Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys

The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3 months post-enrollment, 27 caregivers at 6 months, and 22 caregivers at 12 months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1 year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.

Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults

OBJECTIVES

Describe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Homebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n = 974).

METHODS

Use of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, ≥40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS.

RESULTS

Approximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind.

CONCLUSIONS AND IMPLICATIONS

Although home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.

The heterogeneity of the homebound: A latent class analysis of a national sample of homebound older adults

BACKGROUND

Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics.

MATERIALS AND METHODS

Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression.

RESULTS

We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%).

CONCLUSIONS

This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population.

Prevalence of use and characteristics of users of home-based medical care in Medicare Advantage

BACKGROUND/OBJECTIVES

Home-based medical care (HBMC) is longitudinal medical care provided by physicians, advanced practice providers, and, often, inter-professional care teams to patients in their homes. Our objective is to determine the prevalence of HBMC among older adults (≥65) insured by a Medicare Advantage (MA) plan and compare characteristics of those who receive HBMC to those who do not.

METHODS

Study used de-identified medical claims and enrollment records for MA beneficiaries during calendar years 2017 and 2018 linked with socioeconomic status data in the OptumLabs Data Warehouse. We defined a cohort of MA beneficiaries age ≥65 receiving HBMC for at least 2 months during 2017-2018, described the cohort using demographic, utilization, and comorbidity data and compared it to a 5% random sample of a population of MA beneficiaries age ≥65 not receiving HBMC (No HBMC).

RESULTS

Overall, 1.45% of the study cohort age ≥65 received HBMC. Compared to No HBMC (n = 132,147), those receiving HBMC (n = 38,800) were more likely to be: older (46.6% vs. 11.9% age 85+); female (70.8% vs. 58.5%); Black (12.3% vs. 11.3%); urban (90.3% vs. 81.3%); experience hospitalization (38.0% vs. 13.3%), emergency department visit (58.3% vs. 26.9%), ambulance trip (44.1% vs. 9.6%), skilled nursing facility (37.6% vs. 6.4%), or hospice care admission (21.1% vs. 3.5%). They also were more likely to experience a wide range of chronic conditions including dementia (58.1% vs. 5.2%), morbidity burden (Charlson score 3.4 vs. 1.8), and serious illness (77.1% vs. 29.5%). All comparisons p < 0.0001.

CONCLUSIONS

MA beneficiaries who received HBMC are older, experience greater chronic and serious illness burden, and higher levels of facility-based care than those who did not receive HBMC. MA plans need strategies to identify patients that would benefit from HBMC and develop approaches to deliver such care to this impactful, often invisible population.

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

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

Survival and characteristics of older adults receiving home-based medical care: A nationwide analysis in Taiwan

BACKGROUND

In Taiwan, the National Health Insurance Administration initiated the integrated home-based medical care (iHBMC) program in 2016 to improve accessibility to health care for homebound patients. This study aimed to describe the characteristics of older people receiving iHBMC services in Taiwan as well as the relationship between patient characteristics and survival.

METHODS

All older adults registered in the iHBMC application dataset were enrolled between March 1, 2016, and December 31, 2018. Data on social determinants of health (income level, residential area), functional status, consciousness status, nasogastric tube or urinary catheter placement, and major diseases were retrieved from the database. Data on the frequency of multidisciplinary team members' visits were collected. The survival rate was investigated using the Kaplan-Meier method. A Cox proportional hazards univariate regression was conducted to analyze factors influencing survival rates.

RESULTS

A total of 41,079 patients aged ≥65 years were enrolled in iHBMC services. The results showed that the one-year survival rates were 72.1%, 67.4%, and 14.7% in the home-based primary care (HBPC), home-based primary care plus (HBPC-Plus), and home-based palliative care (HBPalC), respectively. Nearly two-thirds of the HBPC-Plus patients underwent nasogastric tube placement. The Cox proportional hazards univariate regression analysis showed that a low urbanization level, a low income level, a low functional status, and an impaired consciousness status were significant predictors of poor survival after adjustment for confounding variables.

CONCLUSIONS

Older adults receiving iHBMC services had a high mortality rate. The high rate of feeding tube use indicated that education and support for both clinical practitioners and family caregivers regarding careful hand feeding are warranted. There was a relationship between low income levels and poor survival in rural areas. Further research on whether social care could impact prognosis should be considered.

Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism

BACKGROUND

Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access.

METHODS

Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia.

RESULTS

Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas.

CONCLUSION

Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.

Home-Based Primary and Palliative Care in the Medicaid Program: Systematic Review of the Literature

BACKGROUND/OBJECTIVES

To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries.

DESIGN

A systematic review of the peer-reviewed and gray literature of home-based primary care and palliative care programs among Medicaid beneficiaries including dual eligibles.

SETTING

HBMC including home-based primary care and palliative care programs.

PARTICIPANTS

Studies describing Medicaid beneficiaries receiving HBMC.

MEASUREMENTS

Three groups of studies were included: those focused on HBMC specifically for Medicaid beneficiaries, studies that described the proportion of Medicaid patients receiving HBMC, and those that used Medicaid status as a dependent variable in studying HBMC.

RESULTS

The peer-reviewed and gray literature searches revealed 574 unique studies of which only 16 met inclusion criteria. Few publications described HBMC as an integral care delivery model for Medicaid programs. Data from the programs described suggest the use of HBMC for Medicaid beneficiaries can reduce healthcare costs. The addition of social supports to HBMC appears to convey additional savings and benefits.

CONCLUSION

This systematic literature review highlights the relative dearth of literature regarding the use and impact of HBMC in the Medicaid population. HBMC has great potential to reduce Medicaid costs, and innovative programs combining HBMC with social support systems need to be tested.

Impact of a national medical fee schedule revision on the cessation of physician home visits among older patients in Tokyo: A retrospective study

As Japan's population continues to age rapidly, the national government has implemented several measures to improve the efficiency of healthcare services and to control rising medical expenses for older patients. One such measure was the revision of the medical fee schedule for physician home visits in April 2014, in which eligibility for these visits was restricted to patients who are unable to visit outpatient clinics without assistance. Through an investigation of patients who were receiving physician home visits in Tokyo, this study examines whether this fee schedule revision resulted in an increase in patients who transitioned from home visits to outpatient care. In a retrospective analysis of health insurance claims data, we examined 80,914 Tokyo residents aged 75 years or older who had received at least one physician home visit between January and May 2014. The study period was divided into four periods (January-February, February-March, March-April, and April-May), and we examined the number of patients receiving home visits in the index month of each period who subsequently transitioned to outpatient care in the following month. Potential factors associated with this transition to outpatient care were examined using a generalised estimating equation. The March-April period that included the fee schedule revision was significantly associated with a higher number of patients who transitioned from home visits in the index month to outpatient care in the following month (odds ratio: 4.46, p < 0.001) than the other periods. In addition, patients receiving home visits at residential facilities were more likely to transition to outpatient care (odds ratio: 10.40, p < 0.001). These findings indicate that the fee schedule revision resulted in an increase in patients who ceased physician home visits and began visiting outpatient clinics for treatment.

Hospital at Home-Plus: A Platform of Facility-Based Care

OBJECTIVES

To describe the evolution of a hospital at home (HaH) program to a HaH with a 30-day posthospitalization transition period (HaH-Plus) and results of a retrospective review of cases.

DESIGN

After launching HaH-Plus, we used the same interdisciplinary clinical team to provide acute home-based care for a broader range of home-based acute-level services than originally conceived in the Hospital at Home model. These included a palliative care unit at home (PCUaH), an observation unit at home (OUaH), a post-acute care rehabilitation at home (RaH), and a program for the hospital averse - those patients needing to be in the hospital but who refuse.

SETTING

Urban health system.

PARTICIPANTS

Individuals 18 years or older residing in specified catchment area with Medicare fee-for-service or accepted Medicare/Medicaid Advantage plans requiring facility-based care.

INTERVENTION

Provision of facility-based acute-level care at home to 685 participants.

MEASUREMENTS

Length of stay, readmission, and mortality.

RESULTS

HaH-Plus cared for 685 individuals. The PCUaH had the oldest participants (mean age 87), and all groups were predominantly female and dually eligible for Medicare and Medicaid. Diagnoses and length of stay were similar in all groups except that those in RaH had a larger group of diagnoses, than those accepted in to HaH-Plus and those in OUaH had a shorter stay. Rate of readmission was highest for RaH (19%). Mortality during the active treatment episode was highest for PCUaH and hospital averse as compared to HaH-Plus, OUaH and RaH.

CONCLUSION

Providing a broader range of facility-based care in the home has significant advantages for patients and increases the scalability of HaH. Developing a spectrum of services was possible by leveraging a robust, 24-hour HaH team. Community- and home-based care could become a greater part of the U.S. healthcare system if a platform of HaH services along with advances in technology and payment models were developed. J Am Geriatr Soc 67:596-602, 2019.