Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program

BACKGROUND

Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC.

METHODS

Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery).

RESULTS

We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs.

CONCLUSIONS

HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults

OBJECTIVES

Medicare Home Health Care (HHC) services are integral to the care of homebound seriously ill older adults requiring ongoing specialized medical care. Although disparities in health outcomes are well documented in inpatient and primary care, disparities experienced by historically marginalized racial and ethnic groups underrepresented in HHC are understudied. This study aimed to examine the relationship between individual characteristics and differences in HHC health outcomes for seriously ill older adults.

DESIGN

Secondary data analysis, repeated measure.

SETTING AND PARTICIPANTS

Seriously ill older adults who received HHC in 2016 in the HHC Outcome and Assessment Information Set (OASIS).

METHODS

Start of care and discharge data from the 2016 HCC OASIS were used to examine the relationship between individual characteristics and differences in HHC health outcomes identified by the Centers for Medicare and Medicaid Services as key indicators of quality in HHC, including dyspnea, pain frequency, cognitive functioning, and presence of unhealed pressure ulcer stage II or higher. A generalized ordered logit model with partial proportional odds was used for the ordinal categorical outcomes and a logistic regression was used for the binary dependent variable (pressure ulcer).

RESULTS

Findings indicated that of 227,402 seriously ill individuals with an HHC episode in 2016, those from underrepresented racial and ethnic groups had between 14% and 57% higher odds of worse health outcomes compared with non-Hispanic White patients with the exception of pain frequency.

CONCLUSIONS AND IMPLICATIONS

For people living with serious illness, there are significant differences in Medicare HHC health outcomes when comparing underrepresented racial or ethnic beneficiaries with White counterparts. More research is needed to understand how health care processes such as referral patterns or time to care initiation, and structural factors such as HHC agency quality and neighborhood social deprivation are related to health differences observed in the population.

Home Health Care to Asian Americans: a Systematic Review

OBJECTIVE

Despite being the fastest growing minority group in the USA, Asian Americans are among the least studied ones, particularly in the home and community-based services settings. This study aimed to review and synthesize extant evidence on Asian American's access, utilization, and outcomes of home health care.

METHODS

This is a systematic review study. A comprehensive literature search was conducted in PubMed and CINAHL as well as hand search. Each study was screened, reviewed, and evaluated for quality by at least two reviewers independently.

RESULTS

Twelve articles were determined eligible and included for review. Asian Americans were less likely to be discharged to home health care following hospitalization. At admission to home health care, Asian Americans had a high rate of inappropriate medication issues (28%) and they also had poorer functional status compared to White Americans. Asian Americans were also reported with less improvement in functional status at the end of home health care; however, there were some inconsistencies in the evidence on Asian Americans' utilization of formal/skilled home health care. Quality evaluation indicated that findings from some studies were limited by small sample size, single site/home health agency, analytic approaches, and other methodologic limitations.

CONCLUSIONS

Asian Americans often experience inequities in home health care access, utilization, and outcomes. Multilevel factors may contribute to such inequities, including structural racism. Robust research using population-based data and advanced methodology is needed to better understand home health care to Asian Americans.

Patient Portal Use during Home Health Care at an Academic Health System

OBJECTIVES

To characterize patient portal use among older adults receiving skilled home health (HH) care.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Older adults (aged ≥65 years) who received HH care from a large, academic health system between 2017 to 2022 (n = 8409 HH episodes provided to n = 4878 unique individuals).

METHODS

We captured individual and HH episode characteristics from the electronic health record and identified specific types and dates of portal use for those with an active patient portal. We calculated the proportion of episodes in which patients engaged in specific patient portal activities (eg, viewing test results, managing appointments, sending messages). We used multivariable logistic regression to model the odds of engaging in each activity as a function of patient and episode characteristics, and charted the timing of patient portal activities across the 60-day HH episode.

RESULTS

The patient portal was used by older adults in more than half (58%) of the episodes examined. Among those using their portal account during an HH episode, 84% viewed test results, 77% managed an existing appointment, 72% managed medications, and 55% sent a message to a provider. Adjusted odds of portal use were higher among HH patients who were married (aOR: 1.77, P < .001), receiving HH post-COVID pandemic (aOR: 2.73, P < .001), and accessing HH following a hospitalization (aOR: 1.30, P < .001) and lower among those who were Black compared with white (aOR: 0.52, P < .001). Portal use, particularly viewing test results and clinical notes and managing existing appointments, was highest during the first 10 days of an HH episode, especially among patients referred following a hospitalization.

CONCLUSIONS AND IMPLICATIONS

HH patients use the patient portal to perform care management tasks and access clinical information. Study findings support opportunities to harness the patient portal to bridge information gaps and care coordination during HH care.

Explaining the challenges of Iranian caregivers in provision of home health care to spinal cord injury patients: a qualitative study

BACKGROUND

The incidence of spinal cord injury (SCI) is increasing across the globe. The caregivers of patients with spinal cord injuries experience many problems during providing care to these patients. Identifying the problems experienced by caregivers can facilitate the process of care provision to these patients. So, the aim of this study was to explore the challenges of caregivers in provision of home health care to SCI patients.

METHODS

This study was conducted by qualitative description approach in Iran from Apr 2021 to Dec 2022. The participants included the caregivers of SCI patients recruited by purposive sampling. The data were collected by face-to-face interviews and analyzed using the method proposed by Lundman and Graneheim.

RESULTS

Two themes emerged from the data analysis, including burnout (with the categories of physical challenge and psychological challenges) and coping strategies (with the categories of social support and professional support).

CONCLUSION

Resolving the obstacles and problems faced by home caregivers can improve the circumstances of care provision so that they can be relieved of their own physical and psychological conundrums and deliver suitable home care to SCI patients.

TRIAL REGISTRATION NUMBER

Not applicable.

Home health care nurse routing and scheduling problem considering ergonomic risk factors

Home health care routing and scheduling is a complex problem that requires many aspects to be considered simultaneously. One of the important aspects is ergonomics. Home health care nurses are at higher risk of work-related health problems such as musculoskeletal disorders and burnout since they are frequently exposed to physical, mental, and environmental ergonomic risks in their jobs. Therefore, it is essential to integrate ergonomic considerations into the construction of daily schedules for home health care nurses to mitigate these health risks. The purpose of this study is to present a mathematical model that incorporate ergonomic risks. We introduce a set of constraints into our model to prevent nurses from encountering excessive workloads. To assess the workload, we propose a subjective assessment method and employ a fuzzy inference system to calculate nurses' perceived workload levels. We applied our model to a several numerical examples to investigate the impact of workload on the nurse daily schedules. We observed that, at a specified workload level, there may be alternative solutions where the number of patients visited is the same. Therefore, we defined an objective function to maximize patient visits while minimizing nurses' workload levels as much as possible. As a result, our model generates solutions that effectively reduce nurse workloads, leading to more balanced schedules. Thus, our study offers a comprehensive approach to home health care scheduling by incorporating ergonomic considerations, ultimately enhancing both patient care and nurse well-being.

Natural Language Processing Applied to Clinical Documentation in Post-acute Care Settings: A Scoping Review

OBJECTIVES

To determine the scope of the application of natural language processing to free-text clinical notes in post-acute care and provide a foundation for future natural language processing-based research in these settings.

DESIGN

Scoping review; reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

SETTING AND PARTICIPANTS

Post-acute care (ie, home health care, long-term care, skilled nursing facilities, and inpatient rehabilitation facilities).

METHODS

PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched in February 2023. Eligible studies had quantitative designs that used natural language processing applied to clinical documentation in post-acute care settings. The quality of each study was appraised.

RESULTS

Twenty-one studies were included. Almost all studies were conducted in home health care settings. Most studies extracted data from electronic health records to examine the risk for negative outcomes, including acute care utilization, medication errors, and suicide mortality. About half of the studies did not report age, sex, race, or ethnicity data or use standardized terminologies. Only 8 studies included variables from socio-behavioral domains. Most studies fulfilled all quality appraisal indicators.

CONCLUSIONS AND IMPLICATIONS

The application of natural language processing is nascent in post-acute care settings. Future research should apply natural language processing using standardized terminologies to leverage free-text clinical notes in post-acute care to promote timely, comprehensive, and equitable care. Natural language processing could be integrated with predictive models to help identify patients who are at risk of negative outcomes. Future research should incorporate socio-behavioral determinants and diverse samples to improve health equity in informatics tools.

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

OBJECTIVES

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

DESIGN

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

SETTING AND PARTICIPANT

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

MEASURES

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Point of Care Tests: Changing Paradigms in the Diagnosis of SARS-CoV-2

Background

Point of care tests provide rapid information about the patient's condition, with a turnaround time of 15 min. During the COVID-19 pandemic, many such point of care tests were developed, to aid in the rapid diagnosis of SARS-Cov-2 infection.

Aim

To describe and synthesize the available literature on point of care tests for diagnosis of SARS-CoV-2.

Methodology

This narrative review was done through online literature search, using Google Scholar and PubMed.

Result

There were 51 point of care tests for diagnosis of SARS-CoV-2 which were validated using different samples, such as such as nasopharyngeal swabs(42), oropharyngeal and naso-pharyngealswabs(2), oropharyngeal swab in VTM(1) nasal swabs(5) and throat swab(1).

Conclusion

There was global developement of point of care tests on a war footing. The Indian states of Delhi, Maharashtra, Gujarat, Uttar Pradesh, Tamil Nadu, Karnataka, Haryana, Rajasthan, Kerala, Himachal Pradesh, Goa and Uttarakhand, were in the forefront of these developments, as also the USA, Belgium, Taiwan, Korea and South Korea.

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

PURPOSE

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

METHODS

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

FINDINGS

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

IMPLICATIONS

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

Evaluation of Quality Indicators in Home Health Services Delivery

Background

We aimed to evaluate the quality indicators monitored within the scope of quality standards health.

Methods

In this descriptive study, patients who visited the home health services unit in 2021, were included. Patient age and diagnostic data were obtained from the Basic Health Statistics Module. Other information such as the number of patient visits and nutritional status were obtained from the indicator data collection form followed by the quality management unit of our hospital and from the home health services unit. We included the data of Antalya Training and Research Hospital. Microsoft Excel and SPSS 25.0 program were used in the analysis of the data, and the data obtained were shown as numbers and ratios (%).

Results

When the quality indicators of home health services delivery were examined, the timely response rate of the application was 100%, the nutritional status of all patients was evaluated using the Nutritional Risk Score (NRS-2002) evaluation form at the first patient visit; the patients receiving health care from the home health unit of our hospital visited an average of three times in a year, and the health service from the home health unit was determined: the annual average rate of medical appointments kept with patients who receive medical care at the scheduled time is 83%.

Conclusion

Quality indicators are being met well, and good-quality care services are being delivered in the home health service of the training and research hospitals.

Patients' and next of kin's expectations and experiences of a mobile integrated care model with a home health care physician - a qualitative thematic study

BACKGROUND

The organizational principle of remaining at home has offset care from the hospital to the home of the older person where care from formal and informal caregivers is needed. Globally, formal care is often organized to handle singular and sporadic health problems, leading to the need for several health care providers. The need for an integrated care model was therefore recognized by health care authorities in one county in Sweden, who created a cross-organisational integrated care model to meet these challenges. The Mobile integrated care model with a home health care physician (MICM) is a collaboration between regional and municipal health care. Descriptions of patients' and next of kin's experiences of integrated care is however lacking, motivating exploration.

METHOD

A qualitative thematic study. Data collection was done before the patients met the MICM physician, and again six months later.

RESULTS

The participants expected a sense of relief when admitted to MICM, and hoped for shared responsibility, building a personal contact and continuity but experienced lack of information about what MICM was. At the follow-up interview, participants described having an easier daily life. The increased access to the health care personnel (HCP) allowed participants to let go of responsibility, and created a sense of safety through the personalised contact and continuity. However, some felt ignored and that the personnel teamed up against the patient. The MICM structure was experienced as hierarchical, which influenced the possibility to participate. However, the home visits opened up the possibility for shared decision making.

CONCLUSION

Participants had an expectation of receiving safe and coherent health care, to share responsibility, personal contact and continuity. After six months, the participants expressed that MICM had provided an easier daily life. The direct access to HCP reduced their responsibility and they had created a personalised contact with the HCP and that the individual HCP mattered to them, which could be perceived as in line with the goals in the shift to local health care. The MICM was experienced as a hierarchic structure with impact on participation, indicating that all dimensions of person-centred care were not fulfilled.

Care challenges of home health patients living with dementia: a pathway forward with palliative care

BACKGROUND

Home health care (HHC) is a leading source of care support for older adults with serious illness, particularly patients living with dementia (PLWD). Demand for HHC is expected to continue to grow, driven by an aging population and preference for non-institutional care. HHC agencies are frequently under pressure to find effective approaches for improving care delivery and quality. One strategy that has the potential to improve the quality of life and patient satisfaction in HHC for PLWD is the integration of palliative care. Therefore, we sought to understand the experiences and needs of PLWD and their family caregivers specifically focusing on ways that HHC and palliative care may be integrated as part of the care transition from hospital to home, to better support PLWD and their families.

METHODS

We conducted a descriptive qualitative study focusing on the perspectives of patients, caregivers, and healthcare team members about palliative care delivery for patients receiving HHC. Interviews were audio-recorded and professionally transcribed. In this analysis, we specifically report on dementia-related content using an iterative, team-based thematic analysis approach.

RESULTS

We identified three themes: 1) 'Living in the Whirlwind' which describes the many competing demands on caregivers time and the associated feeling of loss of control, 2) 'Thinking Ahead' which describes the importance of thinking beyond the day-to-day tasks to begin planning for the future, and 3) 'Pathways Forward' which describes the integration of palliative care into HHC to provide enhanced support for PLWD and their caregivers.

CONCLUSION

In this qualitative study, our formative work identified the importance of providing anticipatory guidance (e.g., safety, advance care planning) coupled with emotional and pragmatic care supports (e.g., finding resources, navigating insurance) to sustain caregivers who are struggling with the whirlwind.

Can home care work be organized to promote health among the workers while maintaining productivity? An investigation into stakeholders' perspectives on organizational work redesign concepts based on the Goldilocks Work principles

BACKGROUND

Due to the aging population, the need for home care services is increasing in most Western countries, including Norway. However, the highly physical nature of this job could contribute to make recruiting and retaining qualified home care workers (HCWs) challenging. This issue may be overcome by adopting the Goldilocks Work principles, aiming at promoting workers' physical health by determining a "just right" balance between work demands and recovery periods while maintaining productivity. The aim of this study was to 1) gather suggestions from home care employees on suitable organizational (re)design concepts for promoting HCWs' physical health and 2) have researchers and managers define actionable behavioral aims for the HCWs for each proposed (re)design concept and evaluate them in the context of the Goldilocks Work principles.

METHODS

HCWs, safety representatives, and operation coordinators (n = 14) from three Norwegian home care units participated in digital workshops led by a researcher. They suggested, ranked, and discussed redesign concepts aimed at promoting HCWs' health. The redesign concepts were subsequently operationalized and evaluated by three researchers and three home care managers.

RESULTS

Workshop participants suggested five redesign concepts, namely "operation coordinators should distribute work lists with different occupational physical activity demands more evenly between HCWs", "operation coordinators should distribute transportation modes more evenly between HCWs", "Managers should facilitate correct use of ergonomic aids and techniques", "HCWs should use the stairs instead of the elevator", and "HCWs should participate in home-based exercise training with clients". Only the first two redesign concepts were considered to be aligned with the Goldilocks Work principles. A corresponding behavioral aim for a "just right" workload was defined: reduce inter-individual differences in occupational physical activity throughout a work week.

CONCLUSIONS

Operation coordinators could have a key role in health-promoting organizational work redesign based on the Goldilocks Work principles in home care. By reducing the inter-individual differences in occupational physical activity throughout a work week, HCWs' health may be improved, thus reducing absenteeism and increasing the sustainability of home care services. The two suggested redesign concepts should be considered areas for evaluation and adoption in practice by researchers and home care services in similar settings.

Patient safety in home health care: a grounded theory study

BACKGROUND

The home environment is designed for living, not for professional care. For this reason, safe patient care is one of the most important challenges of home health care. Despite abundant research on safe care, there is still little understanding of safety issues in home care.

DESIGN

The aim of the present study was to explain the process of safe patient care in home health care. A qualitative, grounded theory study was conducted based on the approach proposed by Corbin & Strauss in 2015.

METHOD

In total, 22 interviews were conducted with 16 participants including 9 home care nurses, 2 home care nursing assistants, 1 home care inspector, 1 home care physician and 3 family caregivers in Tehran, Iran. Four observation sessions were conducted in different homes. Purposeful sampling was used followed by theoretical sampling from August 2020-July 2022. Data analysis was carried out based on the approach proposed by Corbin & Strauss in 2015.

RESULTS

The results showed that the healthcare members (nurses, family caregivers, patients and home care centers) used the model of safe patient care in home health care based on four assessment methods, i.e. prevention, foresight, establishment of safety and verification. The core variable in this process is foresight-based care.

CONCLUSION

The results of this study showed that the key to safe patient care in home health care, which helps to maintain patient safety and prevent threats to safe care, is the foresight of healthcare members, which is essential for identifying threats to safe care considering the many risks of home health care.

The diffusion of health care fraud: A bipartite network analysis

Many studies have examined the diffusion of health care innovation but less is known about the diffusion of health care fraud. In this paper, we consider the diffusion of potentially fraudulent Medicare home health care billing in the United States during 2002-16, with a focus on the 21 hospital referral regions (HRRs) covered by local Department of Justice (DOJ) anti-fraud "strike force" offices. We hypothesize that patient-sharing across home health care agencies (HHAs) provides a mechanism for the rapid diffusion of fraudulent strategies. We measure such activity using a novel bipartite mixture (or BMIX) network index, which captures patient sharing across multiple agencies and thus conveys more information about the diffusion process than conventional unipartite network measures. Using a complete population of fee-for-service Medicare claims data, we first find a remarkable increase in home health care activity between 2002 and 2009 in many regions targeted by the DOJ; average billing per Medicare enrollee in McAllen TX and Miami increased by $2127 and $2422 compared to just an average $289 increase in other HRRs not targeted by the DOJ. Second, we establish that the HRR-level BMIX (but not other network measures) was a strong predictor of above-average home health care expenditures across HRRs. Third, within HRRs, agencies sharing more patients with other agencies were predicted to increase billing. Finally, the initial 2002 BMIX index was a strong predictor of subsequent changes in HRR-level home health billing during 2002-9. These results highlight the importance of bipartite network structure in diffusion and in infection and contagion models more generally.

Dental care for older adults in home health care services - practices, perceived knowledge and challenges among Norwegian dentists and dental hygienists

BACKGROUND

Providing dental services to dependent older adults might be challenging because of physical and cognitive decline. The present study aimed to explore current practices, knowledge, and experienced challenges related to the treatment of older adults in home health care services (HHCS) among dentists and dental hygienists in Norway.

METHODS

An electronic questionnaire survey was distributed to Norwegian dentists and dental hygienists, inquiring about background characteristics, current practices, self-perceived knowledge, and challenges when providing oral health care for older HHCS patients.

RESULTS

Four hundred and sixty-six dentists and 244 dental hygienists treating older HHCS patients responded to the survey. The majority were female (n=620; 87.3%) and worked in the public dental service (PDS) (n=639; 90%). When older HHCS adults attended the dental practice, the treatments provided were most frequently aimed at relieving acute oral problems, although dental hygienists reported to focus on improving oral health more often than dentists. Dentists reported to have more self-perceived knowledge than dental hygienists regarding patients with complex treatment needs, cognitive or physical impairment. Exploratory Factor Analysis (EFA) was carried out on the 16 items related to challenges, three factors were extracted and Structural Equation Models (SEMs) were performed. Challenges related to dental care for older HHCS adults were related to time, practical organization and communication. Variation within these categories was associated with sex, graduation year and country, as well as time used per patient and work sector, but not with professional status.

CONCLUSIONS

The results indicate that dental care for older HHCS patients is time-demanding and more often aimed at relieving symptoms than improving oral health. A substantial proportion of dentists and dental hygienists in Norway lack confidence when providing dental care for frail elderly.

Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study

Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multi-objective home health care routing: a variable neighborhood search method

Health and convenience are two indispensable indicators of the society promotion. Nowadays, to improve community health levels, the comfort of patients and those in need of health services has received much attention. Providing Home Health Care (HHC) services is one of the critical issues of health care to improve the patient convenience. However, manual nurse planning which is still performed in many HHC institutes results in a waste of time, cost, and ultimately lower efficiency. In this research, a multi-objective mixed-integer model is presented for home health care planning so that in addition to focusing on the financial goals of the institution, other objectives that can help increase productivity and quality of services are highlighted. Therefore, four different objectives of the total cost, environmental emission, workload balance, and service quality are addressed. Taking into account medical staff with different service levels, and the preferences of patients in selecting a service level, as well as different vehicle types, are other aspects discussed in this model. The epsilon-constraint method is implemented in CPLEX to solve small-size instances. Moreover, a Multi-Objective Variable Neighborhood Search (MOVNS) composed of nine local neighborhood moves is developed to solve the practical-size instances. The results of the MOVNS are compared with the epsilon-constraint method, and the strengths and weaknesses of the proposed algorithm are demonstrated by a comprehensive sensitivity analysis. To show the applicability of the algorithm, a real example is designed based on a case study, and the results of the algorithm over real data are evaluated.

The effect of performance pay incentives on market frictions: evidence from medicare

Medicare has increased the use of performance pay incentives for hospitals, with the goal of increasing care coordination across providers, reducing market frictions, and ultimately to improve quality of care. This paper provides new empirical evidence by using novel operations and claims data from a large, independent home health care firm with the Hospital Readmissions Reduction Program (HRRP) penalty on hospitals providing identifying variation. We find that the penalty incentive to reduce re-hospitalizations passed through from hospitals to the firm for at least some types of patients, since it provided more care inputs for heart disease patients discharged from hospitals at greater penalty risk and that contributed more patients to the firm. This evidence suggests that HRRP helped increase coordination between hospitals and home health firms without formal integration. Greater home health effort does not appear to have led to lower patient readmissions.

A sustainable and efficient home health care network design model under uncertainty

To cater to the increasing demands, particularly during diseases such as Covid-19, the design and planning of home health care systems is of significant importance. The current study proposes a multi-objective mixed-integer linear model for a home health care network in two stages; the first is the opening of efficient health centres, and the second is the routing and scheduling considering corporate social responsibility and efficiency. There are multiple objectives that we consider, including minimization of total costs and inefficiency considerations, and maximization of social aspects. A novel aspect of this study is the consideration of social responsibility, which includes employment opportunities and regional economic development, and efficiency in terms of time, energy, and mismanagement of budgets. To measure efficiency, an augmented version of the data envelopment analysis approach is incorporated into the proposed optimization model. Additionally, the TH approach is developed as an interactive fuzzy method to deal with the proposed multi-objective model. Within the HHC problem, costs, social factors, and service time are inherently uncertain, and hence, to solve this problem, a robust-fuzzy approach is proposed. The ensuing model is applied to a real case study of Kermanshah in Iran. Moreover, several problem instances motivated by real cases are generated with different characteristics to measure the performance of the proposed model and approach. The results show that decision-makers' preferences play a key role in human resource planning and regional development. Furthermore, the results confirm the efficiency of the proposed approach in different instances within reasonable time frames.

Medications Associated With Geriatric Syndromes (MAGS) and Hospitalization Risk in Home Health Care Patients

OBJECTIVES

Polypharmacy is common in home health care (HHC). This study examined the prevalence of medications associated with geriatric syndromes (MAGS), its predictors, and association with subsequent hospitalization in HHC.

DESIGN

Analysis of HHC electronic medical records, the Outcome and Assessment Information Set (OASIS), and Medicare HHC claims.

SETTING AND PARTICIPANTS

A total of 6882 adults ≥65 years old receiving HHC in 2019 from a large, not-for-profit home health agency serving multiple counties in New York State.

MEASURES

MAGS use was identified from active medications reconciled during HHC visits (HHC electronic medical records). MAGS use was operationalized as count and in quartiles. Hospitalization during the HHC episode was operationalized as a time-to-event variable (ie, number of days from HHC admission to hospitalization). We used regression analyses to identify predictors of MAGS use, and survival analyses to examine the association between MAGS and hospitalization.

RESULTS

Nearly all (98%) of the HHC patients used at least 1 MAGS and 41% of all active medications used by the sample were MAGS. More MAGS use was found in HHC patients who were community-referred, taking more medications, and having more diagnoses, depressive symptoms, and functional limitations. Adjusted for covariates, higher MAGS quartiles were not independently associated with the risk of hospitalization, but higher MAGS quartiles combined with multimorbidity (ie, having ≥10 diagnoses) were associated with a 2.3-fold increase in hospitalization risk (hazard ratio 2.24; 95% confidence interval: 1.61-3.13; P < .001), relative to the lowest quartile of MAGS use and having <10 diagnoses.

CONCLUSIONS AND IMPLICATIONS

More than 40% of medications taken by HHC patients are MAGS. Multimorbidity and MAGS use collectively increased the risk of hospitalization by up to 2.3 times. HHC clinicians should carefully review patients' medications and use information about MAGS to facilitate discussion about deprescribing with patients and their prescribers.

Risk of Rehospitalization or Emergency Department Visit Is Significantly Higher for Patients Who Receive Their First Home Health Care Nursing Visit Later Than 2 Days After Hospital Discharge

OBJECTIVES

This study explored the association between the timing of the first home health care nursing visits (start-of-care visit) and 30-day rehospitalization or emergency department (ED) visits among patients discharged from hospitals.

DESIGN

Our cross-sectional study used data from 1 large, urban home health care agency in the northeastern United States.

SETTING/PARTICIPANTS

We analyzed data for 49,141 home health care episodes pertaining to 45,390 unique patients who were admitted to the agency following hospital discharge during 2019.

METHODS

We conducted multivariate logistic regression analyses to examine the association between start-of-care delays and 30-day hospitalizations and ED visits, adjusting for patients' age, race/ethnicity, gender, insurance type, and clinical and functional status. We defined delays in start-of-care as a first nursing home health care visit that occurred more than 2 full days after the hospital discharge date.

RESULTS

During the study period, we identified 16,251 start-of-care delays (34% of home health care episodes), with 14% of episodes resulting in 30-day rehospitalization and ED visits. Delayed episodes had 12% higher odds of rehospitalization or ED visit (OR 1.12; 95% CI: 1.06-1.18) compared with episodes with timely care.

CONCLUSIONS AND IMPLICATIONS

The findings suggest that timely start-of-care home health care nursing visit is associated with reduced rehospitalization and ED use among patients discharged from hospitals. With more than 6 million patients who receive home health care services across the United States, there are significant opportunities to improve timely care delivery to patients and improve clinical outcomes.

The role of the home health care physician in mobile integrated care: a qualitative phenomenograpic study

Background

An increasing older population, along with the organizational principle of remaining at home, has moved health care from institutions into the older person’s home, where several health care providers facilitate care. The Mobile Integrated Care Model strives to provide cost-efficient, coherent, person-centered health care in the home. In the integrated care team, where the home health care physician is the medical authority, several health care professions work across organizational borders. Therefore, the aim of this study was to describe Home Health Care Physicians perceptions of working and providing health care in the Mobile Integrated Care Model, as well as perceptions of participating in and forming health care.

Methods

A phenomenographic qualitative study design, with semi-structured interviews using an interview guide.

Results

Working within Mobile Integrated Care Model was a different way of working as a physician. The physicians’ role was to support the patient by making safe medical decisions. Physicians described themselves as a piece in the team puzzle, where the professional knowledge of others was crucial to give quality health care. Being in the patients’ homes was expressed as adding a unique dimension in the provision of health care, and the physicians learned more about the patients by meeting them in their homes than at an institution. This aided the physicians in respecting patient autonomy in medical decision making, even though the physicians sometimes disregarded patient autonomy in favor of their own medical experience. There was a divided view on next of kin participation among the home health care physicians, ranging from always including to total absence of involving next of kin in decision making.

Conclusions

The home health care physicians described the Mobile Integrated Care Model as the best way to work, but there was still a need for additional resources and structure when working in different organizations. The need for full-time employment, additional time or hours, more equipment, access to each other’s medical records, and additional collaboration with other health care providers were expressed, which could contribute to increased work satisfaction and facilitate further development of person-centered care in the Mobile Integrated Care Model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03211-3.

Improving transitions and outcomes of sepsis survivors (I-TRANSFER): a type 1 hybrid protocol

BACKGROUND

This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal.  METHODS: Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions and Outcomes of Sepsis Survivors (I-TRANSFER) intervention compared to usual care on 30-day rehospitalization and emergency department use among sepsis survivors receiving HHC. The study design includes a baseline period with no intervention, a six-month start-up period followed by a one-year intervention period in partnership with five dyads of acute and HHC sites. In addition to the usual care/control periods from the dyad sites, additional survivors from national data will serve as control observations for comparison, weighted to produce covariate balance. The hypotheses will be tested using generalized mixed models with covariates guided by the Andersen Behavioral Model of Health Services. We will produce insights and generalizable knowledge regarding the context, processes, strategies, and determinants of I-TRANSFER implementation.

DISCUSSION

As the largest HHC study of its kind and the first to transform this novel evidence through implementation science, this study has the potential to produce new knowledge about the impact of timely attention in HHC to alleviate symptoms and support sepsis survivor's recovery at home. If effective, the impact of this intervention could be widespread, improving the quality of life and health outcomes for a growing, vulnerable population of sepsis survivors. A national advisory group will assist with widespread results dissemination.

Clinical notes: An untapped opportunity for improving risk prediction for hospitalization and emergency department visit during home health care

BACKGROUND/OBJECTIVE

Between 10 and 25% patients are hospitalized or visit emergency department (ED) during home healthcare (HHC). Given that up to 40% of these negative clinical outcomes are preventable, early and accurate prediction of hospitalization risk can be one strategy to prevent them. In recent years, machine learning-based predictive modeling has become widely used for building risk models. This study aimed to compare the predictive performance of four risk models built with various data sources for hospitalization and ED visits in HHC.

METHODS

Four risk models were built using different variables from two data sources: structured data (i.e., Outcome and Assessment Information Set (OASIS) and other assessment items from the electronic health record (EHR)) and unstructured narrative-free text clinical notes for patients who received HHC services from the largest non-profit HHC organization in New York between 2015 and 2017. Then, five machine learning algorithms (logistic regression, Random Forest, Bayesian network, support vector machine (SVM), and Naïve Bayes) were used on each risk model. Risk model performance was evaluated using the F-score and Precision-Recall Curve (PRC) area metrics.

RESULTS

During the study period, 8373/86,823 (9.6%) HHC episodes resulted in hospitalization or ED visits. Among five machine learning algorithms on each model, the SVM showed the highest F-score (0.82), while the Random Forest showed the highest PRC area (0.864). Adding information extracted from clinical notes significantly improved the risk prediction ability by up to 16.6% in F-score and 17.8% in PRC.

CONCLUSION

All models showed relatively good hospitalization or ED visit risk predictive performance in HHC. Information from clinical notes integrated with the structured data improved the ability to identify patients at risk for these emergent care events.

Influenza vaccination of home health care staff and the impact on patient hospitalizations

BACKGROUND

Influenza is associated with significant morbidity and mortality for adults aged 65 years and older. Influenza vaccination of health care workers is recommended. There is limited evidence regarding influenza vaccinations among health care workers in the home health care (HHC) setting and their impact on HHC patient outcomes.

METHODS

A national survey of HHC agencies was conducted in 2018-2019 and linked with patient data from the Centers for Medicare and Medicaid Services. Adjusted logistic regression models were used to estimate the association between hospital transfers due to respiratory infection during a 60 day HHC episode and staff vaccination policies.

RESULTS

Only 26.2% of HHC agencies had staff vaccination requirements and 71.2% agencies had staff vaccination rates higher than 75%. Agency policies for staff influenza vaccination were associated with reduced hospital transfers due to respiratory infection among HHC patients.

DISCUSSION

Influenza vaccination rates among HHC staff were low during the 2017-2018 influenza season. Policymakers may consider vaccination mandates to improve health care worker vaccination rates and protect patient safety.

CONCLUSIONS

This study sheds light on the potential impact of COVID-19 vaccination among HHC workers on patient outcomes. COVID-19 vaccination mandates could prove to be a vital tool in the fight against COVID-19 variants and infection outbreaks.

[Influence of the COVID-19 pandemic on the number and duration of care counselling provided by outpatient care services]

Hintergrund

Als Reaktion auf die COVID-19-Pandemie hat der deutsche Gesetzgeber die Rahmenbedingungen für die Pflegeberatung nach § 37 Abs. 3 SGB XI geändert. Die hauptsächlich durch ambulante Pflegedienste erbrachte Pflegeberatung muss (befristet bis zum 31.12.2021) nicht mehr in der Häuslichkeit der Pflegebedürftigen erfolgen, sondern ist auch per Telefon oder online möglich. In 2020 war zudem die bestehende Verpflichtung zur Inanspruchnahme einer Pflegeberatung für Pflegegeldbeziehende für einige Monate ausgesetzt.

Ziel

Beschrieben wird der Einfluss der COVID-19-Pandemie auf Anzahl und Dauer der von ambulanten Pflegediensten erbrachten Pflegeberatungen nach § 37 Abs. 3 SGB XI. Ein besonderes Augenmerk liegt auf der Frage, wie sich die Aussetzung der Beratungsverpflichtung auf die Inanspruchnahme von Pflegeberatungen ausgewirkt hat.

Methode

Sekundäranalyse von über 43.000 Datensätzen der BARMER Pflegekasse in Bayern, die ursprünglich zum Zwecke der Abrechnung gesammelt und gespeichert wurden. Auswertung in erster Linie mittels Zeitreihenanalysen und anderer deskriptiver Statistiken. Zusätzlich wurde die Korrelation zwischen der wöchentlichen Anzahl der Pflegeberatungen und den dem Robert Koch-Institut gemeldeten COVID-19-Fälle in Bayern ermittelt.

Ergebnisse

Ende März bis Mitte April 2020 verringerte sich die Zahl der Beratungen gegenüber Februar 2020 um fast 80 %. Für diesen Einbruch der Beratungszahlen war die Sorge vor einer Ansteckung mit SARS-CoV-2 entscheidend. Ermöglicht wurde der Rückgang aber zusätzlich durch die am 27.03.2020 beschlossene Aussetzung der Beratungspflicht. Die Aussetzung der Beratungspflicht allein hat in Bayern zu einem Rückgang zwischen 44 und 49 % geführt. Die vorliegenden Daten zeigen ferner, dass telefonische Pflegeberatungen im Durchschnitt kürzer sind als Präsenzberatungen.

Schlussfolgerungen

Die vorliegenden Daten deuten darauf hin, dass nur rund die Hälfte der Pflegeberatungen von Pflegebedürftigen in Anspruch genommen würde, wenn die in § 37 Abs. 3 verankerte Beratungsverpflichtung dauerhaft wegfiele. Außerdem enthalten sie Hinweise darauf, dass Beratungen bei einer Abrechnung nach Zeit im Durchschnitt kürzer sind als bei einer Abrechnung mittels Einsatzpauschalen.

Association between home health agency ownership status and discharge to community among Medicare beneficiaries

To investigate the association of ownership status, discharge rate and length of stay (LOS) of home health care (HH) services under the prospective payment system (PPS). We used 2016-2018 Outcome Assessment and Information Set (OASIS) data sets for Medicare beneficiaries. Two outcome variables were investigated: rate of discharge from an HH agency and LOS. Our main independent variable was ownership status: for-profit (FP) versus not-for-profit (NFP). FP agencies were 4.2% (p <.01) less likely to discharge patients to the community but more likely (7.3%; p <.001) to have longer LOS (>99 days) compared to NFPs. Findings that FP agencies were less likely to discharge patients to the community and more likely to have a longer length of stay than NFP agencies have implications for quality of care initiatives by the Medicare Post-Acute Transformation Act 2014.

"It changed everything": The safe Home care qualitative study of the COVID-19 pandemic's impact on home care aides, clients, and managers

Background

Home care (HC) services are crucial to the health and social wellbeing of older adults, people with disabilities, and the chronically ill. Although the HC sector is growing rapidly in the USA, there is high job turnover among the HC aide workforce. HC provides an important alternative to facility-based care, yet it has often been overlooked within the larger health care system: most recently, in COVID-19 pandemic planning. The objective of the study was to characterize qualitatively the impact of the COVID-19 pandemic on three key HC stakeholders: clients, aides, and agency managers.

Methods

The study included 37 phone interviews conducted during April – November 2020: HC clients (n = 9), aides (n = 16), and agency managers (n = 12). All interviews were audio recorded and transcribed verbatim. Qualitative analysis of the transcripts followed the grounded theory approach. The interview transcriptions were coded line-by-line into hierarchical themes with NVivo 12 software which allowed weighting of themes based on the number of interviews where they were coded.

Results

Fear of infection and transmission among HC clients and aides were strong themes. Infection prevention and control became the top priority guiding day-to-day business operations at agencies; sourcing adequate personal protective equipment for staff was the most urgent task. HC aides expressed concerns for their clients who showed signs of depression, due to increased isolation during the pandemic. The disappearance of comforting touch – resulting from physical distancing practices – altered the expression of compassion in the HC aide-client care relationship.

Conclusions

The findings suggest that the pandemic has further increased psychosocial job demands of HC aides. Increased isolation of clients may be contributing to a wider public health problem of elder loneliness and depression. To support the HC stakeholders during the on-going COVID-19 pandemic, for future pandemic planning or other health emergencies, it is important to improve HC aide job retention. This action could also ease the serious care services shortage among the growing population of older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07076-x.

Healthy Aging Requires a Healthy Home Care Workforce: the Occupational Safety and Health of Home Care Aides

PURPOSE OF REVIEW

To identify important home care (HC) aide occupational safety and health (OSH) hazards and examine how addressing these can improve aide health and the delivery of HC services overall. Specifically, this review seeks to answer: Why is HC aide OSH important? What are the most significant OSH challenges? How can improving HC aide OSH also improve the safety and health of their clients? What implications do the findings have for future research?

RECENT FINDINGS

HC is one of the fastest growing US industries. Aides comprise its largest workforce and are increasingly needed to care for the rapidly aging population. There is an aide shortage due in part to instabilities in HC work organization and to serious job-specific hazards, resulting in aides losing work time. Recent social, economic, and technological factors are rapidly changing the nature of HC work, creating OSH hazards similar to those found in nursing homes. At the same time, aides are experiencing social and economic inequities that increase their vulnerability to OSH hazards. These hazards are also a burden on employers who are challenged to recruit, retain, and train aides. OSH injuries and illness interrupt the continuity of care delivery to clients. Many OSH hazards also put HC clients and families at risk. A new framework and methodologies are needed to assess aide and client safety together in order to guide future HC research, policies, and practices. Government, industry, and labor commitment is needed to fund and coordinate a comprehensive, multidisciplinary research program.

Insights and decision support for home health care services in times of disasters

Home health care (HHC) services are of vital importance for the health care system of many countries. Further increases in their demand must be expected and with it grows the need to sustain these services in times of disasters. Existing risk assessment tools and guides support HHC service providers to secure their services. However, they do not provide insights on interdependencies of complex systems like HHC. Causal-Loop-Diagrams (CLDs) are generated to visualize the impacts of epidemics, blackouts, heatwaves, and floods on the HHC system. CLDs help to understand the system design as well as cascading effects. Additionally, they simplify the process of identifying points of action in order to mitigate the impacts of disasters. In a case study, the course of the COVID-19 pandemic and its effects on HHC in Austria in spring 2020 are shown. A decision support system (DSS) to support the daily scheduling of HHC nurses is presented and applied to numerically analyze the impacts of the COVID-19 pandemic, using real-world data from a HHC service provider in Vienna. The DSS is based on a Tabu Search metaheuristic that specifically aims to deal with the peculiarities of urban regions. Various transport modes are considered, including time-dependent public transport.

Home healthcare patient, caregiver and provider perspectives on use of unscheduled acute care and the usability and acceptability of on-demand telehealth solutions

BACKGROUND/OBJECTIVES

Home health care (HHC) agencies provide an important role in helping to transition patients from acute care to independent residential living. Telehealth has the potential to transform care delivery in HHC, however the majority of studies in HHC have focused on the use of telemonitoring for patients with specific chronic conditions. The objective of this study was to examine reasons HHC patients use acute care services and assess the acceptability of on-demand telehealth services among HHC patients, caregivers and personnel to help alleviate the need for seeking in-person acute care. Design/Setting/Participants/Measures: This study was a secondary analysis of qualitative data from in-depth interviews of 30 HHC personnel, patients and caregivers from a Medicare-certified HHC agency affiliated with a large healthcare system from January through May 2020. A conventional content analysis approach was used to identify themes.

RESULTS

Themes associated with reasons for seeking acute care included: sense of urgency, behavioral and psychosocial factors, and access to care. Participants described their perceptions of the benefits, usability and acceptability and barriers to using telehealth. Patients and HHC personnel agreed that on-demand telehealth should not replace in-person visits but all identified roles that on-demand telehealth services could play in improving communication and access to care. The biggest barriers to use of telehealth identified by HHC personnel were cost, access and ability to use technology by HHC patients.

CONCLUSION

This study identified reasons HHC patients seek unscheduled acute care and the usability and acceptability of on-demand telehealth services to increase access to care among HHC patients. These findings underscore the need to improve communication and coordination between patients, HHC personnel, and primary care providers and the role that on-demand telehealth services can have in transforming HHC.

Developing an integrated model of community-based palliative care into the primary health care (PHC) for terminally ill cancer patients in Iran

Background

Patients with cancer commonly experience pain and suffering at the end of life days. Community-based palliative care can improve the quality of life of terminally-ill cancer patients and provide them with a merciful death. The purpose of this study was to develop an integrated model of community-based palliative care into PHC for terminally ill cancer patients.

Method

This study is a health system research (HSR) that was conducted in three phases from October 2016 to July 2020. In the first phase, dimensions of community-based palliative care were explored in patients with cancer using qualitative methods and conventional content analysis. In the second phase, a scoping review was carried out to complete the collected data from the qualitative phase of the study. Based on the collected data in the first and second phases of the study, a preliminary draft of community-based palliative care was developed for patients with cancer based on the framework of the World Health Organization. Finally, the developed model was validated using the Delphi technique in the third phase of the study.

Results

Data analysis indicated that providing community-based care to patients with cancer is influenced by the context of care. According to the developed model, patients are identified as terminally ill, and then are referred to the local comprehensive health center in a reverse manner. After patients’ referral, they can receive appropriate healthcare until death by the home care team in relation to the comprehensive health center based on the framework of primary healthcare.

Conclusions

This model was developed based on the current Iranian healthcare structure and the needs of terminally ill cancer patients. According to the model, healthcare is provided in a reverse manner from the subspecialty centers to patients’ homes in order to provide easy access to palliative care. It is suggested to use this model as a pilot at the regional level.

Dehydration and loss of appetite: Key nutrition features in older people receiving home health care

OBJECTIVES

The aim was to describe a population of older people in home health care based on what is probably a novel theoretical model, previously published, and to analyze longitudinal changes in different dimensions of nutritional status.

METHODS

This explorative and longitudinal study examines nutritional status based on four domains in the novel theoretical model: health and somatic disorders; cognitive, affective, and sensory function; physical function and capacity; and food and nutrition. Inclusion criteria were age ≥65 y and need of home health care for more than three months. A total of 69 men and women were enrolled in the study. Participants' nutritional status was studied at baseline and regularly during the following three years.

RESULTS

At baseline, 44% (n = 27) reported one or more severe symptoms and 83% had polypharmacy (≥5 prescribed medications). The prevalence of malnutrition, sarcopenia, frailty, and dehydration at baseline were, respectively, 83% (n = 35), 44% (n = 24), 34% (n = 18), and 45% (n = 25). Participants that died during the 3-y follow-up (n = 14) differed from survivors in the following aspects: more reduced appetite, lower quality of life, worse cognitive function, lower physical activity, and less intake of dietary fiber and water. Dehydration at baseline was associated with lower function in several domains and with general decline over time.

CONCLUSIONS

Most participants had poor nutritional status. Dehydration and reduced appetite were important indicators of worsening nutritional and overall status and mortality.

Infection prevention and control practices in the home environment: Examining enablers and barriers to adherence among home health care nurses

BACKGROUND

Infection Prevention and Control (IPC) practices have been established in home health care. Adherence to IPC practices has been suboptimal with limited available evidence. The study aim was to examine the impact of individual, home environment, and organizational factors on IPC practices using human factors model.

METHODS

Three hundred and fifty-three nurses were surveyed across two large home care agencies to examine the relationship between IPC adherence and individual, home environment, and organizational factors.

RESULTS

Nurses reported multiple barriers to IPC practices in patients' homes (mean = 4.34, standard deviation = 2.53). Frequent barriers included clutter (reported by 74.5% of nurses) and a dirty environment (70.3%). Nurses also reported limited availability of some IPC supplies (mean = 7.76, standard deviation = 2.44), including personal protective equipment. Home environment factors were significant barriers, and availability of IPC supplies were significant enablers of IPC adherence. Agency-provided training and decision-making resources were not significant factors for IPC adherence in the presence of home environment barriers and IPC supplies.

CONCLUSIONS

This study findings suggest that IPC adherence strategies point to addressing barriers in the home environment and increasing availability of IPC supplies. The relationship between the patient's home environment, organizational factors, and IPC practices among home health care nurses warrants further study.

[Does primary care intervention have an impact in the place of death for patients in a palliative care program?]

Objetivos

Conocer si existe relación entre el lugar de fallecimiento y el proveedor de cuidados: equipo de atención primaria (EAP), equipo de soporte atención paliativa domiciliaria (ESAPD) o ambos. Identificar otras variables que pueden influir en el lugar de fallecimiento.

Diseño

Estudio descriptivo observacional retrospectivo.

Emplazamiento

Tres centros de salud, Dirección Asistencial Sureste, Comunidad de Madrid.

Participantes

Pacientes mayores de 18 años con episodio A.99.01 (paciente con necesidad de cuidados paliativos), según la codificación CIAP2, activo en su historia clínica informatizada (AP-Madrid) desde enero de 2016 hasta diciembre de 2018 (n = 499). No cumplieron criterios de inclusión 224 pacientes.

Mediciones y resultados principales

Se incluyeron 275 pacientes, la edad media fue de 78 años. El 80,4% (n = 221) tenían enfermedad oncológica. El 67,6% (n = 186) pertenecían al ámbito urbano. Existían diferencias significativas entre el lugar de fallecimiento y el equipo proveedor de cuidados: fallecieron en domicilio el 23,1% (n = 6) en seguimiento por EAP, el 14,5% (n = 10) en seguimiento por ESAPD y el 29,4% (n = 53) con seguimiento conjunto (p < 0,0001). Fallecieron en domicilio el 20,8% (n = 46) de pacientes oncológicos y el 42,6% (n = 23) no oncológicos (p < 0,0001). El 26,5% (n = 63) de los fallecidos en domicilio tenían cuidador principal y el 16,2% (n = 6) no lo tenían (p < 0,0001). Fallecieron en domicilio el 34,8% (n = 31) del ámbito rural y el 20,4% (n = 38) del ámbito urbano (p < 0,007).

Conclusiones

Los resultados avalan que el seguimiento conjunto aumenta el porcentaje de fallecimientos en domicilio.

Home health care utilization trend, predictors, and association with early rehospitalization following endovascular transcatheter aortic valve replacement

BACKGROUND/PURPOSE

Home healthcare (HHC) utilization is associated with higher rates of rehospitalization in patients with heart failure and transcatheter mitral valve repair. This study sought to assess the utilization, predictors, and the association of HHC with 30-day readmission in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS/MATERIALS

We queried the Nationwide Readmission Database from January 2012 to December 2017 for TAVR discharges with and without HHC referral. Using multivariate analysis, we identified predictors of HHC utilization, and its association with outcomes.

RESULTS

Of 60,950 TAVR discharges, 21,724 (35.7%) had HHC referral. On multivariable analysis, female sex (OR, 1.34; 95% CI, 1.29-1.40), non-elective admission (OR, 1.49; 95% CI, 1.42-1.56), diabetes mellitus (OR, 1.09; 95% CI, 1.05-1.13), prior stroke (OR, 1.06; 95% CI, 1.01-1.12), anemia (OR, 1.16; 95% CI, 1.11-1.21), and in-hospital complications including cardiogenic shock (OR, 1.37; 95% CI, 1.16-1.50), cardiac arrest (OR, 1.22; 95% CI, 1.00-1.50), stroke (OR, 2.62; 95% CI, 2.20-3.18), and new Permanent pacemaker (OR, 1.49; 95% CI, 1.41-1.58) were identified as independent predictors of HHC referral. HHC utilization was associated with longer median length of stay (4 days vs. 2 days, P < 0.001), higher rate of 30-day all-cause (15.5% vs. 10.6%, P < 0.001) and heart failure (2.1%vs. 1.1%, P < 0.001) readmission rates compared to those without HHC.

CONCLUSIONS

Our study identified a vulnerable group of TAVR patients that are at higher risk of 30-day readmission. Evidence-based interventions proven effective in reducing the burden of readmissions should be pursed in these patients to improve outcomes and quality of life.

A qualitative study of home health care experiences among Chinese homebound adults

BACKGROUND

Home health care services (HHC) are emerging in China to meet increased healthcare needs among the homebound population, but there is a lack of research examining the efficiency and effectiveness of this new care model. This study aimed to investigate care recipients' experiences with HHC and areas for improvement in China.

METHODS

This research was a qualitative study based on semi-structured interviews. Qualitative data were collected from homebound adults living in Jinan, Zhangqiu, and Shanghai, China. A sample of 17 homebound participants aged 45 or older (mean age = 76) who have received home-based health care were recruited. Conceptual content analysis and Colaizzi's method was used to generate qualitative codes and identify themes.

RESULTS

The evaluations of participants' experiences with HHC yielded both positive and negative aspects. Positive experiences included: 1) the healthcare delivery method was convenient for homebound older adults; 2) health problems could be detected in a timely manner because clinicians visited regularly; 3) home care providers had better bedside manners and technical skills than did hospital-based providers; 4) medical insurance typically covered the cost of home care services. Areas that could potentially be improved included: 1) the scope of HHC services was too limited to meet all the needs of homebound older adults; 2) the visit time was too short; 3) healthcare providers' technical skills varied greatly.

CONCLUSIONS

Findings from this study suggested that the HHC model benefited Chinese older adults-primarily homebound adults-in terms of convenience and affordability. There are opportunities to expand the scope of home health care services and improve the quality of care. Policymakers should consider providing more resources and incentives to enhance HHC in China. Educational programs may be created to train more HHC providers and improve their technical skills.

Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the US

BACKGROUND

Home health care, a commonly used bridge strategy for transitioning from hospital to home-based care, is expected to contribute to readmission avoidance efforts. However, in studies using disease-specific samples, evidence about the effectiveness of home health care in reducing readmissions is mixed.

OBJECTIVE

To examine the effectiveness of home health care in reducing return to hospital across a diverse sample of patients discharged home following acute care hospitalization.

RESEARCH DESIGN

Secondary analysis of a multi-site dataset from a study of discharge readiness assessment and post-discharge return to hospital, comparing matched samples of patients referred and not referred for home health care at the time of hospital discharge.

SETTING

Acute care, Magnet-designated hospitals in the United States PARTICIPANTS: The available sample (n = 18,555) included hospitalized patients discharged from medical-surgical units who were referred (n = 3,579) and not referred (n = 14,976) to home health care. The matched sample included 2767 pairs of home health care and non- home health care patients matched on patient and hospitalization characteristics using exact and Mahalanobis distance matching.

METHODS

Unadjusted t-tests and adjusted multinomial logit regression analyses to compare the occurrence of readmissions and Emergency Department/Observation visits within 30 and 60-days post-discharge.

RESULTS

No statistically significant differences in readmissions or Emergency Department /Observation visits between home health care and non-home health care patients were observed.

CONCLUSIONS

Home health care referral was not associated with lower rates of return to hospital within 30 and 60 days in this US sample matched on patient and clinical condition characteristics. This result raises the question of why home health care services did not produce evidence of lower post-discharge return to hospital rates. Focused attention by home health care programs on strategies to reduce readmissions is needed.

'They just came with the medication dispenser'- a qualitative study of elderly service users' involvement and welfare technology in public home care services

BACKGROUND

Public home care for the elderly is a key area in relation to improving health care quality. It is an important political goal to increase elderly people's involvement in their care and in the use of welfare technology. The aim of this study was to explore elderly service users' experience of user involvement in the implementation and everyday use of welfare technology in public home care services.

METHOD

This qualitative study has an explorative and descriptive design. Sixteen interviews of service users were conducted in five different municipalities over a period of six months. The data were analysed using reflexive thematic analysis.

RESULTS

Service users receiving public home care service are not a homogenous group, and the participants had different wishes and needs as regards user involvement and the use of welfare technology. The analysis led to four main themes: 1) diverse preferences as regards user involvement, 2) individual differences as regards information, knowledge and training, 3) feeling safe and getting help, and 4) a wish to stay at home for as long as possible.

CONCLUSION

The results indicated that user involvement was only to a limited extent an integral part of public home care services. Participants had varying insight into and interest in welfare technology, which was a challenge for user involvement. User involvement must be facilitated and implemented in a gentle way, highlighting autonomy and collaboration, and with the focus on respect, reciprocity and dialogue.

Antimicrobial stewardship in the outpatient parenteral antimicrobial therapy (OPAT) setting: the impact of prescription assessment by an infectious diseases specialist

Objective

In recent years, the use of outpatient parenteral antimicrobial therapy (OPAT) has increased, resulting in the need to ensure its rational and adequate utilization. This article describes the implementation of an antimicrobial stewardship program in the OPAT setting by a Health Maintenance Organization (HMO) and its results.

Method

An infectious disease (ID) physician made routine assessments of all home care parenteral antimicrobial requests from February to December 2019. Information on diagnosis, renal function, weight, previous antimicrobials, and microbiology were gathered during remote evaluations. Prescription changes recommended by the ID specialist were not mandatory, but implemented by the primary provider as accepted. Antibiotic consumption data was analyzed from January 2018 to December 2019. An active screening was conducted for treatment failures: two or more treatment course requirements, or death within 15 days of the evaluation were reexamined.

Results

A total of 506 antimicrobial requests were assessed. The most frequent diagnoses were urinary tract infection, pneumonia, and orthopedic surgical site infection. Six percent of evaluations were not completed due to insufficient information and 12% were requests by the primary physician for initial antimicrobial guidance. Of the 416 completed prescriptions evaluations, 58% had suggested changes, including different antimicrobials (40%), treatment duration (25%), and route of administration (23%). There was an increase in use of teicoplanin and meropenem, and a decrease in ceftriaxone, ertapenem, cefepime, amikacin and daptomycin use. The HMO’s overall parenteral antimicrobial outpatient consumption, which had shown an upward trend over the previous year, decreased after program initiation. No major adverse results were detected in patients’ clinical outcomes; two treatment failures were detected and promptly corrected; no deaths attributed to antibiotic changes were detected.

Conclusion

Outpatient antimicrobial stewardship, through remote assessment by an ID specialist, was effective and safe in the OPAT setting.

Social factors influencing utilization of home care in community-dwelling older adults: a scoping review

BACKGROUND

Older adults want to live at home as long as possible, even in the face of circumstances that limit their autonomy. Home care services reflect this emergent preference, allowing older adults to 'age in place' in familiar settings rather than receiving care for chronic health conditions or ageing needs in an institutionalized setting. Numerous social factors, generally studied in isolation, have been associated with home care utilization. Even so, social circumstances are complex and how these factors collectively influence home care use patterns remains unclear.

OBJECTIVES

To provide a broad and comprehensive overview of the social factors influencing home care utilization; and to evaluate the influence of discrete social factors on patterns of home care utilization in community-dwelling older adults in high-income countries.

METHODS

A scoping review was conducted of six electronic databases for records published between 2010 and 2020; additional records were obtained from hand searching review articles, reference lists of included studies and documents from international organisations. A narrative synthesis was presented, complemented by vote counting per social factor, harvest plots and an evaluation of aggregated findings to determine consistency across studies.

RESULTS

A total of 2,365 records were identified, of which 66 met inclusion criteria. There were 35 discrete social factors grouped into four levels of influence using a socio-ecological model (individual, relationship, community and societal levels) and grouped according to outcome of interest (home care propensity and intensity). Across all studies, social factors consistently showing any association (positive, negative, or equivocal in pattern) with home care propensity were: age, ethnicity/race, self-assessed health, insurance, housing ownership, housing problems, marital status, household income, children, informal caregiving, social networks and urban/rural area. Age, education, personal finances, living arrangements and housing ownership were associated with home care intensity, also with variable patterns in utilization. Additional community and societal level factors were identified as relevant but lacking consistency across the literature; these included rurality, availability of community services, methods of financing home care systems, and cultural determinants.

CONCLUSION

This is the first literature review bringing together a wide range of reported social factors that influence home care utilization. It confirms social factors do influence home care utilization in complex interactions, distinguishes level of influences at which these factors affect patterns of use and discusses policy implications for home care reform.

Developing a nursing protocol for the remote verification of an expected death

BACKGROUND

Homecare nurses play an important role in end-of-life care. A protocol is needed for the remote verification of expected deaths using information and communication technologies (ICT), that is consistent with Japanese guidelines.

AIM

To clarify the processes that nurses use to verify deaths and to develop a tentative nursing protocol for verifying expected deaths, using home-based ICT.

METHODS

Using literature and semi-structured interviews, a tentative nursing protocol was developed for verifying expected deaths using home-based ICT.

FINDINGS

To protect the dignity of patients and their families, it is important that their understanding and consent is provided for the remote verification of expected deaths. Furthermore, the up-to-date legal and ethical responsibilities of nurses should be discussed regarding the verification of a patient's death to provide the best care for the patients and families when implementing the Death Certification Using Information and Communication Technology (DCUICT).

CONCLUSION

This suggested protocol offers a framework for a new delivery of nursing care. It provides guidance for homecare nurses organising the care processes and nursing roles of DCUICT. Further revisions to this protocol must incorporate the specific requirement for the verification of nurses.

From village health volunteers to paid care givers: the optimal mix for a multidisciplinary home health care workforce in rural Thailand

BACKGROUND

Thailand is a rapidly aging society, which places high demand on home health care services for the elderly. The shortage of health care workforce in rural areas is a crucial obstacle to the delivery of adequate home health care services. The appropriate skill-mix between multidisciplinary health team and care givers (CGs) is an attractive solution for improving home health care services in rural Thailand. This study assessed the potential of trained CGs to provide home health care services and projected what the optimal mix for a multidisciplinary home health care team in rural Thailand would be in 2030.

METHODS

Eleven pilot districts in Thailand were recruited for the study. Secondary data were collected along with surveys of home health care providers. A total of 130 care managers (nurses) and 351 care givers (CG) were recruited for the survey. Workload, skill-mix potential, and acceptance of care givers were assessed in the surveys. The results from secondary data and the survey were used to project the health workforce requirements in 2030.

RESULTS

It is projected that in 2030 the number of elderly living in rural areas will be 7,156,700 (27% of the projected rural population). Of this, 20.3% will be home-bound, 1.1% will be bed-ridden and 1.6% will need rehabilitation. The main members of the multidisciplinary health workforce involved in home health care were nurses, doctors, and physiotherapists. The home health care services that were provided by the multidisciplinary health workforce included patient assessment, development of a care plan and case conference, home visits, and teaching and supervision of CGs. The CGs were village health volunteers trained to carry out regular home visits to patients. The CGs provided assistance with the activities of daily living, basic health services, moral support to patients and relatives, and surveillance of the home environment during home visits. CGs were well accepted by both the health professionals and the patients. Projections showed that 16,094 nurses, 1,542 doctors, 1,022 physiotherapists and 50,148 CGs will be required in 2030 to meet the needs of the dependent elderly for home health care in rural Thailand.

CONCLUSION

With the increased need for home health care services in the future, appropriate team work between the members of the multidisciplinary health team and the CGs in the community is the appropriate solution for likely shortages of health professional workforce.

Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries

OBJECTIVES

Patients who are referred to home health care after an acute care hospitalization may not receive home health care, resulting in incomplete home health referrals. This study examines the prevalence of incomplete referrals to home health, defined as not receiving home health care within 7 days after an initial hospital discharge, and investigates the relationship between home health referral completion and patient outcomes.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Medicare beneficiaries who are discharged from short-term acute care hospitals between October 2015 and December 2016 with a discharge status code on the hospital claim indicating home health care.

METHODS

Patient characteristics and outcomes were compared between Medicare beneficiaries with complete and incomplete home health referrals after hospital discharge. The outcomes included mortality, readmission rate, and total spending over a 1-year episode following hospitalization. These outcomes were risk-adjusted using patient demographic, socioeconomic, clinical characteristic, hospital characteristic, and state fixed effects.

RESULTS

Approximately 29% of the 724,700 hospitalizations in the analytic dataset had incomplete home health referrals after discharge. The rate of incomplete home health referrals varied among clinical conditions, ranging from 17% among joint/musculoskeletal patients and 38% among digestive/endocrine patients. Risk-adjusted 1-year mortality and readmission rates were 1.4 and 2.4 percentage points lower and total spending was $1053 higher among patients with complete home health referrals as compared with those with incomplete home health referrals after hospital discharge.

CONCLUSIONS AND IMPLICATIONS

The analysis revealed that almost 1 in 3 patients discharged from a hospital with a discharge status of home health does not receive home health care. In addition, complete home health referrals are associated with lower mortality and readmission rates and higher spending. As home health care utilization increases, policymakers should pay attention to the tradeoff between quality and cost when implementing alternative policies and payment models.

Telehealth and Home Health Occupational Therapy: Clients' Perceived Satisfaction with and Perception of Occupational Performance

Home health care agencies are restructuring service delivery models to address quality of care and client satisfaction while containing costs. New regulatory changes and the public health emergency due to the COVID-19 pandemic precipitated an immediate need for alternative care models. Telehealth has been recognized as a feasible delivery model to provide health care. This quasi-experimental pretest-posttest study examined the feasibility of performing occupational therapy telehealth visits as an adjunct to on-site visits for homebound clients (N=9). The Outcomes and Assessment Information Set (OASIS) data collection set, Canadian Occupational Performance Measure (COPM), and a survey were used to collect data. This combination of visits resulted in clinically and statistically significant improvements in client perception of performance and satisfaction with activities of daily living. Findings showed that participants favorably perceived this service delivery model met their therapy needs and they would recommend it to others. Results of this study warrant a larger study involving physical and speech therapy services.