Natural Language Processing to Identify Home Health Care Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates

OBJECTIVES

Home health care patients who are at risk for becoming Incapacitated with No Evident Advance Directives or Surrogates (INEADS) may benefit from timely intervention to assist them with advance care planning. This study aimed to develop natural language processing algorithms for identifying home care patients who do not have advance directives, family members, or close social contacts who can serve as surrogate decision-makers in the event that they lose decisional capacity.

DESIGN

Cross-sectional study of electronic health records.

SETTING AND PARTICIPANTS

Patients receiving post-acute care discharge services from a large home health agency in New York City in 2019 (n = 45,390 enrollment episodes).

METHODS

We developed a natural language processing algorithm for identifying information documented in free-text clinical notes (n = 1,429,030 notes) related to 4 categories: evidence of close relationships, evidence of advance directives, evidence suggesting lack of close relationships, and evidence suggesting lack of advance directives. We validated the algorithm against Gold Standard clinician review for 50 patients (n = 314 notes) to calculate precision, recall, and F-score.

RESULTS

Algorithm performance for identifying text related to the 4 categories was excellent (average F-score = 0.91), with the best results for "evidence of close relationships" (F-score = 0.99) and the worst results for "evidence of advance directives" (F-score = 0.86). The algorithm identified 22% of all clinical notes (313,290 of 1,429,030) as having text related to 1 or more categories. More than 98% of enrollment episodes (48,164 of 49,141) included at least 1 clinical note containing text related to 1 or more categories.

CONCLUSIONS AND IMPLICATIONS

This study establishes the feasibility of creating an automated screening algorithm to aid home health care agencies with identifying patients at risk of becoming INEADS. This screening algorithm can be applied as part of a multipronged approach to facilitate clinician support for advance care planning with patients at risk of becoming INEADS.

Leveraging home health aides to improve outcomes in heart failure: A pilot study protocol

Heart failure (HF) affects six million people in the U.S., is associated with high morbidity, mortality, and healthcare utilization.(1, 2) Despite a decade of innovation, the majority of interventions aimed at reducing hospitalization and readmissions in HF have not been successful.(3-7) One reason may be that most have overlooked the role of home health aides and attendants (HHAs), who are often highly involved in HF care.(8-13) Despite their contributions, studies have found that HHAs lack specific HF training and have difficulty reaching their nursing supervisors when they need urgent help with their patients. Here we describe the protocol for a pilot randomized control trial (pRCT) assessing a novel stakeholder-engaged intervention that provides HHAs with a) HF training (enhanced usual care arm) and b) HF training plus a mobile health application that allows them to chat with a nurse in real-time (intervention arm). In collaboration with the VNS Health of New York, NY, we will conduct a single-site parallel arm pRCT with 104 participants (HHAs) to evaluate the feasibility, acceptability, and effectiveness (primary outcomes: HF knowledge; HF caregiving self-efficacy) of the intervention among HHAs caring for HF patients. We hypothesize that educating and better integrating HHAs into the care team can improve their ability to provide support for patients and outcomes for HF patients as well (exploratory outcomes include hospitalization, emergency department visits, and readmission). This study offers a novel and potentially scalable way to leverage the HHA workforce and improve the outcomes of the patients for whom they care. Clinical trial.gov registration: NCT04239911.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19

BACKGROUND

Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge.

METHODS

Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization.

RESULTS

Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization.

CONCLUSIONS

HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Utilizing patient-nurse verbal communication in building risk identification models: the missing critical data stream in home healthcare

BACKGROUND

In the United States, over 12 000 home healthcare agencies annually serve 6+ million patients, mostly aged 65+ years with chronic conditions. One in three of these patients end up visiting emergency department (ED) or being hospitalized. Existing risk identification models based on electronic health record (EHR) data have suboptimal performance in detecting these high-risk patients.

OBJECTIVES

To measure the added value of integrating audio-recorded home healthcare patient-nurse verbal communication into a risk identification model built on home healthcare EHR data and clinical notes.

METHODS

This pilot study was conducted at one of the largest not-for-profit home healthcare agencies in the United States. We audio-recorded 126 patient-nurse encounters for 47 patients, out of which 8 patients experienced ED visits and hospitalization. The risk model was developed and tested iteratively using: (1) structured data from the Outcome and Assessment Information Set, (2) clinical notes, and (3) verbal communication features. We used various natural language processing methods to model the communication between patients and nurses.

RESULTS

Using a Support Vector Machine classifier, trained on the most informative features from OASIS, clinical notes, and verbal communication, we achieved an AUC-ROC = 99.68 and an F1-score = 94.12. By integrating verbal communication into the risk models, the F-1 score improved by 26%. The analysis revealed patients at high risk tended to interact more with risk-associated cues, exhibit more "sadness" and "anxiety," and have extended periods of silence during conversation.

CONCLUSION

This innovative study underscores the immense value of incorporating patient-nurse verbal communication in enhancing risk prediction models for hospitalizations and ED visits, suggesting the need for an evolved clinical workflow that integrates routine patient-nurse verbal communication recording into the medical record.

Social Risk Factors are Associated with Risk for Hospitalization in Home Health Care: A Natural Language Processing Study

OBJECTIVE

This study aimed to develop a natural language processing (NLP) system that identified social risk factors in home health care (HHC) clinical notes and to examine the association between social risk factors and hospitalization or an emergency department (ED) visit.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We used standardized assessments and clinical notes from one HHC agency located in the northeastern United States. This included 86,866 episodes of care for 65,593 unique patients. Patients received HHC services between 2015 and 2017.

METHODS

Guided by HHC experts, we created a vocabulary of social risk factors that influence hospitalization or ED visit risk in the HHC setting. We then developed an NLP system to automatically identify social risk factors documented in clinical notes. We used an adjusted logistic regression model to examine the association between the NLP-based social risk factors and hospitalization or an ED visit.

RESULTS

On the basis of expert consensus, the following social risk factors emerged: Social Environment, Physical Environment, Education and Literacy, Food Insecurity, Access to Care, and Housing and Economic Circumstances. Our NLP system performed "very good" with an F score of 0.91. Approximately 4% of clinical notes (33% episodes of care) documented a social risk factor. The most frequently documented social risk factors were Physical Environment and Social Environment. Except for Housing and Economic Circumstances, all NLP-based social risk factors were associated with higher odds of hospitalization and ED visits.

CONCLUSIONS AND IMPLICATIONS

HHC clinicians assess and document social risk factors associated with hospitalizations and ED visits in their clinical notes. Future studies can explore the social risk factors documented in HHC to improve communication across the health care system and to predict patients at risk for being hospitalized or visiting the ED.

Uncovering hidden trends: identifying time trajectories in risk factors documented in clinical notes and predicting hospitalizations and emergency department visits during home health care

OBJECTIVE

This study aimed to identify temporal risk factor patterns documented in home health care (HHC) clinical notes and examine their association with hospitalizations or emergency department (ED) visits.

MATERIALS AND METHODS

Data for 73 350 episodes of care from one large HHC organization were analyzed using dynamic time warping and hierarchical clustering analysis to identify the temporal patterns of risk factors documented in clinical notes. The Omaha System nursing terminology represented risk factors. First, clinical characteristics were compared between clusters. Next, multivariate logistic regression was used to examine the association between clusters and risk for hospitalizations or ED visits. Omaha System domains corresponding to risk factors were analyzed and described in each cluster.

RESULTS

Six temporal clusters emerged, showing different patterns in how risk factors were documented over time. Patients with a steep increase in documented risk factors over time had a 3 times higher likelihood of hospitalization or ED visit than patients with no documented risk factors. Most risk factors belonged to the physiological domain, and only a few were in the environmental domain.

DISCUSSION

An analysis of risk factor trajectories reflects a patient's evolving health status during a HHC episode. Using standardized nursing terminology, this study provided new insights into the complex temporal dynamics of HHC, which may lead to improved patient outcomes through better treatment and management plans.

CONCLUSION

Incorporating temporal patterns in documented risk factors and their clusters into early warning systems may activate interventions to prevent hospitalizations or ED visits in HHC.

Predicting emergency department visits and hospitalizations for patients with heart failure in home healthcare using a time series risk model

OBJECTIVES

Little is known about proactive risk assessment concerning emergency department (ED) visits and hospitalizations in patients with heart failure (HF) who receive home healthcare (HHC) services. This study developed a time series risk model for predicting ED visits and hospitalizations in patients with HF using longitudinal electronic health record data. We also explored which data sources yield the best-performing models over various time windows.

MATERIALS AND METHODS

We used data collected from 9362 patients from a large HHC agency. We iteratively developed risk models using both structured (eg, standard assessment tools, vital signs, visit characteristics) and unstructured data (eg, clinical notes). Seven specific sets of variables included: (1) the Outcome and Assessment Information Set, (2) vital signs, (3) visit characteristics, (4) rule-based natural language processing-derived variables, (5) term frequency-inverse document frequency variables, (6) Bio-Clinical Bidirectional Encoder Representations from Transformers variables, and (7) topic modeling. Risk models were developed for 18 time windows (1-15, 30, 45, and 60 days) before an ED visit or hospitalization. Risk prediction performances were compared using recall, precision, accuracy, F1, and area under the receiver operating curve (AUC).

RESULTS

The best-performing model was built using a combination of all 7 sets of variables and the time window of 4 days before an ED visit or hospitalization (AUC = 0.89 and F1 = 0.69).

DISCUSSION AND CONCLUSION

This prediction model suggests that HHC clinicians can identify patients with HF at risk for visiting the ED or hospitalization within 4 days before the event, allowing for earlier targeted interventions.

Having a Say Matters: The Association Between Home Health Aides' Voice and Job Satisfaction

Purpose

Despite a rapidly growing need for home health aides (HHAs), turnover rates are high. While this is driven in large part by the demanding nature of their work and low wages, another factor may be that HHAs are often not considered part of the medical team which can leave them feeling unheard by other healthcare professionals. We sought to determine whether this concept, or HHAs' perceived voice, was associated with job satisfaction.

Methods and Design

This cross-sectional survey of English- and Spanish-speaking HHAs caring for adults with heart failure (HF) was conducted from June 2020 to July 2021 in New York, NY in partnership with a labor management fund of a large healthcare union that provides benefits and training to HHAs. Voice was assessed with a validated 5-item scale (total score range 5 to 25). Job Satisfaction was assessed with the 5-item Work Domain Satisfaction Scale (total score range 5 to 35). Multivariable linear regression analysis was used to examine the association between voice and job satisfaction.

Results

A total of 413 HHAs employed by 56 unique home care agencies completed the survey; they had a mean age of 48 years, 97.6% were female, 60.2% were Hispanic, and they worked as HHAs for a median of 10 years (IQR, 5, 17). They had a median Voice score of 18 (IQR 15-20) and mean job satisfaction score of 26.4 (SD 5.6). Higher levels of voice (1.75 [0.46-3.04]) were associated with greater job satisfaction (p=0.008). When adjusting for Race/Ethnicity, HF training, and HF knowledge, the association between Voice and job satisfaction remained significant ((1.77 [0.40-3.13]).

Conclusion

HHAs with a voice in the care of their patients experienced greater job satisfaction. Voice may be an important target for interventions aiming to improve HHAs' retention in the field.

Continuity of Care Versus Language Concordance as an Intervention to Reduce Hospital Readmissions From Home Health Care

BACKGROUND

Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact.

OBJECTIVE

The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency.

DESIGN

A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care.

PARTICIPANTS

The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge.

MEASURES

The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis.

RESULTS

When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%).

CONCLUSION

In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.

Home Healthcare Patients With Distinct Psychological, Cognitive, and Behavioral Symptom Profiles and At-Risk Subgroup for Hospitalization and Emergency Department Visits Using Latent Class Analysis

One-third of home healthcare patients are hospitalized or visit emergency departments during a 60-day episode of care. Among all risk factors, psychological, cognitive, and behavioral symptoms often remain underdiagnosed or undertreated in older adults. Little is known on subgroups of older adults receiving home healthcare services with similar psychological, cognitive, and behavioral symptom profiles and an at-risk subgroup for future hospitalization and emergency department visits. Our cross-sectional study used data from a large, urban home healthcare organization (n = 87,943). Latent class analysis was conducted to identify meaningful subgroups of older adults based on their distinct psychological, cognitive, and behavioral symptom profiles. Adjusted multiple logistic regression was used to understand the association between the latent subgroup and future hospitalization and emergency department visits. Descriptive and inferential statistics were conducted to describe the individual characteristics and to test for significant differences. The three-class model consisted of Class 1: "Moderate psychological symptoms without behavioral issues," Class 2: "Severe psychological symptoms with behavioral issues," and Class 3: "Mild psychological symptoms without behavioral issues." Compared to Class 3, Class 1 patients had 1.14 higher odds and Class 2 patients had 1.26 higher odds of being hospitalized or visiting emergency departments. Significant differences were found in individual characteristics such as age, gender, race/ethnicity, and insurance. Home healthcare clinicians should consider the different latent subgroups of older adults based on their psychological, cognitive, and behavioral symptoms. In addition, they should provide timely assessment and intervention especially to those at-risk for hospitalization and emergency department visits.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Qualitative Study of Home Health Aides' Perspectives towards COVID-19 Vaccination

Home health aides provide care to homebound older adults and those with chronic conditions. Aides were less likely to receive COVID-19 vaccines when they became available. We examined aides' perspectives towards COVID-19 vaccination. Qualitative interviews were conducted with 56 home health aides at a large not-for-profit home care agency in New York City. Results suggested that aides' vaccination decisions were shaped by (1) information sources, beliefs, their health, and experiences providing care during COVID-19; (2) perceived susceptibility and severity of COVID-19; (3) perceived benefits of vaccination including protection from COVID-19, respect from colleagues and patients, and fulfillment of work-related requirements; (4) perceived barriers to vaccination including concerns about safety, efficacy, and side effects; and (5) cues to action including access to vaccination sites/appointments, vaccination mandates, question and answer sessions from trusted sources, and testimonials. Providing tailored information with support to address vaccination barriers could lead to improved vaccine uptake.

The identification of clusters of risk factors and their association with hospitalizations or emergency department visits in home health care

AIMS

To identify clusters of risk factors in home health care and determine if the clusters are associated with hospitalizations or emergency department visits.

DESIGN

A retrospective cohort study.

METHODS

This study included 61,454 patients pertaining to 79,079 episodes receiving home health care between 2015 and 2017 from one of the largest home health care organizations in the United States. Potential risk factors were extracted from structured data and unstructured clinical notes analysed by natural language processing. A K-means cluster analysis was conducted. Kaplan-Meier analysis was conducted to identify the association between clusters and hospitalizations or emergency department visits during home health care.

RESULTS

A total of 11.6% of home health episodes resulted in hospitalizations or emergency department visits. Risk factors formed three clusters. Cluster 1 is characterized by a combination of risk factors related to "impaired physical comfort with pain," defined as situations where patients may experience increased pain. Cluster 2 is characterized by "high comorbidity burden" defined as multiple comorbidities or other risks for hospitalization (e.g., prior falls). Cluster 3 is characterized by "impaired cognitive/psychological and skin integrity" including dementia or skin ulcer. Compared to Cluster 1, the risk of hospitalizations or emergency department visits increased by 1.95 times for Cluster 2 and by 2.12 times for Cluster 3 (all p < .001).

CONCLUSION

Risk factors were clustered into three types describing distinct characteristics for hospitalizations or emergency department visits. Different combinations of risk factors affected the likelihood of these negative outcomes.

IMPACT

Cluster-based risk prediction models could be integrated into early warning systems to identify patients at risk for hospitalizations or emergency department visits leading to more timely, patient-centred care, ultimately preventing these events.

PATIENT OR PUBLIC CONTRIBUTION

There was no involvement of patients in developing the research question, determining the outcome measures, or implementing the study.

Measuring Palliative Care-Related Knowledge, Attitudes, and Confidence in Home Health Care Clinicians, Patients, and Caregivers: A Systematic Review

Background: Integrating palliative care services in the home health care (HHC) setting is an important strategy to provide care for seriously ill adults and improve symptom burden, quality of life, and caregiver burden. Routine palliative care in HHC is only possible if clinicians who provide this care are prepared and patients and caregivers are well equipped with the knowledge to receive this care. A key first step in integrating palliative care services within HHC is to measure preparedness of clinicians and readiness of patients and caregivers to receive it. Objective: The objective of this systematic review was to review existing literature related to the measurement of palliative care-related knowledge, attitudes, and confidence among HHC clinicians, patients, and caregivers. Methods: We searched PubMed, CINAHL, Web of Science, and Cochrane for relevant articles between 2000 and 2021. Articles were included in the final analysis if they (1) reported specifically on palliative care knowledge, attitudes, or confidence, (2) presented measurement tools, instruments, scales, or questionnaires, (3) were conducted in the HHC setting, (4) and included HHC clinicians, patients, or caregivers. Results: Seventeen articles were included. While knowledge, attitudes, and confidence have been studied in HHC clinicians, patients, and caregivers, results varied significantly across countries and health care systems. No study captured knowledge, attitudes, and confidence of the full HHC workforce; notably, home health aides were not included in the studies. Conclusion: Existing instruments did not comprehensively contain elements of the eight domains of palliative care outlined by the National Consensus Project (NCP) for Quality Palliative Care. A comprehensive psychometrically tested instrument to measure palliative care-related knowledge, attitudes, and confidence in the HHC setting is needed.

Factors associated with poor self-management documented in home health care narrative notes for patients with heart failure

BACKGROUND

Patients with heart failure (HF) who actively engage in their own self-management have better outcomes. Extracting data through natural language processing (NLP) holds great promise for identifying patients with or at risk of poor self-management.

OBJECTIVE

To identify home health care (HHC) patients with HF who have poor self-management using NLP of narrative notes, and to examine patient factors associated with poor self-management.

METHODS

An NLP algorithm was applied to extract poor self-management documentation using 353,718 HHC narrative notes of 9,710 patients with HF. Sociodemographic and structured clinical data were incorporated into multivariate logistic regression models to identify factors associated with poor self-management.

RESULTS

There were 758 (7.8%) patients in this sample identified as having notes with language describing poor HF self-management. Younger age (OR 0.982, 95% CI 0.976-0.987, p < .001), longer length of stay in HHC (OR 1.036, 95% CI 1.029- 1.043, p < .001), diagnosis of diabetes (OR 1.47, 95% CI 1.3-1.67, p < .001) and depression (OR 1.36, 95% CI 1.09-1.68, p < .01), impaired decision-making (OR 1.64, 95% CI 1.37-1.95, p < .001), smoking (OR 1.7, 95% CI 1.4-2.04, p < .001), and shortness of breath with exertion (OR 1.25, 95% CI 1.1-1.42, p < .01) were associated with poor self-management.

CONCLUSIONS

Patients with HF who have poor self-management can be identified from the narrative notes in HHC using novel NLP methods. Meaningful information about the self-management of patients with HF can support HHC clinicians in developing individualized care plans to improve self-management and clinical outcomes.

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.

Detecting Language Associated With Home Healthcare Patient's Risk for Hospitalization and Emergency Department Visit

BACKGROUND

About one in five patients receiving home healthcare (HHC) services are hospitalized or visit an emergency department (ED) during a home care episode. Early identification of at-risk patients can prevent these negative outcomes. However, risk indicators, including language in clinical notes that indicate a concern about a patient, are often hidden in narrative documentation throughout their HHC episode.

OBJECTIVE

The aim of the study was to develop an automated natural language processing (NLP) algorithm to identify concerning language indicative of HHC patients' risk of hospitalizations or ED visits.

METHODS

This study used the Omaha System-a standardized nursing terminology that describes problems/signs/symptoms that can occur in the community setting. First, five HHC experts iteratively reviewed the Omaha System and identified concerning concepts indicative of HHC patients' risk of hospitalizations or ED visits. Next, we developed and tested an NLP algorithm to identify these concerning concepts in HHC clinical notes automatically. The resulting NLP algorithm was applied on a large subset of narrative notes (2.3 million notes) documented for 66,317 unique patients ( n = 87,966 HHC episodes) admitted to one large HHC agency in the Northeast United States between 2015 and 2017.

RESULTS

A total of 160 Omaha System signs/symptoms were identified as concerning concepts for hospitalizations or ED visits in HHC. These signs/symptoms belong to 31 of the 42 available Omaha System problems. Overall, the NLP algorithm showed good performance in identifying concerning concepts in clinical notes. More than 18% of clinical notes were detected as having at least one concerning concept, and more than 90% of HHC episodes included at least one Omaha System problem. The most frequently documented concerning concepts were pain, followed by issues related to neuromusculoskeletal function, circulation, mental health, and communicable/infectious conditions.

CONCLUSION

Our findings suggest that concerning problems or symptoms that could increase the risk of hospitalization or ED visit were frequently documented in narrative clinical notes. NLP can automatically extract information from narrative clinical notes to improve our understanding of care needs in HHC. Next steps are to evaluate which concerning concepts identified in clinical notes predict hospitalization or ED visit.

Do nurses document all discussions of patient problems and nursing interventions in the electronic health record? A pilot study in home healthcare

Objective

To assess the overlap of information between electronic health record (EHR) and patient–nurse verbal communication in home healthcare (HHC).

Methods

Patient–nurse verbal communications during home visits were recorded between February 16, 2021 and September 2, 2021 with patients being served in an organization located in the Northeast United States. Twenty-two audio recordings for 15 patients were transcribed. To compare overlap of information, manual annotations of problems and interventions were made on transcriptions as well as information from EHR including structured data and clinical notes corresponding to HHC visits.

Results

About 30% (1534/5118) of utterances (ie, spoken language preceding/following silence or a change of speaker) were identified as including problems or interventions. A total of 216 problems and 492 interventions were identified through verbal communication among all the patients in the study. Approximately 50.5% of the problems and 20.8% of the interventions discussed during the verbal communication were not documented in the EHR. Preliminary results showed that statistical differences between racial groups were observed in a comparison of problems and interventions.

Discussion

This study was the first to investigate the extent that problems and interventions were mentioned in patient–nurse verbal communication during HHC visits and whether this information was documented in EHR. Our analysis identified gaps in information overlap and possible racial disparities.

Conclusion

Our results highlight the value of analyzing communications between HHC patients and nurses. Future studies should explore ways to capture information in verbal communication using automated speech recognition.

Audio Recording Patient-Nurse Verbal Communications in Home Health Care Settings: Pilot Feasibility and Usability Study

Background

Patients’ spontaneous speech can act as a biomarker for identifying pathological entities, such as mental illness. Despite this potential, audio recording patients’ spontaneous speech is not part of clinical workflows, and health care organizations often do not have dedicated policies regarding the audio recording of clinical encounters. No previous studies have investigated the best practical approach for integrating audio recording of patient-clinician encounters into clinical workflows, particularly in the home health care (HHC) setting.

Objective

This study aimed to evaluate the functionality and usability of several audio-recording devices for the audio recording of patient-nurse verbal communications in the HHC settings and elicit HHC stakeholder (patients and nurses) perspectives about the facilitators of and barriers to integrating audio recordings into clinical workflows.

Methods

This study was conducted at a large urban HHC agency located in New York, United States. We evaluated the usability and functionality of 7 audio-recording devices in a laboratory (controlled) setting. A total of 3 devices—Saramonic Blink500, Sony ICD-TX6, and Black Vox 365—were further evaluated in a clinical setting (patients’ homes) by HHC nurses who completed the System Usability Scale questionnaire and participated in a short, structured interview to elicit feedback about each device. We also evaluated the accuracy of the automatic transcription of audio-recorded encounters for the 3 devices using the Amazon Web Service Transcribe. Word error rate was used to measure the accuracy of automated speech transcription. To understand the facilitators of and barriers to integrating audio recording of encounters into clinical workflows, we conducted semistructured interviews with 3 HHC nurses and 10 HHC patients. Thematic analysis was used to analyze the transcribed interviews.

Results

Saramonic Blink500 received the best overall evaluation score. The System Usability Scale score and word error rate for Saramonic Blink500 were 65% and 26%, respectively, and nurses found it easier to approach patients using this device than with the other 2 devices. Overall, patients found the process of audio recording to be satisfactory and convenient, with minimal impact on their communication with nurses. Although, in general, nurses also found the process easy to learn and satisfactory, they suggested that the audio recording of HHC encounters can affect their communication patterns. In addition, nurses were not aware of the potential to use audio-recorded encounters to improve health care services. Nurses also indicated that they would need to involve their managers to determine how audio recordings could be integrated into their clinical workflows and for any ongoing use of audio recordings during patient care management.

Conclusions

This study established the feasibility of audio recording HHC patient-nurse encounters. Training HHC nurses about the importance of the audio-recording process and the support of clinical managers are essential factors for successful implementation.

Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative study with home healthcare clinicians

OBJECTIVE

To identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors.

METHODS

We interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians' response to risk factors and documentation of risk factors.

RESULTS

Fifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)).

DISCUSSION

Clinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them.

CONCLUSION

This study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies.

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.

Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial

BACKGROUND

Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures.

METHODS

This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures.

RESULTS

Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants.

CONCLUSIONS

The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.

Nurse perspectives on the psychosocial care of patients with urinary incontinence in home hospice: A qualitative study

BACKGROUND

Urinary incontinence is prevalent among patients receiving home hospice and presents multiple care management challenges for nurses and family caregivers.

AIM

This study sought to understand how urinary incontinence influences the psychosocial care of patients receiving home hospice and the strategies that nurses employ to maximize patient and family comfort.

DESIGN

Qualitative descriptive study using semi-structured interviews.

SETTING/PARTICIPANTS

Nurses employed at a large not-for-profit hospice agency in New York City.

RESULTS

Analyses of 32 interviews revealed three primary themes. First, nurses considered urinary incontinence to be associated with multiple psychosocial issues including embarrassment for patients and caregiver burden. Second, nurses described urinary incontinence as a threat to patient dignity and took steps to preserve their continence function. Third, nurses assisted patients and their families to cope with urinary incontinence through normalization, reframing incontinence as part of the disease process, mobilizing caregiving assistance, and encouraging use of continence supplies such as diapers and liners.

CONCLUSION

Urinary incontinence influences the psychosocial care of patients receiving home hospice and nurses employ strategies to maximize patient and family comfort. Additional research is needed to examine the psychosocial benefits of facilitated discussions with patients and family members about incontinence, provision of caregiving support, and distribution of comprehensive incontinence supplies to patients with fewer resources.

Capturing Concerns about Patient Deterioration in Narrative Documentation in Home Healthcare

Home healthcare (HHC) agencies provide care to more than 3.4 million adults per year. There is value in studying HHC narrative notes to identify patients at risk for deterioration. This study aimed to build machine learning algorithms to identify "concerning" narrative notes of HHC patients and identify emerging themes. Six algorithms were applied to narrative notes (n = 4,000) from a HHC agency to classify notes as either "concerning" or "not concerning." Topic modeling using Latent Dirichlet Allocation bag of words was conducted to identify emerging themes from the concerning notes. Gradient Boosted Trees demonstrated the best performance with a F-score = 0.74 and AUC = 0.96. Emerging themes were related to patient-clinician communication, HHC services provided, gait challenges, mobility concerns, wounds, and caregivers. Most themes have been cited by previous literature as increasing risk for adverse events. In the future, such algorithms can support early identification of patients at risk for deterioration.

Exploring Reasons for Delayed Start-of-Care Nursing Visits in Home Health Care: Algorithm Development and Data Science Study

BACKGROUND

Delayed start-of-care nursing visits in home health care (HHC) can result in negative outcomes, such as hospitalization. No previous studies have investigated why start-of-care HHC nursing visits are delayed, in part because most reasons for delayed visits are documented in free-text HHC nursing notes.

OBJECTIVE

The aims of this study were to (1) develop and test a natural language processing (NLP) algorithm that automatically identifies reasons for delayed visits in HHC free-text clinical notes and (2) describe reasons for delayed visits in a large patient sample.

METHODS

This study was conducted at the Visiting Nurse Service of New York (VNSNY). We examined data available at the VNSNY on all new episodes of care started in 2019 (N=48,497). An NLP algorithm was developed and tested to automatically identify and classify reasons for delayed visits.

RESULTS

The performance of the NLP algorithm was 0.8, 0.75, and 0.77 for precision, recall, and F-score, respectively. A total of one-third of HHC episodes (n=16,244) had delayed start-of-care HHC nursing visits. The most prevalent identified category of reasons for delayed start-of-care nursing visits was no answer at the door or phone (3728/8051, 46.3%), followed by patient/family request to postpone or refuse some HHC services (n=2858, 35.5%), and administrative or scheduling issues (n=1465, 18.2%). In 40% (n=16,244) of HHC episodes, 2 or more reasons were documented.

CONCLUSIONS

To avoid critical delays in start-of-care nursing visits, HHC organizations might examine and improve ways to effectively address the reasons for delayed visits, using effective interventions, such as educating patients or caregivers on the importance of a timely nursing visit and improving patients' intake procedures.

Continuity of Nursing Care in Home Health: Impact on Rehospitalization Among Older Adults With Dementia

BACKGROUND

Home health care (HHC) is a leading form of home and community-based services for persons with dementia (PWD). Nurses are the primary providers of HHC; however, little is known of nursing care delivery and quality.

OBJECTIVE

The objective of this study was to examine the association between continuity of nursing care in HHC and rehospitalization among PWD.

RESEARCH DESIGN

This is a retrospective cohort study using multiple years (2010-2015) of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency.

SUBJECTS

This study included 23,886 PWD receiving HHC following a hospitalization.

MEASURES

Continuity of nursing care was calculated using the Bice and Boxerman method, which considered the number of total visits, nurses, and visits from each nurse during an HHC episode. The outcome was all-cause rehospitalization during HHC. Risk-adjusted logistic regression was used for analysis.

RESULTS

Approximately 24% of PWD were rehospitalized. The mean continuity of nursing care score was 0.56 (SD=0.33). Eight percent of PWD received each nursing visit from a different nurse (no continuity), and 26% received all visits from one nurse during an HHC episode (full continuity). Compared with those receiving high continuity of nursing care (third tertile), PWD receiving low (first tertile) or moderate (second tertile) continuity of nursing care had an adjusted odds ratio of 1.33 (95% confidence interval: 1.25-1.46) and 1.30 (95% confidence interval: 1.22-1.43), respectively, for being rehospitalized.

CONCLUSIONS

Wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.

Nurse Perspectives on Urinary Incontinence in the Home Hospice Setting

CONTEXT

To date, no studies have characterized the impacts of urinary incontinence (UI) at the end of life in the home hospice (HH) setting. UI is highly prevalent at the end of life and adversely affects quality of life.

OBJECTIVES

To characterize HH nurses' perspectives on UI in HH patients.

METHODS

We conducted a qualitative descriptive study of interviews between HH nurses and the study investigator. Thirty-two interviews with HH nurses were transcribed and analyzed. Nurses were mostly female, college-educated, and had several years of experience in HH nursing.

RESULTS

We identified findings in four major themes: 1) HH nurses' definition and identification of UI, 2) the absence of formal guidelines for diagnosing UI in HH patients, 3) UI's adverse effect on HH patients and their families, and 4) the lack of standardized guidelines for the management of UI in the HH setting. We found that there was a general lack of clarity on the subtypes of UI and no standardized guidelines for management of UI in the HH setting. Nurses reported that UI was bothersome to HH patients and their caregivers, citing patient discomfort, loss of dignity, and additional labor burden as reasons for this. Management strategies for UI lacked standardization.

CONCLUSION

UI is a prevalent and debilitating condition in HH patients. There is a need for studies to further characterize the impacts of UI on HH patients and their caregivers. Formal training on UI subtypes and management is needed to facilitate proper documentation, research, and improve patient outcomes.

Stimulating Research to Enhance Aging in Place

Older adults may benefit from interventions to successfully age in place. Research has an opportunity to test interventions and implementation strategies to fulfill the needs of older adults through collective evidence building. The purpose of this article is to describe the proceedings of the American Occupational Therapy Foundation (AOTF) 2019 Planning Grant Collective and describe the areas of research that were identified as critical. The AOTF convened scientists with expertise in the area of aging in place to catalyze research on aging in place for older adults. Four priority areas in the aging in place literature were highlighted: (a) identification of factors that support aging in place, (b) classification of processes by which family members and care partners are included in aging in place efforts, (c) categorization of technology supporting older adults to age in place, and (d) development of science that clarifies implementation of evidence-based practice.

Individual, social, and environmental factors for infection risk among home healthcare patients: A multi-method study

There has been limited research into the individual, social, and environmental factors for infection risk among patients in the home healthcare (HHC) setting, where the infection is a leading cause of hospitalisation. The aims of this study were to (1) explore nurse perceptions of individual, social, and environmental factors for infection risk among HHC patients; and (2) identify the frequency of environmental barriers to infection prevention and control in HHC. Data were collected in 2017-2018 and included qualitative interviews with HHC nurses (n = 50) and structured observations of nurse visits to patients' homes (n = 400). Thematic analyses of interviews with nurses suggested they perceived infection risk among patients as being influenced by knowledge of and attitudes towards infection prevention and engagement in hygiene practices, receipt of support from informal caregivers and nurse interventions aimed at cultivating infection control knowledge and practices, and the home environment. Statistical analyses of observation checklists revealed nurses encountered an average of 1.7 environmental barriers upon each home visit. Frequent environmental barriers observed during visits to HHC patients included clutter (39.5%), poor lighting (38.8%), dirtiness (28.5%), and pets (17.2%). Additional research is needed to clarify inter-relationships among these factors and identify strategies for addressing each as part of a comprehensive infection control program in HHC.

"A catalyst for action": Factors for implementing clinical risk prediction models of infection in home care settings

OBJECTIVE

The study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow.

MATERIALS AND METHODS

This was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses' perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis.

RESULTS

Two themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings.

DISCUSSION

The findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action.

CONCLUSIONS

It is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.

Improving Patient Prioritization During Hospital-Homecare Transition: Protocol for a Mixed Methods Study of a Clinical Decision Support Tool Implementation

Background

Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient’s capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits.

Objective

This study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT.

Methods

Employing a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data.

Results

The study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021.

Conclusions

Mixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting.

Trial Registration

ClinicalTrials.gov NCT04136951; https://clinicaltrials.gov/ct2/show/NCT04136951

International Registered Report Identifier (IRRID)

PRR1-10.2196/20184

A Predictive Risk Model for Infection-Related Hospitalization Among Home Healthcare Patients

Infection prevention is a high priority for home healthcare (HHC), but tools are lacking to identify patients at highest risk of developing infections. The purpose of this study was to develop and test a predictive risk model to identify HHC patients at risk of an infection-related hospitalization or emergency department visit. A nonexperimental study using secondary data was conducted. The Outcome and Assessment Information Set linked with relevant clinical data from 112,788 HHC admissions in 2014 was used for model development (70% of data) and testing (30%). A total of 1,908 patients (1.69%) were hospitalized or received emergency care associated with infection. Stepwise logistic regression models discriminated between individuals with and without infections. Our final model, when classified by highest risk of infection, identified a high portion of those who were hospitalized or received emergent care for an infection while also correctly categorizing 90.5% of patients without infection. The risk model can be used by clinicians to inform care planning. This is the first study to develop a tool for predicting infection risk that can be used to inform how to direct additional infection control intervention resources on high-risk patients, potentially reducing infection-related hospitalizations, emergency department visits, and costs.

Implications of a US study on infection prevention and control in community settings in the UK

Healthcare-associated infections are a significant reason for readmission to hospital post-discharge to the community. In this paper, the authors describe some of the key findings from a programme of work conducted in a home care agency (community care organisation) in the US. A survey was conducted to explore home care nurses' knowledge, attitudes and beliefs around infection control (n=415); 400 nurse-patient visits were observed, and 50 nurses were interviewed about their infection control practices. Nurses reported high compliance with infection control practices. However, the overall average adherence rate to observed hand hygiene practices was 45.6%. Interview data provided valuable insights into specific challenges faced by nurses in a home care setting. This study provides insights that can be used to enhance infection control practice in community care in the UK.

Home care nurses' identification of patients at risk of infection and their risk mitigation strategies: A qualitative interview study

BACKGROUND

There is an increase in the number of individuals who receive care at home. A significant proportion of these patients acquire infections during their care episode. Whilst there has been significant focus on strategies for infection prevention and control in acute care environments, there is a lack of research into infection prevention in a home care setting.

OBJECTIVES

To understand (1) if and how home care nurses identify patients at high risk of infection and (2) the strategies they use to mitigate that risk.

DESIGN

A qualitative descriptive study, using semi-structured interviews.

SETTING

A large not for profit home care agency located in the New York region of the United States.

PARTICIPANTS

Fifty nurses with a range of experience in home care nursing.

METHODS

Purposive and snowball sampling was used to recruit nurses from across the home care agency with varied years of work experience. Interviews were audio recorded and transcribed. The interviews explored how home care nurses evaluate their patients' risk of developing an infection and if/how they modify the plan of care based on that risk. Data were analysed using thematic analysis.

RESULTS

Three themes were derived from the data; assessing a patient's risk of infection, the risk assessment process, and strategies for mitigating infection risk. Factors identified by nurses as putting a patient at higher risk of infection included being older, having diabetes, inadequate nutrition; along with inadequate clinical information available at start of care. The patient's knowledge and understanding of infection prevention, and the availability and knowledge of caregivers were also important, as was the cleanliness of the home environment. Given the context of home care, where nurses have little control over the environment and care processes in-between visits, the main strategy for infection prevention was patient and caregiver education. Nurses also discussed the importance of their own infection prevention behaviours, and the ability to adjust a patient's plan of care according to their infection risk.

CONCLUSIONS

The study highlights the complexity of the risk assessment process in relation to infection. Existing guidelines for infection prevention and control do not adequately cover the home care environment and more research needs to determine which interventions (such as patient/caregiver education) would be most effective to prevent infections in the home care setting.

Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial

BACKGROUND

Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group.

METHODS

A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months.

RESULTS

Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC.

CONCLUSION

The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01918891.

Detecting Disparities in Medication Management Among Limited English Proficient and English Proficient Home Health Patients

According to the U.S. census Bureau, close to 20% of the U.S. population speaks a language other than English at home. Home health care (HHC) patients who speak English less than very well or have limited English proficiency (LEP) are at an increased risk for medication mismanagement and serious health consequences. The purpose of this study was to examine if there were differences in medication management between English-speaking patients and patients with LEP receiving HHC services. Data for this cross-sectional observation study were collected from 2010 to 2014. Medication management was measured by two items in the Centers for Medicare and Medicaid Services–mandated Outcomes Assessment Information Set (OASIS). All patients in the database who were taking medications and had a valid admission and discharge assessment from HHC were included in the analysis. Inverse probability of treatment weighting (IPTW) with a marginal structural model was used to address potential imbalances in observed patient characteristics when estimating the effect of having LEP or being an English-speaking HHC patient on changes in medication management over the course of a HHC episode. Estimates from marginal structural model with inverse probability weighting indicate that being LEP was associated with less improvement in medication management and increased likelihood of getting worse over the course of a HHC episode. This study is one of the first to demonstrate that patients with LEP experience disparities in medication management when compared to English-speaking patients in HHC.

Provider Perspectives of Medication Complexity in Home Health Care: A Qualitative Secondary Data Analysis

A primary service provided by home care is medication management. Issues with medication management at home place older adults at high risk for hospital admission, readmission, and adverse events. This study sought to understand medication management challenges from the home care provider perspective. A qualitative secondary data analysis approach was used to analyze program evaluation interview data from an interprofessional educational intervention study designed to decrease medication complexity in older urban adults receiving home care. Directed and summative content analysis approaches were used to analyze data from 90 clinician and student participants. Medication safety issues along with provider–provider communication problems were central themes with medication complexity. Fragmented care coordination contributed to medication management complexity. Patient-, provider-, and system-level factors influencing medication complexity and management were identified as contributing to both communication and coordination challenges.

Mining fall-related information in clinical notes: Comparison of rule-based and novel word embedding-based machine learning approaches

BACKGROUND

Natural language processing (NLP) of health-related data is still an expertise demanding, and resource expensive process. We created a novel, open source rapid clinical text mining system called NimbleMiner. NimbleMiner combines several machine learning techniques (word embedding models and positive only labels learning) to facilitate the process in which a human rapidly performs text mining of clinical narratives, while being aided by the machine learning components.

OBJECTIVE

This manuscript describes the general system architecture and user Interface and presents results of a case study aimed at classifying fall-related information (including fall history, fall prevention interventions, and fall risk) in homecare visit notes.

METHODS

We extracted a corpus of homecare visit notes (n = 1,149,586) for 89,459 patients from a large US-based homecare agency. We used a gold standard testing dataset of 750 notes annotated by two human reviewers to compare the NimbleMiner's ability to classify documents regarding whether they contain fall-related information with a previously developed rule-based NLP system.

RESULTS

NimbleMiner outperformed the rule-based system in almost all domains. The overall F- score was 85.8% compared to 81% by the rule based-system with the best performance for identifying general fall history (F = 89% vs. F = 85.1% rule-based), followed by fall risk (F = 87% vs. F = 78.7% rule-based), fall prevention interventions (F = 88.1% vs. F = 78.2% rule-based) and fall within 2 days of the note date (F = 83.1% vs. F = 80.6% rule-based). The rule-based system achieved slightly better performance for fall within 2 weeks of the note date (F = 81.9% vs. F = 84% rule-based).

DISCUSSION & CONCLUSIONS

NimbleMiner outperformed other systems aimed at fall information classification, including our previously developed rule-based approach. These promising results indicate that clinical text mining can be implemented without the need for large labeled datasets necessary for other types of machine learning. This is critical for domains with little NLP developments, like nursing or allied health professions.

Black/Hispanic Disparities in a Vulnerable Post-Stroke Home Care Population

Significant racial and ethnic disparities in stroke risk factors, occurrence, and outcomes persist in the USA. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP > 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients' SBP-the leading modifiable cause of stroke-and physical function-a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy, and current alcohol drinking (vs. abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.

Factors for compliance with infection control practices in home healthcare: findings from a survey of nurses' knowledge and attitudes toward infection control

BACKGROUND

Infection is a leading cause of hospitalization among home healthcare patients. Nurses play an important role in reducing infection among home healthcare patients by complying with infection control procedures. However, few studies have examined the compliance of home healthcare nurses with infection control practices or the range of sociocultural and organizational factors that may be associated with compliance.

METHODS

This study analyzed survey responses from nurses at 2 large, certified home healthcare agencies (n = 359), to explore levels of compliance with infection control practices and identify associated demographic, knowledge, and attitudinal correlates.

RESULTS

Nurses reported a high level of infection control compliance (mean = 0.89, standard deviation [SD] = 0.16), correct knowledge (mean = 0.85, SD = 0.09), and favorable attitudes (mean = 0.81, SD = 0.14). Multivariate mixed regression analyses revealed significant positive associations of attitudinal scores with reported level of compliance (P < .001). However, knowledge of inflection control practices was not associated with compliance. Older (P < .05) and non-Hispanic black (P < .001) nurses reported higher compliance with infection control practices than younger and white non-Hispanic nurses.

CONCLUSION

These findings suggest that efforts to improve compliance with infection control practices in home healthcare should focus on strategies to alter perceptions about infection risk and other attitudinal factors.

Geriatric Interdisciplinary Team Training 2.0: A collaborative team-based approach to delivering care

Interprofessional collaborative education and practice has become a cornerstone of optimal person-centered management in the current complex health care climate. This is especially important when working with older adults, many with multiple chronic conditions and challenging health care needs. This paper describes a feasibility study of the Geriatric Interdisciplinary Team Training 2.0 (GITT 2.0) program focused on providing interprofessional care to complex and frail older adults with multiple chronic conditions. A concurrent triangulation mixed-methods design facilitated program implementation and evaluation. Over three years (2013-2016), 65 graduate students from nursing, midwifery, social work, and pharmacy participated along with 25 preceptors. Participants were surveyed on their attitudes toward interprofessional collaboration pre and post-intervention and participated in focus groups. While attitudes toward interprofessional collaboration did not change quantitatively, focus groups revealed changes in language and enhanced perspectives of participants. Based on the evaluation data, the GITT 2.0 Toolkit was refined for use in interprofessional education and practice activities related to quality initiatives.

Home-based interventions for black patients with uncontrolled hypertension: a cluster randomized controlled trial

AIM

Assess the comparative effectiveness of two blood pressure (BP) control interventions for black patients with uncontrolled hypertension.

PATIENTS & METHODS

A total of 845 patients were enrolled in a three-arm cluster randomized trial. On admission of an eligible patient, field nurses were randomized to usual care, a basic or augmented intervention.

RESULTS

Across study arms there were no significant 12 months differences in BP control rates (primary outcome) (25% usual care, 26% basic intervention, 22% augmented intervention); systolic BP (143.8 millimeters of mercury [mmHg], 146.9 mmHG, 143.9 mmHG, respectively); medication intensification (47, 43, 54%, respectively); or self-management score (18.7, 18.7, 17.9, respectively). Adjusted systolic BP dropped more than 10 mmHg from baseline to 12 months (155.5-145.4 mmHg) among all study participants.

CONCLUSION

Neither the augmented nor basic intervention was more effective than usual care in improving BP control, systolic BP, medication intensification or patient self-management. Usual home care yielded substantial improvements, creating a high comparative effectiveness threshold.

CLINICAL TRIAL REGISTRATION

NCT00139490.

Outcomes of clinical decision support (CDS) and correlates of CDS use for home care patients with high medication regimen complexity: a randomized trial

RATIONALE, AIMS AND OBJECTIVES

To assess the outcomes of a clinical decision support (CDS) intervention designed for home care patients with high medication regimen complexity (MRC) and to examine correlates of CDS use.

METHOD

The CDS consisted of a computerized algorithm that identified high MRC patients, electronic alerts and a care management module. Nurses were randomized upon identification of an eligible patient. Full intention to treat and intervention group-only analyses were completed. Regression-adjusted outcomes were hospitalization, emergency department use and reduction in MRC.

RESULTS

Five hundred nurses were randomized with 7919 of their patients. Approximately 20% of the intervention group was hospitalized versus 21% in the control group; 16.5% versus 16.7% had an emergency department visit; and 6% in each group dropped below the high MRC threshold. No statistically significant differences were found in the intention to treat analysis. Eighty-two percent of intervention nurses used the CDS but for only 42% of their patients. Among intervention patients, CDS use (vs. non-use) was associated with reduced MRC and hospitalization. CDS use was associated with various clinician and patient characteristics.

CONCLUSION

CDS use was limited, negating the impact of the intervention overall. Findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding short patient lengths of stay, improving continuity of care, increasing reliance on salaried nurses and/or increasing per diem nurses' incentives to use CDS.

A hybrid process fidelity assessment in a home-based randomized clinical trial

A process fidelity assessment was conducted as a nested study within a home-based randomized clinical trial teaching self-management to 101 long-term indwelling urinary catheter users in the treatment group. Our hybrid model combined external assessments (outside observations and tape recordings) with internal evaluation methods (through study nurse forms and notes) for a comprehensive process fidelity assessment. Barriers, patient-related issues, and nurse perspectives were identified demonstrating the complexity in home care intervention research. The complementary and synergistic approaches provided in-depth information about the context of the delivery and the impact of the intervention on study outcomes.

Self-care management questionnaire for long-term indwelling urinary catheter users

AIMS

Self-management is believed to be an important behavioral capacity in people with chronic illness, and self-efficacy is an important component contributing to self-management. Two new and related measures for urinary catheter self-efficacy (C-SE) and self-management (C-SMG) were developed based on existing tools and tested for psychometrics for use in a randomized clinical trial (RCT) teaching urinary catheter self-management.

METHODS

The instruments were evaluated at baseline (intake face to face interview) with 202 persons and with 158 of the same individuals 6 months later by telephone interviews. Exploratory factor analysis was conducted in an iterative process related to items' theoretical and statistical appropriateness. To assess construct validity and goodness of fit for model testing, confirmatory factor analysis was conducted with the samples at intake and 6 months. Also, bivariate analyses were conducted of the measures in relation to each other.

RESULTS

Both scales were modified reducing the items to 13 in each, with four factors in C-SE and three factors in C-SMG. Reliability testing (Cronbach's alpha) was viewed as satisfactory for both scales, though some of the subscale (factors) reliabilities were lower in the self-management measure. Confirmatory factor analysis was adequate. Correlation of the two instruments (r = 0.25, P < 001) suggests that they are related scales.

CONCLUSION

With a change in the C-SMG scale from 3- to 5-level responses and subsequent testing, both new scales are appropriate for use separately or together as a questionnaire related to catheter self-care management in intervention research with long-term indwelling urinary catheter users. Neurourol. Urodynam. 35:492-496, 2016. © 2015 Wiley Periodicals, Inc.

Center for stroke disparities solutions community- based care transition interventions: study protocol of a randomized controlled trial

BACKGROUND

Racial and ethnic disparities persist in stroke occurrence, recurrence, morbidity and mortality. Uncontrolled hypertension (HTN) is the most important modifiable risk factor for stroke risk. Home health care organizations care for many patients with uncontrolled HTN and history of stroke; however, recurrent stroke prevention has not been a home care priority. We are conducting a randomized controlled trial (RCT) to compare the effectiveness, relative to usual home care (UHC), of two Community Transitions Interventions (CTIs). The CTIs aim to reduce recurrent stroke risk among post-stroke patients via home-based transitional care focused on better HTN management.

METHODS/DESIGN

This 3-arm trial will randomly assign 495 black and Hispanic post-stroke home care patients with uncontrolled systolic blood pressure (SBP) to one of three arms: UHC, UHC complemented by nurse practitioner-delivered transitional care (UHC + NP) or UHC complemented by an NP plus health coach (UHC + NP + HC). Both intervention arms emphasize: 1) linking patients to continuous, responsive preventive and primary care, 2) increasing patients'/caregivers' ability to manage a culturally and individually tailored BP reduction plan, and 3) facilitating the patient's reintegration into the community after home health care discharge. The primary hypothesis is that both NP-only and NP + HC transitional care will be more effective than UHC alone in achieving a SBP reduction. The primary outcome is change in SPB at 3 and 12 months. The study also will examine cost-effectiveness, quality of life and moderators (for example, race/ethnicity) and mediators (for example, changes in health behaviors) that may affect treatment outcomes. All outcome data are collected by staff blinded to group assignment.

DISCUSSION

This study targets care gaps affecting a particularly vulnerable black/Hispanic population characterized by persistent stroke disparities. It focuses on care transitions, a juncture when patients are particularly susceptible to adverse events. The CTI is innovative in adapting for stroke patients an established transitional care model shown to be effective for HF patients, pairing the professional NP with a HC, implementing a culturally tailored intervention, and placing primary emphasis on longer-term risk factor reduction and community reintegration rather than shorter-term transitional care outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01918891 ; Registered 5 August 2013.

Self-management intervention for long-term indwelling urinary catheter users: randomized clinical trial

BACKGROUND

People using long-term indwelling urinary catheters experience multiple recurrent catheter problems. Self-management approaches are needed to avoid catheter-related problems.

OBJECTIVES

The aim was to determine effectiveness of a self-management intervention in prevention of adverse outcomes (catheter-related urinary tract infection, blockage, and accidental dislodgement). Healthcare treatment associated with the adverse outcomes and catheter-related quality of life was also studied.

METHODS

A randomized clinical trial was conducted. The intervention involved learning catheter-related self-monitoring and self-management skills during home visits by a study nurse (twice during the first month and at 4 months-with a phone call at 2 months). The control group received usual care. Data were collected during an initial face-to-face home interview followed by bimonthly phone interviews. A total of 202 adult long-term urinary catheter users participated. Participants were randomized to treatment or control groups following collection of baseline data. Generalized estimating equations were used for the analysis of treatment effect.

RESULTS

In the intervention group, there was a significant decrease in reported blockage in the first 6 months (p = .02), but the effect did not persist. There were no significant effects for catheter-related urinary tract infection or dislodgment. Comparison of baseline rates of adverse outcomes with subsequent periods suggested that both groups improved over 12 months.

DISCUSSION

A simple-to-use catheter problems calendar and the bimonthly interviews might have functioned as a modest self-monitoring intervention for persons in both groups. A simplified intervention using a self-monitoring calendar is suggested-with optimal and consistent fluid intake likely to add value.

Successful recruitment methods in the community for a two-site clinical trial

Effective screening and recruitment are essential to the success of randomized clinical trials. This report is to describe key screening and recruitment strategies in a two site randomized clinical trial (RCT) conducted in community settings with a vulnerable chronically ill population and to suggest valuable approaches when planning trials. Differences between sites in a complex study with two considerably different environments (academic versus home care) and their participant pools presented challenges which required different screening and recruitment methods. A high level of communication between sites, creative problem solving and the ability to be flexible when problems were encountered were needed for successful screening and recruitment.

Long-term urinary catheter users self-care practices and problems

AIMS AND OBJECTIVES

To characterise a sample of 202 adult community-living long-term indwelling urinary catheter users, to describe self-care practices and catheter problems, and to explore relationships among demographics, catheter practices and problems.

BACKGROUND

Long-term urinary catheter users have not been well studied, and persons using the device indefinitely for persistent urinary retention are likely to have different patterns of catheter practices and problems.

DESIGN

The study was a cross-sectional descriptive and exploratory analysis.

METHODS

Home interviews were conducted with catheter users who provided information by self-reported recall over the previous two months. Data were analysed by descriptive statistics and tests of association between demographics, catheter practices and catheter problems.

RESULTS

The sample was widely diverse in age (19-96 years), race and medical diagnosis. Urethral catheters were used slightly more often (56%) than suprapubic (44%), for a mean of six years (SD 7 years). Many persons were highly disabled, with 60% having difficulty in bathing, dressing, toileting and getting out of the bed; 19% also required assistance in eating. A high percentage of catheter problems were reported with: 43% experiencing leakage (bypassing of urine), 31% having had a urinary tract infection, 24% blockage of the catheter, 23% catheter-associated pain and 12% accidental dislodgment of the catheter. Treatments of catheter-related problems contributed to additional health care utilisation, including extra nurse or clinic visits, trips to the emergency department or hospitalisation. Symptoms of catheter-associated urinary tract infections were most often related to changes in the colour or character of urine or generalised symptoms.

CONCLUSIONS

Catheter-related problems contribute to excess morbidity and health care utilisation and costs.

RELEVANCE TO CLINICAL PRACTICE

More research is needed in how to minimise catheter-associated problems in long-term catheter users. Information from this study could help inform the development of interventions in this population.