Care manager, older adult, and caregiver perspectives on co-occurring care management among high-need older adults

BACKGROUND

Care management programs are widely used to improve care coordination and management of chronic conditions for high-need older adults. With many care management programs targeting a small number of people, high-need older adults may receive services from more than one care management program (co-occurring care management), the implications of which are unknown.

METHODS

We conducted semi-structured interviews with 37 care managers, 15 older adults, and 13 caregivers, who were recruited through an urban academic medical center and a large rural health system in Maryland. We analyzed interview transcripts using qualitative content analysis with the aim of understanding contributors to, implications of, and strategies to manage co-occurring care management among high-need older adults.

RESULTS

Contributors to co-occurring care management included siloed programs due to program-specific financial incentives and inability to easily identify other involved care managers, and the complex needs of the enrolled older adult population, which motivated involvement of more than one program. Implications of co-occurring care management included older adults and caregivers feeling cared for and safe when they had multiple care management programs involved and reporting value in their relationships with care managers. Older adults were identified as having greater access to resources and improved care when care manager roles were aligned in a complementary way; however, misaligned roles posed the potential for confusion about care manager accountability for tasks and resulted in frustration and lack of follow-through. Strategies for managing co-occurring care management included alignment of care manager roles through communication and negotiation and older adults and caregivers identifying and relying on a single care manager with whom they had the strongest relationship.

CONCLUSIONS

Initiatives that clarify strengthen the relationship between care managers and older adults, increase care manager visibility, and facilitate communication across care managers may help foster collaboration.

Skilled home healthcare clinicians' experiences in communicating with physicians: A national survey

BACKGROUND

Effective communication between skilled home healthcare (SHHC) clinicians and physicians is critical to care coordination. No studies have examined this from the point of view of SHHC clinicians at the national level. The objective is to determine in national sample issues related to how SHHC agency clinicians communicate with physicians.

DESIGN

Mailed survey.

METHODS

Mailed survey to a national representative random sample of SHHC agencies. The survey measured the experiences of SHHC clinicians in communicating with physicians. Multilevel logistic regression models examining odds of adverse patient outcomes associated with communication failures.

RESULTS

A total of 265 surveys from 168 SHHC agencies were returned for a response rate of 13.3% at the individual respondent level and 16.8% at the SHHC agency level. Agency-level characteristics were similar between responding and nonresponding agencies. The most common method of contacting physicians during routine SHHC visits was telephone; communication via the electronic health record was uncommon. Nearly 40% of SHHC clinicians report never or rarely being able to reach a physician. SHHC clinicians rate the Center for Medicare and Medicaid Services Home Health Certification and Plan of Care (CMS-485) as a useful means of communication 6.3 (SD, 2.5) scale of 1 (least useful) to 10 (most useful); only 14% could have SHHC orders signed electronically. In multilevel logistic models, compared to SHHC clinicians who could reach a physician nearly every time or always, the odds of an SHHC clinician sending someone to the emergency department were 3.66 (95% confidence interval 1.16-11.5) for SHHC clinicians who were sometimes or often able to reach a physician and 5.43 (95% CI 1.56-18.9) for those who never or rarely reached a physician.

CONCLUSIONS

In this exploratory study, SHHC clinicians experience significant communication barriers with physicians who order SHHC services. Strategies to enhance meaningful communication between SHHC clinicians and physicians must be developed.

Skilled Home Healthcare Clinician and Staff Perspectives on Communication With Physicians: A Multisite Qualitative Study

Communication between physicians who order, and clinicians who provide skilled home healthcare (SHHC), is critical to well-coordinated care. The views of SHHC staff on communication with physicians have not been well studied. The objective of this study was to explore how SHHC staff view the communication processes with physicians who order SHHC services. Using purposive and snowball sampling, we conducted semistructured interviews with 22 SHHC staff across multiple regions of the United States. Qualitative thematic content analysis was used to analyze the data. SHHC staff experienced significant barriers to effective communication with physicians, including not being able to communicate in a timely manner when necessary for patient care, and challenges identifying the correct physician to coordinate care and sign SHHC orders. Key strategies to enhance communication focused on creating standardized processes to streamline communication, setting expectations for response times in communication, and improving the Centers for Medicare & Medicaid Services Home Health Certification and Plan of Care form (commonly referred to as the "CMS-485"/Plan of Care). SHHC staff experience significant communication challenges with physicians who order SHHC services that can compromise care coordination and delivery. Modifications to workflows are urgently needed to improve efficiency and quality of communication, care coordination, and quality of care.

Skilled Home Health Care Agency Perspectives on Communication With Physicians: A National Survey

BACKGROUND: Communication is important in the care of older adults receiving skilled home health care (SHHC). In a prior national survey, physicians viewed communication and care coordination with SHHC agencies as dismal. The views of SHHC personnel (Registered Nurses, Licensed Practical Nurses, Physical Therapists, Occupational Therapists, and Speech-Language Pathologists) on this issue have not been well studied. OBJECTIVE: To determine the effectiveness of communication between SHHC personnel and physicians who order SHHC services. METHODS: A nationally representative mailed survey of personnel from SHHC agencies identified through the 2016 Home Health Compare data set from the Centers of Medicare and Medicaid Services. RESULTS: 263 of 2000 surveys returned (13.2% response rate). Responding agencies were mainly proprietary (75.3%) and urban-based (83.7%). Most agencies were in the South (38.8%); 28.3% Midwest, 22.9% West, 12.1% Northeast. Only 62.2% of SHHC personnel completing start of care visits (n=202) reported being able to contact a physician when needed. The most common strategies used to contact physicians are phone (76.0%) and fax (11.2%). The greatest barriers to communication are having to communicate through a third party (64.9%) and a perception by SHHC personnel that “Physicians [are] not interested in communicating with SHHC Personnel” (45.1%). Failed communication resulted in delayed orders (70.8%) and sending a patient to the emergency room (37.1%). IMPLICATIONS: SHHC agency personnel experience significant barriers in communicating with physicians. Modes of communication remain rudimentary, and there are serious consequences of failed communication.

"It's Tricky": Care Managers' Perspectives on Interacting with Primary Care Clinicians

Care management programs that facilitate collaboration between care managers and primary care clinicians are more likely to be successful in improving chronic disease metrics than programs that do not facilitate such collaboration. The authors sought to understand care managers' perspectives on interacting with primary care clinicians. Semi-structured qualitative interviews were conducted with care managers (n = 29) from 3 health systems in and around a large, urban academic center. Interviews were audio recorded, transcribed verbatim, and iteratively analyzed using a grounded theory approach. Care managers worked for health plans (14%), outpatient specialty clinics (31%), hospitals and emergency departments (24%), and primary care offices (14%). Care managers identified the primary care clinician as leading patients' care and as essential to avoiding unnecessary utilization. Care managers described variability in and barriers to interacting with primary care clinicians. When possible, care managers use the electronic medical record to facilitate interaction rather than communicating directly (eg, phone call) with primary care clinicians. The role of the care manager varied across programs, contributing to primary care clinicians' poor understanding of what the care manager could provide. Consequently, primary care clinicians asked the care manager for help with tasks beyond his/her role. Care managers felt inferior to primary care clinicians, a potential result of the traditional medical hierarchy, which also hindered interactions. Although care managers view interactions with the primary care clinician as essential to the health of the patient, communication challenges, variability of the care manager's role, and medical hierarchy limit collaboration.

A Systematic Review of in-vivo Studies on Dietary Mushroom Supplementation for Cognitive Impairment (P14-021-19)

Objectives

A systematic review was undertaken of the evidence on the use of Hericium erinaceus (Reishi), Ganoderma lucidum (Lion's Mane), Ophiocordyceps sinensis (Cordyceps) and Cordyceps militaris (Cordyceps), dietary supplementation on cognitive impairment outcomes.

Methods

Relevant articles were identified in major databases (PubMed, Embase, Web of Science, and SCOPUS). Key search words were Hericium erinaceus, Ganoderma lucidum, Ophiocordyceps sinensis, Lion's mane, Reishi, Cordyceps, cognitive, memory, dementia, Alzheimer's. Included studies were peer-reviewed in-vivo articles published in English before January 2019, with cognitive outcomes.

Results

Twenty-five (25) of 194 studies met the inclusion criteria: eight (8) studies on lion's mane mushroom, seven (7) studies on reishi mushroom and ten (10) studies on cordyceps mushroom. Three (3) randomized-controlled trials were included in this review. Studies varied by animals used, preparation of supplement, dosage and duration of supplementation, and cognitive outcomes. Twenty-two (22) animal studies found positive results (P < 0.05) on at least one of the doses tested for at least one cognitive impairment outcome. Of the human trials, two (2) studies found positive results (P < 0.05) on at least one of the cognitive assessments.

Conclusions

Despite heterogeneous study design, the results of this review suggest that dietary supplementation with lion's mane, reishi and cordyceps mushrooms may have a beneficial effect on cognitive impairment. Further clinical research studies are needed to demonstrate the potential medicinal benefits of dietary mushroom supplementation in humans with cognitive impairments.

Funding Sources

No external funding.