Challenges for Home Health Care Providers: A Needs Assessment

The effects of occupational and mental stress among home care rehabilitation professionals working during the COVID-19 pandemic: An exploratory qualitative study

Home care rehabilitation professionals (hcRPs) provide health services for clients with a broad range of medical conditions. During the COVID-19 pandemic, home care rehabilitation professionals experienced exacerbations of pre-existing work-related stressors, increased risk of transmission of the COVID-19 virus, reduced resource availability, greater workloads, and staffing shortages. The primary aim of this study was to examine the experience and impact of occupational and mental stress on hcRPs working during the COVID-19 pandemic. Semi-structured interviews were conducted with 24 hcRPs working in Ontario, Canada during the COVID-19 pandemic. Inductive thematic analysis was used to interpret and organize the data into conceptualized themes. Interview data was organized into three themes: (a) unique challenges of a home care rehabilitation professional, (b) COVID-19 exacerbations of home care occupational and mental stress, and (c) personal and workplace coping strategies. Many participants reported reducing their hours or taking on adjunctive roles in different clinical settings outside of home care due to work-related stress exacerbated by the COVID-19 pandemic. With a focus on the effects of COVID-19 on the practice of home care, this study provides a unique perspective on the challenges experienced by hcRPs during an emergent and evolving global public health concern. The exploratory nature of this research works towards providing a framework of factors to be addressed when creating sustainable healthcare interventions, as well as recommendations to support hcRPs to benefit both the community and health-care providers.

Transition of care from post-acute services for the older adults in Quebec: a pilot impact evaluation

BACKGROUND

Early discharge of frail older adults from post-acute care service may result in individuals' reduced functional ability to carry out activities of daily living, and social, emotional, and psychological distress. To address these shortcomings, the Montreal West Island Integrated University Health and Social Services Centre in Quebec, Canada piloted a post-acute home physiotherapy program (PAHP) to facilitate the transition of older adults from the hospital to their home. This study aimed to evaluate: (1) the implementation fidelity of the PAHP program; (2) its impact on the functional independence, physical and mental health outcomes and quality of life of older adults who underwent this program (3) its potential adverse events, and (4) to identify the physical, psychological, and mental health care needs of older adults following their discharge at home.

METHODS

A quasi-experimental uncontrolled design with repeated measures was conducted between April 1st, 2021 and December 31st, 2021. Implementation fidelity was assessed using three process indicators: delay between referral to and receipt of the PAHP program, frequency of PAHP interventions per week and program duration in weeks. A battery of functional outcome measures, including the Functional Independence Measure (FIM) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 scale, as well as fall incidence, emergency visits, and hospitalizations were used to assess program impact and adverse events. The Patient's Global Impression of Change (PGICS) was used to determine changes in participants' perceptions of their level of improvement/deterioration. In addition, the Camberwell Assessment of Need for the Elderly (CANE) questionnaire was administered to determine the met and unmet needs of older adults.

RESULTS

Twenty-four individuals (aged 60.8 to 94 years) participated in the PAHP program. Implementation fidelity was low in regards with delay between referral and receipt of the program, intensity of interventions, and total program duration. Repeated measures ANOVA revealed significant improvement in FIM scores between admission and discharge from the PAHP program and between admission and the 3-month follow-up. Participants also reported meaningful improvements in PGICS scores. However, no significant differences were observed on the physical or mental health T-scores of the PROMIS Global-10 scale, in adverse events related to the PAHP program, or in the overall unmet needs.

CONCLUSION

Findings from an initial sample undergoing a PAHP program suggest that despite a low implementation fidelity of the program, functional independence outcomes and patients' global impression of change have improved. Results will help develop a stakeholder-driven action plan to improve this program. A future study with a larger sample size is currently being planned to evaluate the overall impact of this program.

CLINICAL TRIAL REGISTRATION

Retrospectively registered NCT05915156 (22/06/2023).

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Distilling lessons from home hospital implementation: a narrative scoping review

INTRODUCTION

Multiple Cochrane Reviews have demonstrated 'hospital at home' (HaH) as a promising healthcare model to be explored, with benefits such as higher care quality, reduced readmissions, shorter lengths of stay, lower cost and greater patient satisfaction. While there have been many reviews focusing on the quantitative clinical outcomes of HaH, there is generally a lack of collation of qualitative insights from stakeholders and lessons learnt from past HaH implementation.

METHODS

We performed a systematic literature search on four databases and included 17 papers involving the provision of acute and/or subacute care by healthcare professionals in patients' homes. Review characteristics and relevant outcomes were extracted from the reported findings and tables in the reviews, and these included stakeholder attitudes and factors contributing to the success of HaH implementation.

RESULTS

Factors relating to patients and caregivers included home setup, preference for care and death settings, and support for caregiver. Factors involving the healthcare professionals and intervention included a multidisciplinary care team, accessibility to emergency care and support, training of providers and patients, adequate manpower allocation, robust eligibility and referral criteria, sufficient awareness of the HaH referral pathway, communication and medication management.

CONCLUSION

HaH presents a promising alternative care model, and many of the success factors identified, including the strong push for multidisciplinary single care teams, existing frameworks for data sharing and strong community network, are already present today. As such, Singapore appears to be well positioned to adopt a new care model like HaH.

"Caregiving is teamwork…" Information sharing in home care for older adults with disabilities living in the community

AIM

We examined information sharing between direct care workers, family caregivers, and clinicians involved in the care of older adults with disabilities.

METHODS

Semi-structured interviews with N = 11 representatives of home care agencies ("residential service agencies" in Maryland).

RESULTS

Work system and process characteristics relevant to information sharing included: (1) using electronic management systems and patient portals to communicate within agencies and with clinicians, (2) implementing tools to gather information about client goals, preferences, and routines, and (3) relying on family members for information about clients' needs. Participants did not report differences in dementia-related care coordination; however, dementia-related adaptations involved additional considerations for navigating relationships with family and standardizing processes to communicate with clinicians.

CONCLUSION

Findings highlight care demands experienced by direct care workers and support calls to better coordinate information sharing between interdisciplinary care teams.

Home Health Care Workers' Interactions with Medical Providers, Home Care Agencies, and Family Members for Patients with Heart Failure

BACKGROUND

Despite providing frequent care to heart failure (HF) patients, home health care workers (HHWs) are generally considered neither part of the health care team nor the family, and their clinical observations are often overlooked. To better understand this workforce's involvement in care, we quantified HHWs' scope of interactions with clinicians, health systems, and family caregivers.

METHODS

Community-partnered cross-sectional survey of English- and Spanish-speaking HHWs who cared for a HF patient in the last year. The survey included 6 open-ended questions about aspects of care coordination, alongside demographic and employment characteristics. Descriptive statistics were performed.

RESULTS

Three hundred ninety-one HHWs employed by 56 unique home care agencies completed the survey. HHWs took HF patients to a median of 3 doctor appointments in the last year with 21.9% of them taking patients to ≥ 7 doctor appointments. Nearly a quarter of HHWs reported that these appointments were in ≥ 3 different health systems. A third of HHWs organized care for their HF patient with ≥ 2 family caregivers.

CONCLUSIONS

HHWs' scope of health-related interactions is large, indicating that there may be novel opportunities to leverage HHWs' experiences to improve health care delivery and patient care in HF.

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

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

Community-based personal support workers' satisfaction with job-related training at the organization in Ontario, Canada: Implications for future training

BACKGROUND AND AIMS

Complexity of community-based homecare for older adults has increased significantly in the past decade in Ontario, Canada. Personal support workers (PSWs), who are unregulated and vary in formal education, provide the majority of community homecare work for increasingly complex clients. This paper seeks to understand community-based PSWs' satisfaction with opportunities for job-related training at their employing organization to provide the skills and knowledge to meet the demands of their evolving role.

METHODS

Data for this paper are from a cross-sectional survey of 1746 community-based PSWs in Ontario, Canada entitled, "The PSW Health and Safety Matters Survey" www.pswshaveasay.ca. This survey was part of a research project "Keeping Community Based PSWs Safe in a Changing World of Work," funded by the Ontario Ministry of Labour. The data were analyzed using descriptive statistics, correlations, multivariate regression, and thematic analysis.

RESULTS

Quantitative analysis revealed most community homecare organizations offer PSWs job-related training to help them retain and update their skills and that PSWs have a moderate level of satisfaction with their job-related training. The analysis revealed that PSWs' satisfaction with organizational training is greater when the organization provides work-related training on challenging tasks, lifting and transferring tasks, and tasks delegated by nurses and supervisors. Data from the open-ended question highlighted seven key themes for desired training by PSWs: safe body mechanics for moving/lifting clients, managing aggression primarily with clients, infection control, CPR/first aid, mental illness, equipment training, and basic health and safety.

CONCLUSION

Implications for factors associated with PSWs' satisfaction with opportunities for job-related training are discussed along with recommendations for mitigating variability in education and training to meet the demands of their evolving role.

Primary care providers' perceptions and experiences of family-centered care for older adults: a qualitative study of community-based diabetes management in China

Background

Family-centered care, as a contemporary model of health service delivery, involves a mutually beneficial partnership between healthcare providers, patients and their families. Although evidence on the positive effects of family-centered care on older adults and their families is accumulating, less is known about the providers’ beliefs, attitudes and practices related to family-centeredness, especially regarding community-based primary healthcare services for the rapidly-ageing Chinese population.

Methods

This study investigated Chinese primary care providers’ perceptions and experiences of family-centered care for older adults, using community-based diabetes management services as an example. Ten focus-group interviews involving 48 community health professionals were conducted. Major themes were identified using thematic analysis.

Results

The interviews revealed that the providers acknowledged the importance of the family in older patients’ diabetes management, while their current scope of practice with the patients’ families was limited and informal. The barriers to implementing family-centered care were attributed to structural and environmental obstacles associated with the patients’ families and the community healthcare context and culture. To engage patients’ families more effectively, the providers suggested that family-centered values endorsed by their healthcare organizations and reinforced by policies, a trained interdisciplinary team of health professionals and community social workers, and also that the utilization of technology would be beneficial.

Conclusions

Our study extends the evidence of family-centered care for older adults in Chinese community-based healthcare settings, contributing to the design of a tailored healthcare delivery model embodying ageing in place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02380-x.

Asian Attitudes and Perceptions Toward Hospital-At-Home: A Cross-Sectional Study

Introduction: Hospital-at-Home (HaH) programmes are well-established in Australia, Europe, and the United States. However, there is limited experience in Asia, where the hospital is traditionally seen as a safe and trusted space for healing. This cross-sectional study aimed to explore attitudes and perceptions among patients and caregivers in Singapore toward this care model. Methods: A quantitative study design was adopted to collect data among patients and their caregivers from medical wards within two acute hospitals in Singapore. Using a series of closed-ended and open-ended questions, the investigator-administered survey aimed to explore barriers and facilitators determining patients' and caregivers' responses. The study questionnaire was pretested and validated. Data were summarised using descriptive statistics, and logistic regression was performed to determine key factors influencing patients' decisions to enrol in such programmes. Results: Survey responses were collected from 120 participants (101 patients, 19 caregivers; response rate: 76%), of which 87 respondents (72.5%) expressed willingness to try HaH if offered. Many respondents valued non-quantifiable programme benefits, including perceived gains in quality of life. Among them, reasons cited for acceptance included preference for the comfort of their home environment, presence of family members, and confidence toward remote monitoring modalities. Among respondents who were unwilling to accept HaH, a common reason indicated was stronger confidence toward hospital care. Discussion: Most patients surveyed were open to having acute care delivered in their home environment, and concerns expressed may largely be addressed by operational considerations. The findings provide useful insights toward the planning of HaH programmes in Singapore.

Comparison of BRFSS Data Between Home-Based Care Providers and Health Care Support Workers in Clinical Environments in Washington State

Background: The demand for home-based health care support providers (HB providers) is growing as the locus of care shifts to private homes. However, industry representative data of these workers are limited. Methods: Washington Behavioral Risk Factor Surveillance System (WA BRFSS) data from 2011 to 2016 were analyzed to compare HB providers (n = 385) with health care support occupations not based in the home, non-HB providers (n = 229), and all other occupations (n = 32,011). Findings: More HB providers were overweight (4.2%, 95% confidence interval [CI] = [3.3%, 5.2%]) than non-HB providers and all other occupations. Significantly more HB providers had arthritis (33.2%, 95% CI = [27.0%, 39.4%]) and diabetes (9.4%, 95% CI = [5.7%, 13.2%]) than non-HB providers. Nearly twice as many HB providers currently smoked (31.3%, 95% CI = [24.2%, 38.4%]) than non-HB providers. Significantly more HB providers reported serious mental illness (6.8%, 95% CI = [2.8%, 10.7%]) than all other occupations (2.2%). Conclusion/Application to Practice: It is imperative to maintain good health in this home-based health care population as these workers are aging and their professional time becomes limited.

Constituents of effective support for homecare workers providing care to people with dementia at end of life

OBJECTIVE

The aim of this study was to enhance understanding about homecare workers providing care to people with dementia at end of life by exploring homecare workers' perceptions of challenges and the support they needed and sometimes received.

METHODS

Qualitative semi-structured interviews were conducted with 29 homecare workers and 13 homecare managers in England. Framework analysis was used to analyse the data.

FINDINGS

Four overarching challenges were identified: working with clients with dementia, including clients' sometimes unpredictable responses, communication difficulties, and mood changes; caring for the dying; conflict with family members; and working alone, which often left homecare workers at risk of exhaustion, fatigue, and a sense of isolation. When their work entailed high levels of emotion, such as a client's death or getting embroiled in a client's family conflict, they felt emotionally drained, under-prepared, and overwhelmed. Supportive elements include receiving encouragement and learning from experienced peers and their feelings being acknowledged by managers at their employing homecare agency. Some workers were offered time off or encouraged to attend the client's funeral as a means of supporting the process of bereavement.

CONCLUSIONS

Peer and manager support are essential and effective in coping with work pressures. There is a need to develop models of effective support to alleviate staff's practical, emotional, and interpersonal pressures. However, due to the isolating nature of homecare work, managers may not recognise early signs of their staff finding stress unmanageable and miss the opportunity to mitigate these negative effects.

The evolving role of the personal support worker in home care in Ontario, Canada

To meet increasing demand for home care, the role of personal support workers (PSWs) is shifting from providing primarily personal and supportive care to include care activities previously provided by regulated health professionals (RHPs). Much of the research examining this shift focuses on specialty programmes, with few studies investigating the daily care being provided by PSWs, frequency of care activities being provided by PSWs, and characteristics of the population receiving more complex tasks. Between January and April 2015, a review of 517 home-care service user charts was undertaken in Ontario, Canada, to: (1) describe the range of tasks being performed by PSWs in home care, (2) identify tasks transferred by RHPs to PSWs, and (3) examine characteristics of service users receiving transferred care. Findings indicate that normally, PSWs provide personal and supportive care commensurate with their training. However, in approximately one quarter of care plans reviewed, PSWs also completed more complex care activities transferred to them by RHPs. Service users receiving transferred care were older and had higher levels of cognitive and functional impairment. Although there is potential for the expansion of home-care services through increased utilisation of PSWs, healthcare leadership must ensure that the right provider is being utilised at the right time and in the right place to ensure safe and effective quality care. Thus, several actions are recommended: PSW core competencies be clearly articulated, processes used to transfer care activities from RHPs to PSWs be standardised and a team-based approach to the delivery of home-care services be considered. Utilisation of a team-based model can help establish positive relationships among home-care providers, provide increased support for PSWs, allow for easier scheduling of initial training and ensure regular reassessments of PSW competence among PSWs providing added skills.

An Intervention to Reduce Medication Noncompliance and Hospitalizations

Medication noncompliance is a major healthcare problem contributing to patients being rehospitalized shortly after they are discharged. In addition to financial penalties for certain diagnoses, health systems are penalized on quality measures for all rehospitalizations within 30 days, regardless of diagnosis. The purpose of this quality improvement project was to develop and implement a tool utilizing principles of the Theory of Goal Attainment to assist clinicians and patients in mutual goal setting to improve medication compliance, thus indirectly decreasing hospitalization rates. A tool that addresses mutual goal setting in the home healthcare setting was developed by a consultant and implemented at a midsized home healthcare agency. The tool stresses the patient's role in the process to attain goals and presents the clinician as a support system and educator. Effectiveness was evaluated based on data gathered from Home Health Compare. Improvement was noted in five quality indicators.

CHALLENGES OF TRAINING OLDER ADULTS IN A HOME HEALTH CARE CONTEXT

The health care domain is experiencing a shift from traditional hospital-based care to care delivered in a patient's home setting. Although home health care provides many benefits, it creates new challenges and difficulties for professional caregivers (e.g., registered nurses) who are performing complex medical tasks without the support often present in a health care environment. In addition to performing these tasks themselves, registered nurses are also responsible for training patients to perform many of these tasks, which may include using medical devices and managing complex medication regimens. The purpose of this research was to identify and systematically categorize the issues facing registered nurses (RNs) when training older adult patients. Eight RNs participated in individual structured interviews wherein they were asked to describe the difficulties and frustrations associated with training older adult patients to use medical devices and manage medication independently. The data were categorized as patient-related, RN-related, or situation-related issues. The results highlight the complexity of training device use and medication management, as well as the needs of RNs for forms of additional support in training older adult patients.

Understanding challenges in the front lines of home health care: a human-systems approach

A human-systems perspective is a fruitful approach to understanding home health care because it emphasizes major individual components of the system - persons, equipment/technology, tasks, and environments - as well as the interaction between these components. The goal of this research was to apply a human-system perspective to consider the capabilities and limitations of the persons, in relation to the demands of the tasks and equipment/technology in home health care. Identification of challenges and mismatches between the person(s) capabilities and the demands of providing care provide guidance for human factors interventions. A qualitative study was conducted with 8 home health Certified Nursing Assistants and 8 home health Registered Nurses interviewed about challenges they encounter in their jobs. A systematic categorization of the challenges the care providers reported was conducted and human factors recommendations were proposed in response, to improve home health. The challenges inform a human-systems model of home health care.

Need and Potential Use of Information Technology for Case Manager–Physician Communication in Home Care

Case management has become a popular model for providing home care services to nursing home-eligible older adults. To maximize collaborative decision making and patient outcomes, members of the case management team must engage in ongoing, open communication. However, little is known about the quality of communication between home care case managers and their clients’ physicians. This study examined geriatric home care case managers’ perceptions of their communication with their clients’ physicians. Participating case managers were employed at two large home care agencies located in the South Florida region. The findings suggest that communication between home care case managers and physicians is limited and inefficient. Implication for policy and practice are provided. Finally, we propose ways to leverage Information Technology to bridge this communication gap.

Understanding Use Errors for Medical Devices: Analysis of the MAUDE Database

Use error is a type of error in a system wherein a user’s actions—or lack of actions— result in a different outcome than intended, possibly resulting in an adverse event. Use error in medicine is especially important, as adverse events can result in life-critical situations. Studies investigating use error have been conducted using databases of medical adverse events (e.g., the United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database of adverse events related to device usage). However, these studies are limited by being specific to a context of use (e.g., drug delivery pumps in anesthesia). Therefore, this study investigated use error for medical devices across all contexts of use through a systematic search of the MAUDE database. We found that use error 1) is reported across many sub-fields and contexts of medicine; 2) is associated with many steps in the device usage process; 3) occurs during device operation by both lay users and health professionals; 4) has varying underlying causes; 5) cooccurs in adverse events; and 6) results in a wide array of outcomes, including death. This analysis provides valuable insights into characteristics and context of use errors that can guide design to minimize such errors.