which was intended to reduce potentially inappropriate medication management and risks of uncontrolled polypharmacy through the integration of different medication sources for chronic conditions among homebound patients. This study investigated factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients.

METHODS

This retrospective cohort study enrolled 3,142 community-dwelling homebound patients from Taipei City Hospital. Homebound patients' adherence to using home care physicians as an integrated source of chronic condition medications was defined as having all prescriptions for their chronic conditions prescribed by a single home care physician for at least six months. Both patient and home care physician characteristics were analysed. Multivariable logistic regression was applied.

RESULTS

Of the 3,142 patients with chronic conditions, 1,002 (31.9%) had consistently obtained all medications for their chronic illnesses from their home care physicians for 6 months and 2,140 (68.1%) had not. The most common chronic diseases among homebound patients were hypertension, diabetes mellitus, dementia, cerebrovascular disease, and constipation. Oldest-old patients with poor functional status, fewer daily medications, no co-payment exemption, and no recent inpatient experience were more likely to adhere to this medication integration system. In addition, patients whose outpatient physicians were also their home care physicians were more likely to adhere to the system.

CONCLUSION

The finding suggests that building trust and enhancing communication among homebound patients, caregivers, and home care physicians are critical. Patient and provider variations highlight the need for further improvement and policy modification for medication reconciliation and management in home care settings. The improvement in medication management and care integration in home care settings may reduce misuse and polypharmacy and improve homebound patients' safety.

Prospective assessment of dementia on transitions in homeboundness using multistate Markov models

BACKGROUND

One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions.

METHODS

Using 2011-2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community-dwelling Medicare beneficiaries. Homebound status (independent, semi-homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self-report. Transition probabilities across states were assessed using a multistate Markov model.

RESULTS

Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two-fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia.

DISCUSSION

Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home-based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care.

Impact of home healthcare on end-of-life outcomes for people with dementia: a systematic review

BACKGROUND

Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD.

METHODS

Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes.

INTERVENTIONS

HHC.

PARTICIPANTS

At least 80% of study participants had dementia and lived at home.

MEASUREMENTS

Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes.

RESULTS

From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decision-making and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood.

CONCLUSIONS

This review highlights the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.

A mixed-methods evaluation of home-based primary care in dementia within an integrated system

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.

Using Telemedicine to Assess and Manage Psychosis Among Outpatients with Neurodegenerative Disease

The presence of hallucinations and delusions in patients with neurodegenerative disease correlates negatively with function, cognition, quality of life, and survival. When these patients still have insight, the treatment of mild hallucinations may reduce the risk of progression to more severe symptoms, specifically hallucinations without insight or delusions. On October 22, 2020, a multidisciplinary consensus panel comprising United States-based experts in geriatric psychiatry, geriatric medicine, family medicine, movement disorders, and neuropsychology was convened remotely to discuss best practices for using telemedicine to evaluate, diagnose, and treat psychosis in patients with neurodegenerative diseases. This review reflects the opinions and recommendations discussed at this meeting. Despite drawbacks, telemedicine can offer several advantages over in-person care, particularly for older adults, and may be a unique opportunity for care of patients with neuropsychiatric symptoms. While telemedicine may not be suitable for all patients, it allows the involvement of specialists from multiple geographic locations and the extension of care to homebound individuals. Patients with neurodegenerative diseases who are likely to become homebound as the disease advances may benefit greatly from telemedicine as a standard of care. Healthcare provided via telemedicine should be nothing less than what would be offered to the patient in person. Telemedicine may present some difficulties, including technological issues and inherent constraints of remote care, but with proper planning many problems could be diminished. Technical issues associated with telemedicine are inevitable but may be partially offset by providing clear directions ahead of any tele-visit to ensure connectivity and access to the videoconferencing platform. Alternative procedures to communicate should be established in the eventuality of technological issues. Using these strategies, telemedicine can serve as a valuable complement to traditional in-person practices for the diagnosis and management of hallucinations and delusions associated with Parkinson’s disease psychosis or dementia-related psychosis.

Quality indicators for dementia and older people nearing the end of life: A systematic review

BACKGROUND

Robust quality indicators (QIs) are essential for monitoring and improving the quality of care and learning from good practice. We aimed to identify and assess QIs for the care of older people and people with dementia who are nearing the end of life and recommend QIs for use with routinely collected electronic data across care settings.

METHODS

A systematic review was conducted, including five databases and reference chaining. Studies describing the development of QIs for care of older people and those with dementia nearing the end of life were included. QIs were categorized as relating to processes or outcomes, and mapped against six care domains. The psychometric properties (acceptability, evidence base, definition, feasibility, reliability, and validity) of each QI were assessed; QIs were categorized as robust, moderate, or poor.

RESULTS

From 12,980 titles and abstracts screened, 37 papers and 976 QIs were included. Process and outcome QIs accounted for 780 (79.7%) and 196 (20.3%) of all QIs, respectively. Many of the QIs concerned physical aspects of care (n = 492, 50.4%), and very few concerned spiritual and cultural aspects of care (n = 19, 1.9%). Three hundred and fifteen (32.3%) QIs were robust and of those 220 were measurable using routinely collected electronic data. The final shortlist of 71 QIs came from seven studies.

CONCLUSIONS

Of the numerous QIs developed for care of older adults and those with dementia nearing the end of life, most had poor or moderate psychometric properties or were not designed for use with routinely collected electronic datasets. Infrastructure for data availability, combined with use of robust QIs, is important for enhancing understanding of care provided to this population, identifying unmet needs, and improving service provision.

Home Based Palliative Care: Known Benefits and Future Directions

Purpose of Review

To summarize key recent evidence regarding the impact of Home-Based Palliative Care (HBPalC) and to highlight opportunities for future study.

Recent Findings

HBPalC is cost effective and benefits patients and caregivers across the health care continuum.

Summary

High-quality data support the cost effectiveness of HBPalC. A growing literature base supports the benefits of HBPalC for patients, families, and informal caregivers by alleviating symptoms, reducing unwanted hospitalizations, and offering support at the end of life. Numerous innovative HBPalC models exist, but there is a lack of high-quality evidence comparing specific models across subpopulations. Our wide literature search captured no research regarding HBPalC for underserved populations. Further research will also be necessary to guide quality standards for HBPalC.

A Qualitative Study of the Social and Lived Experiences of Homebound Older Adults

OBJECTIVE

The number of homebound older adults is increasing in the United States. We aimed to examine their social and lived experiences and to understand their perspectives on their situation, feelings, and coping mechanisms.

METHODS

We conducted a cross-sectional qualitative study using semi-structured interviews with 18 older homebound individuals in Central Virginia.

RESULTS

Homebound older adults experienced both physical and mental health challenges that restricted their ability to participate in activities of daily living, recreation, and social interactions. Participants often felt dependent, helpless, lonely, and socially isolated. Those who communicated regularly with friends, family, and health care providers reported positive benefits from these interactions.

DISCUSSION

Participants faced challenges to their physical, emotional, and mental well-being. Our findings might help clinicians, policymakers, and community organizations understand how to better support homebound older adults. We should provide educational opportunities, respect their autonomy, and implement initiatives to address their isolation and loneliness.

Evaluation of a Home-Based, Nurse Practitioner-led Advanced Illness Care Program

OBJECTIVES

In the United States, people with serious illness often experience gaps and discontinuity in care. Gaps are frequently exacerbated by limited mobility, need for social support, and challenges managing multiple comorbidities. The Advanced Illness Care (AIC) Program provides nurse practitioner-led, home-based care for people with serious or complex chronic illnesses that specifically targets palliative care needs and coordinates with patients' primary care and specialty health care providers. We sought to investigate the effect of the AIC Program on hospital encounters [hospitalizations and emergency department (ED) visits], hospice conversion, and mortality.

DESIGN

Retrospective nearest-neighbor matching.

SETTING AND PARTICIPANTS

Patients in AIC who had ≥1 inpatient stay within the 60 days prior to AIC enrollment to fee-for-service Medicare controls at 9 hospitals within one health system.

METHODS

We matched on demographic characteristics and comorbidities, with exact matches for diagnosis-related group and home health enrollment. Outcomes were hospital encounters (30- and 90-day ED visits and hospitalizations), hospice conversion, and 30- and 90-day mortality.

RESULTS

We included 110 patients enrolled in the AIC Program matched to 371 controls. AIC enrollees were mean age 77.0, 40.9% male, and 79.1% white. Compared with controls, AIC enrollees had a higher likelihood of ED visits at 30 [15.1 percentage points, confidence interval (CI) 4.9, 25.3; P = .004] and 90 days (27.8 percentage points, CI 16.0, 39.6; P < .001); decreased likelihood of hospitalization at 30 days (11.4 percentage points, CI -17.7, -5.0; P < .001); and a higher likelihood of converting to hospice (22.4 percentage points, CI 11.4, 33.3; P < .001).

CONCLUSIONS

The AIC Program provides care and coordination that the home-based serious illness population may not otherwise receive.

IMPLICATIONS

By identifying and addressing care needs and gaps in care early, patients may avoid unnecessary hospitalizations and receive timely hospice services as they approach the end of life.

COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey

Objectives

Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic.

Design

Mixed-methods national survey.

Setting and Participants

HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs.

Methods

Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions.

Results

Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%).

Conclusions and Implications

HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.

Pharmacist medication review: An integrated team approach to serve home-based primary care patients

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.

Receipt Of Home-Based Medical Care Among Older Beneficiaries Enrolled In Fee-For-Service Medicare

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.

The dynamics of being homebound over time: A prospective study of Medicare beneficiaries, 2012-2018

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.

In Traditional Medicare, Modest Growth In The Home Care Workforce Largely Driven By Nurse Practitioners

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.

Home Health Agencies: Empirical Evidence on the Patient-Driven Groupings Model’s Expected Effects on Agency Reimbursements

Beginning January 1, 2020, Medicare’s Patient-Driven Groupings Model (PDGM) eliminated therapy as a direct determinant of Home Health Agencies’ (HHAs’) reimbursements. Instead, PDGM advances Medicare’s shift toward value-based payment models by directly linking HHAs’ reimbursements to patients’ medical conditions. We use 3 publicly-available datasets and ordered logistic regression to examine the associations between HHAs’ pre-PDGM provision of therapy and their other agency, patient, and quality characteristics. Our study therefore provides evidence on PDGM’s likely effects on HHA reimbursements assuming current patient populations and service levels do not change. We find that PDGM will likely increase payments to rural and facility-based HHAs, as well as HHAs serving greater proportions of non-white, dual-eligible, and seriously ill patients. Payments will also increase for HHAs scoring higher on quality surveys, but decrease for HHAs with higher outcome and process quality scores. We also use ordinary least squares regression to examine residual variation in HHAs’ expected reimbursement changes under PDGM, after accounting for any expected changes related to their pre-PDGM levels of therapy provision. We find that larger and rural HHAs will likely experience residual payment increases under PDGM, as will HHAs with greater numbers of seriously ill, younger, and non-white patients. HHAs with higher process quality, but lower outcome quality, will similarly benefit from PDGM. Understanding how PDGM affects HHAs is crucial as policymakers seek ways to increase equitable access to safe and affordable non-facility-provided healthcare that provides appropriate levels of therapy, nursing, and other care.

Implementing Health Care Quality Measures in Electronic Health Records: A Conceptual Model

BACKGROUND/OBJECTIVES

There is significant literature on the development and validation of quality measures, but comparably less on their implementation into learning health systems. Electronic Health Records (EHRs) have made vast amounts of data available for quality improvement purposes. In this paper we describe a conceptual model for EHR implementation of quality measures.

DESIGN

The model involves five steps: (1) select a measure; (2) define measure criteria; (3) validate criteria and measurement process; (4) improve recording of measure-related activity; and (5) engage quality improvement processes. The model was used to develop and implement a quality measure in the Home-Based Medical Care (HBMC) setting.

SETTING

Harris Health House Call Program (HHHC) provides primary medical and palliative care for homebound patients in Houston.

PARTICIPANTS

Four-hundred twenty-four primary care patients followed in the HHHC.

MEASUREMENT

Completion rate of the 9-item Patient Health Questionnaire (PHQ-9) within the Electronic Health Record of newly enrolled HHHC patients.

RESULTS

Use of the conceptual model to guide implementation of a quality measure of depression screening in a HMBC practice was successful. Additional components of early leadership and clinician buy-in were required, as well as strong relationships with IT to ease implementation and limit disruptions in clinicians' work-flow.

CONCLUSION

This conceptual model was feasible for guiding implementation of a quality measure for depression care of HBMC patients, and it can guide broader implementation of EHR-based quality measures in the future.

VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans

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.

Attitudes of Homebound Older Adults and Their Caregivers Toward Research and Participation as Research Advisors

Background and Objectives

Homebound older adults and their caregivers have not historically been engaged as advisors in patient-centered outcomes research. This study aimed to understand the attitudes of homebound older adults and their caregivers toward research and participation as research advisors.

Research Design and Methods

Descriptive thematic analysis of semistructured interviews conducted with 30 homebound older adults and caregivers recruited from home-based medical care practices. Interview questions addressed opinions on research and preferences for engaging as research advisors.

Results

Of 30 participants, 22 were female, 17 were people of color, and 11 had Medicaid. Two themes emerged related to perceptions of research overall: (a) utility of research and (b) relevance of research. Overall, participants reported positive attitudes toward research and felt that research could affect people like them. Three themes emerged related to participating as research advisors: (a) motivators, (b) barriers, and (c) preferences. Participants were open to engaging in a variety of activities as research advisors. Most participants were motivated by helping others. Common barriers included time constraints and caregiving responsibilities, and physical barriers for homebound individuals. Participants also reported fears such as lacking the skills or expertise to contribute as advisors. Many were willing to participate if these barriers were accommodated and shared their communication preferences.

Discussion and Implications

Diverse homebound older adults and caregivers are willing to be engaged as research advisors and provided information to inform future engagement strategies. Findings can inform efforts to meet new age-inclusive requirements of the National Institutes of Health.

Effects of an Integrated Palliative Care Pathway: More Proactive GPs, Well Timed, and Less Acute Care: A Clustered, Partially Controlled Before-After Study

OBJECTIVES

This study presents the design of an integrated, proactive palliative care pathway covering the full care cycle and evaluates its effects using 3 types of outcomes: (1) physician-reported outcomes, (2) outcomes reported by family, and (3) (utilization of) health care outcomes.

DESIGN

A clustered, partially controlled before-after study with a multidisciplinary integrated palliative care pathway as its main intervention.

SETTING AND PARTICIPANTS

after assessment in hospital departments of oncology, and geriatrics, and in 13 primary care facilities, terminally ill patients were proactively included into the pathway. Patients' relatives and patients' general practitioners (GPs) participated in a before/after survey and in interviews and focus groups.

INTERVENTION

A multidisciplinary, integrated palliative care pathway encompassing (among others) early identification of the palliative phase, multidisciplinary consultation and coordination, and continuous monitoring of outcomes.

MEASURES

Measures included GP questionnaire: perceived quality of palliative care; questionnaires by family members: FAMCARE, QOD-LTC, EDIZ; and 3 types of health care outcomes: (1) utilization of primary care: consultations, intensive care, communication, palliative home visits, consultations and home visits during weekends and out-of-office-hours, ambulance, admission to hospital; (2) utilization of hospital care: outpatient ward consultations, day care, emergency room visits, inpatient care, (radio) diagnostics, surgical procedures, other therapeutic activities, intensive care unit activities; (3) pharmaceutical care utilization.

RESULTS

GPs reported that palliative patients die more often at their preferred place of death, and that they now act more proactively toward palliative patients. Relatives of included, deceased patients reported clinically relevant improved quality of dying, and more timely palliative care. Patients in the pathway received more (intensive) primary care, less unexpected care during out-of-office hours, and more often received hospital care in the form of day care.

CONCLUSIONS AND IMPLICATIONS

An integrated palliative care pathway improves a variety of clinical outcomes important to patients, their families, physicians, and the health care system. The integration of palliative care into multidisciplinary, proactive palliative care pathways, is therefore a desirable future development.

The Association Between Income and Incident Homebound Status Among Older Medicare Beneficiaries

IMPORTANCE

A large and growing population of older adults with multimorbidity, cognitive impairment, and functional disability live in the community, but many never or rarely leave their homes. Being homebound is associated with decreased access to medical services, poor health outcomes, and increased mortality. Yet, it is unknown what factors, in particular socioeconomic factors, are associated with new onset of homebound status.

OBJECTIVE

To evaluate the association between income and risk of becoming homebound.

DESIGN

Observational cohort study using 2011 to 2018 data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries aged 65 years and older.

SETTING

Population-based study in the United States.

PARTICIPANTS

A total of 7,042 initially nonhomebound community-dwelling older adults.

EXPOSURE

Total annual household income at baseline (in 2011) measured via self-report.

OUTCOME

Annual measure of homebound status, defined as leaving home an average of 1 d/wk or less.

RESULTS

Over 7 years, 15.81% of older adults in the lowest income quartile (≤$15,003) became homebound, compared with only 4.64% of those in the highest income quartile (>$60,000). In a competing risks analysis accounting for risks of death and nursing home admission, and adjusted for clinical and demographic characteristics, those in the lowest income quartile had a substantially higher subhazard of becoming homebound than those in the highest income quartile (1.65; 95% confidence interval = 1.20-2.29). Moreover, we see evidence of a gradient in risk of homebound status by income quartile.

CONCLUSION AND RELEVANCE

Our work demonstrates that financial resources shape the risk of becoming homebound, which is associated with negative health consequences. In the context of existing income disparities, more support is needed to assist older adults with limited financial resources who wish to remain in the community.

Trajectories of Homebound Status in Medicare Beneficiaries Aged 65 and Older

BACKGROUND AND OBJECTIVES

The purpose of this study was to examine the trajectories of homebound status in older adults and to investigate the risk factors in shaping the pattern of these trajectories.

RESEARCH DESIGN AND METHODS

The study sample was a nationally representative sample of Medicare beneficiaries aged 65 and older (N = 7,607) from the National Health and Aging Trends Study (Round 1-Round 7). Homebound state was defined as never or rarely went out the home in the last month. Homebound trajectories were identified using an enhanced group-based trajectory modeling that accounted for nonrandom attrition. Multinomial logistic regression was used to examine risk factors of homebound trajectories.

RESULTS

Three trajectory groups were identified: the "never" group (65.5%) remained nonhomebound; the "chronic" group were largely persistently homebound (8.3%); and the "onset" group (26.2%) had a rapid increase in their risk of being homebound over the 7-year period. The following factors increased the relative risk for being on the "onset" and "chronic" versus the "never" trajectory: older age, Hispanic ethnicity, social isolation, past or current smoking, instrumental activities of daily living limitations, probable dementia, and use of a walker or wheelchair. Male sex and living alone were associated with a lower risk of being on the "chronic" trajectory, whereas depression and anxiety symptoms, chronic conditions, and activities of daily living limitations increased the risk.

DISCUSSION AND IMPLICATIONS

The progression of homebound status among community-dwelling older adults followed three distinct trajectories over a 7-year period. Addressing social isolation and other risk factors may prevent or delay the progression to homebound state.

Evaluating the care provision of a community-based serious-illness care program via chart measures

BACKGROUND

Although quality-of-care domains for home-based primary and palliative programs have been proposed, they have had limited testing in practice. Our aim was to evaluate the care provision in a community-based serious-illness care program, a combined home-based primary and palliative care model.

METHODS

Retrospective chart review of patients in an academic community-based serious-illness care program in central North Carolina from August 2014 to March 2016 (n = 159). Chart review included demographics, health status, and operationalized measures of seven quality-of-care domains: medical assessment, care coordination, safety, quality of life, provider competency, goal attainment, and access.

RESULTS

Patients were mostly women (56%) with an average age of 70 years. Patients were multi-morbid (53% ≥3 comorbidities), functionally impaired (45% had impairment in ≥2 activities of daily living) and 32% had dementia. During the study period, 31% of patients died. Chart review found high rates assessment of functional status (97%), falls (98%), and medication safety (96%). Rates of pain assessment (70%), advance directive discussions (65%), influenza vaccination (59%), and depression assessment (54% of those with a diagnosis of depression) were lower. Cognitive barriers, spiritual needs, and behavioral issues were assessed infrequently (35, 22, 21%, respectively).

CONCLUSION

This study is one of the first to operationalize and examine quality-of-care measures for a community-based serious-illness care program, an emerging model for vulnerable adults. Our operationalization should not constitute validation of these measures and revealed areas for improvement; however, the community-based serious-illness care program performed well in several key quality-of-care domains. Future work is needed to validate these measures.

A qualitative study of health-care experiences and challenges faced by ageing homebound adults

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.

Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments

BACKGROUND

Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking.

OBJECTIVE

We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments.

DESIGN

Population-based retrospective cohort study.

SETTING

The setting was Ontario, Canada, from October 2014 to September 2016.

PARTICIPANTS

Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care.

MEASUREMENTS

We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment.

RESULTS

There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits.

CONCLUSION

Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.

What's Happening at Home: A Claims-based Approach to Better Understand Home Clinical Care Received by Older Adults

BACKGROUND

Home clinical care (HCC) includes home-based medical care (HBMC-medical visits in the home) and skilled home health care (skilled nursing or therapy visits). Over 7 million older adults would benefit from HCC; however, we know surprisingly little about homebound older adults and HCC.

OBJECTIVE

To describe HCC received by older adults using claims data within the OptumLabs Data Warehouse.

RESEARCH DESIGN

Using administrative claims data for commercial and Medicare Advantage enrollees, we describe morbidity profiles, health service use, and care coordination (operationalized as care plan oversight [CPO]) for people receiving HCC and the subgroup receiving HBMC.

PARTICIPANTS

Three million adults (3,027,247) age ≥65 with 12 months of continuous enrollment 2013-2014.

MEASURES

CPT or HCPCS codes delineated HCC, HBMC, and CPO recipients and care site, frequency, and provider type. Other measures included demographic characteristics, clinical characteristics, and health care utilization.

RESULTS

Overall, 5% of the study population (n=161,801) received 2+ months of HCC visits; of these, 46% also received 2+ HBMC visits (n=73,638) while 54% received only skilled home health (n=88,163 HCC but no HBMC). HBMC-recipients had high comorbidity burden (Charlson score 4.3), dementia (35%), and ambulance trips (58%), but few nursing facility admissions (4.9%). Evidence of care coordination (CPO claims) occurred in 30% of the HCC population, 46% of HBMC, and 17% of the skilled home health care only.

CONCLUSIONS

Approximately 1 of 20 older adults in this study received HCC; 30% or less have a claim for care coordination by their primary care provider.

Triaging the Terminally Ill-Development of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool

CONTEXT

Evidence-based resource allocation is receiving increasing attention as we strive for equity, transparency, and cost-effectiveness across health care. In the context of finite resources, which of our patients with terminal illness should be prioritized for urgent palliative care?

OBJECTIVES

To develop the scoring system for the novel Responding to Urgency of Need in Palliative Care triage tool.

METHODS

Online international discrete choice experiment involving palliative care clinicians to establish the relative importance of seven key attributes of palliative care triage identified during an earlier qualitative study.

RESULTS

Participants (n = 772) were mainly female (79.9%) with a decade of clinical experience. All attributes contributed significantly (all P-values < 0.001) and independently to clinician assessment of urgency. This study found physical suffering (coefficient 3.45; 95% confidence interval: 3.24 to 3.66) was the most important determinant of urgency, followed by imminent dying (coefficient 1.56; 1.43 to 1.69), psychological suffering (coefficient 1.49; 1.37 to 1.60), caregiver distress (coefficient 1.47; 1.35 to 1.59), discrepancy between care needs and care arrangements (coefficient 1.14; 1.02 to 1.26), mismatch between current and desired site of care (coefficient 0.94; 0.85 to 1.03), and unmet communication needs (coefficient 0.84; 0.76 to 0.92).

CONCLUSION

Palliative care triage, which is complex and contextual, has been made more transparent through this discrete choice experiment. The Responding to Urgency of Need in Palliative Care triage tool provides an important step toward evidence-based assessment of priority for palliative care. Further research is underway to determine the validity of the tool in clinical practice and its impact on patient and caregiver outcomes.

General practitioners' perceptions of best practice care at the end of life: a qualitative study

BACKGROUND

GPs can play a central role in palliative care delivery. However, little is known about their views on what constitutes best practice care at the end of life.

AIM

To explore, in a sample of Australian GPs, their perceptions of best practice palliative care and their ideal role in its delivery.

DESIGN & SETTING

A qualitative interview study of 25 GPs practising in metropolitan and non-metropolitan locations in New South Wales, Australia.

METHOD

Semi-structured telephone interviews were conducted. Data were analysed using qualitative content analysis.

RESULTS

Participants had a mean age of 51 years, and had practised between 3 and 38 years (mean 19 years). Best practice palliative care was perceived to be proactive and responsive to a wide range of patient and family needs. Many participants indicated a need for relational continuity, which involves GPs establishing a care pathway from diagnosis to palliation, coordinating care across the pathway, and collaborating with other healthcare providers. A number of participants perceived palliative care as a natural extension of primary care and indicated that best practice palliative care mainly requires experiential knowledge and good communication skills, rather than specialised medical knowledge. Participants listed a number of communication strategies to offer patients and their families choice and ongoing negotiation about the recommended treatments.

CONCLUSION

This study provides novel in-depth insights into GPs' perceptions of best practice palliative care. Future research should further investigate the identified features of care, and whether they can maximise the outcomes of patients and their families.

Palliative Care in a Community-Based Serious-Illness Care Program

Background: Although community-based serious-illness care (CBSC) is an innovative care model, it is unclear to what extent CBSC addresses palliative care needs, particularly for those patients near death. Objectives: To evaluate palliative care services of a CBSC program. Design: Retrospective chart reviews. Setting/Subjects: Patients enrolled in a CBSC program in central North Carolina. Measurement: Descriptive statistics of palliative care needs and services, such as symptom management, psychosocial support, and advance care planning (ACP), for survivors and decedents. Results: Patients were seen in an 18-month time frame (n = 159). Mean enrollment in the program was 261.1 days (standard deviation 180.6). Patients' average age was 70 years, 56% were female, and 33% were black. Patients' most frequent comorbidities were dementia (32%), heart failure (32%), and diabetes (28%). Fifty patients (31%) died during the study period. Clinicians most frequently screened for pain (70%), constipation (57%), and dyspnea (57%). Of those screened positive, clinicians most frequently treated pain (92%), anxiety (84%), and constipation (83%). Among the 54% who screened positive for psychosocial distress, 82% received support. Clinicians screened 22% for spiritual needs; 4% received spiritual care. Among decedents, 66% were enrolled in hospice; 14% died in in-hospital. Decedents were more likely than survivors to have ACP (34% vs. 18%, p = 0.03) and a primary goal of comfort (40% vs. 12%, p < 0.01). Conclusions: A CBSC program provided palliative care services comparable with other home-based palliative care programs. Although the CBSC program does not address all domains of palliative care, it provided most with symptom management, psychosocial support, and ACP.

Care Team Perspectives and Acceptance of Telehealth in Scaling a Home-Based Primary Care Program: Qualitative Study

Background

Novel and sustainable approaches to optimizing home-based primary care (HBPC) programs are needed to meet the medical needs of a growing number of homebound older adults in the United States. Telehealth may be a viable option for scaling HBPC programs.

Objective

The purpose of this qualitative study was to gain insight into the perspectives of HBPC staff regarding adopting telehealth technology to increase the reach of HBPC to more homebound patients.

Methods

We collected qualitative data from HBPC staff (ie, physicians, registered nurses, nurse practitioners, care managers, social workers, and medical coordinators) at a practice in the New York metropolitan area through 16 semistructured interviews and three focus groups. Data were analyzed thematically using the template analysis approach with Self-Determination Theory concepts (ie, relatedness, competence, and autonomy) as an analytical lens.

Results

Four broad themes—pros and cons of scaling, technology impact on staff autonomy, technology impact on competence in providing care, and technology impact on the patient-caregiver-provider relationship—and multiple second-level themes emerged from the analysis. Staff acknowledged the need to scale the program without diminishing effective patient-centered care. Participants perceived alerts generated from patients and caregivers using telehealth as potentially increasing burden and necessitating a rapid response from an already busy staff while increasing ambiguity. However, they also noted that telehealth could increase efficiency and enable more informed care provision. Telehealth could enhance the patient-provider relationship by enabling caregivers to be an integral part of the patient’s care team. Staff members raised the concern that patients or caregivers might unnecessarily overutilize the technology, and that some home visits are more appropriate in person rather than via telehealth.

Conclusions

These findings suggest the importance of considering the perspectives of medical professionals regarding telehealth adoption. A proactive approach exploring the benefits and concerns professionals perceive in the adoption of health technology within the HBPC program will hopefully facilitate the optimal integration of telehealth innovations.

Stressors Facing Home-Based Primary Care Providers

The numbers of homebound patients in the United States are increasing. Home-based primary care (HBPC) is an effective model of interdisciplinary care that has been shown to have high patient satisfaction rates and excellent clinical outcomes. However, there are few clinicians that practice HBPC and clinicians that do face additional stressors. This study sought to better understand the stressors that HBPC providers face in caring for homebound patients. This was a cross-sectional qualitative survey and analysis of HBPC providers. Responses were categorized into four themes: The patient in the home setting, caregiver support, logistics, and administrative concerns. This research is the first to analyze the stressors that providers of HBPC face in serving the needs of complex homebound patients. Awareness and attention to these issues will be important for the future sustainability of home-based primary care.

Managing Pain in Chronically Ill Homebound Patients Through Home-Based Primary and Palliative Care

BACKGROUND:

Many older adults are homebound due to chronic illness and suffer from significant symptoms, including pain. Home-based primary and palliative care (HBPC), which provides interdisciplinary medical and psychosocial care for this population, has been shown to significantly reduce symptom burden. However, little is known about how pain is managed in the homebound.

OBJECTIVE:

This article describes pain management for chronically, ill homebound adults in a model, urban HBPC program.

DESIGN/MEASUREMENTS:

This was a prospective observational cohort study of newly enrolled HBPC patients, who completed a baseline Edmonton Symptom Assessment System (ESAS) survey during the initial HBPC visit (N = 86). Baseline pain burden was captured by ESAS and pain severity was categorized as none, mild, or moderate-severe. All pain-related assessments and treatments over a 6-month period were categorized by medication type and titration, referrals to outside providers, procedures, and equipment.

RESULTS:

At baseline, 55% of the study population had no pain, 18% had mild pain, and 27% had moderate-severe pain. For those with moderate-severe pain at baseline (n = 23), prescriptions for pharmacological treatments for pain, such as opiates and acetaminophen, increased during the study period from 48% to 57% and 52% to 91%, respectively. Nonpharmacological interventions, including referrals to outside providers such as physical therapy, procedures, and equipment for pain management, were also common and 67% of the study population received a service referral during the follow-up period.

CONCLUSIONS:

Pharmacological and nonpharmacological treatments are widely used in the setting of HBPC to treat the pain of homebound, older adults.