Association of Medicare Home Health Ratings With Older Adult Fall Injuries: An Instrumental Variables Analysis

OBJECTIVES

To understand the role of high-quality home health care for fall prevention.

DESIGN

A 100% sample of national Medicare claims and home health survey data (2015-2017) were used to assess fall injuries and receipt of a fall risk assessment among recently hospitalized Medicare fee-for-service home health users aged ≥66 years. Subanalyses examined patients by prior fall history status and hospital admission diagnosis type (eg, neurologic, respiratory, cardiovascular, infection, and orthopedic diagnoses). An instrumental variables design addressed potential endogeneity in home health care use by patient fall risk.

SETTING AND PARTICIPANTS

Home health agencies and Medicare fee-for-service beneficiaries.

METHODS

Multivariate regression and instrumental variables.

RESULTS

Among 962,610 patients with hospital discharges to home health, being treated by home health agencies with the highest star ratings in a person's zip code was associated with a 1.8-percentage point (ppt) (95% CI: 0.1, 3.5; P = .03) higher likelihood of receipt of fall risk assessment. There was no overall change in 30-day (-0.6 ppt, 95% CI: -1.3, 0.1; P = .09), 15-day (-0.3 ppt, 95% CI: -0.0.8, 0.2; P = .35), or 7-day fall injury risk (-0.2 ppt, 95% CI: -0.5, 0.1; P = .22), but a 1.9-ppt (95% CI: -3.9, -0.02; P = .048) lower 30-day fall injury risk for individuals with a history of falls. Effects were directionally similar by diagnosis type.

CONCLUSIONS AND IMPLICATIONS

Fall injury risk is reduced at higher-rated home health agencies. Star ratings may be adequate indicators of quality for key outcomes not explicitly measured in the ratings.

Hospices and Emergency Preparedness Planning: A Scoping Review of the Literature

Objective. Palliative and end-of-life care, as provided by hospices, are important elements of a healthcare response to disasters. A scoping review of the literature was conducted to examine and synthesize what is currently known about emergency preparedness planning by hospices. Methods. A literature search of academic and trade publications was conducted through 6 publication databases, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines when applicable. Publications were selected and findings were organized into themes. Results. A total of 26 articles were included in the literature review. Six themes of Policies and Procedures; Testing/Training/Education; Integration and Coordination; Mitigation; Risk Assessment/Hazard and Vulnerability Analysis; and Regulations were identified. Conclusions. This review demonstrates that hospices have begun to individualize emergency preparedness features that support their unique role. The review supports all-hazards planning for hospices, and emerging from this review is a developing vision for expanded roles of hospices to help communities in times of disaster. Continued research in this specialized area is needed to improve hospices' emergency preparedness efforts.

Successful Discharge to Community From Home Health Less Likely for People in Late Stages of Dementia

BACKGROUND AND PURPOSE

Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health.

METHODS

This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool.

RESULTS AND DISCUSSION

Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance.

CONCLUSIONS

Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.

Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

Public Reporting and Consumer Demand in the Home Health Sector

Health care report cards improve information and are a crucial part of health care reform of the federal government of the United States. I exploit a natural experiment in the home health sector to assess whether a higher rating under the star ratings program affects patient choice. Higher rated agencies increased their market share by 1.4% or 0.25 (95% confidence interval: [-0.63, 1.12]) percentage points, a practically and statistically insignificant amount. I find no evidence of heterogeneous effects across the rating distribution or over time. I also find precise null effects among consumers expected to be more responsive, including community-entry patients and patients in competitive markets with more options and star types. Agencies may have modestly impeded consumer choice by engaging in some patient selection behaviors, although the evidence is only weakly suggestive. The star ratings are unlikely to improve home health quality despite continued policymaker interest.

Prevalence of cognitive impairment in home health physical therapy

BACKGROUND

The prevalence of cognitive impairment in home health physical therapy (HHPT) is unknown. We sought to identify the prevalence of cognitive impairment, including cognitive impairment no dementia (CIND) and dementia, among older adults who used HHPT, and if cognitive impairment prevalence was higher among those with HHPT-relevant characteristics.

METHODS

For our cross-sectional analysis, we identified 963 fee-for-service Medicare beneficiaries with HHPT claims (>85 years old: 28.8%, women: 63.7%, non-Hispanic White: 82.1%) in the 2014 and 2016 waves of the Health and Retirement Study (HRS) and used a validated algorithm to categorize cognitive status as normal, CIND, or dementia. We estimated the population prevalence and calculated age, gender, race/ethnicity adjusted odds ratio (aOR) of CIND and dementia for characteristics relevant to HHPT service delivery including depression, walking difficulty, fall history, incontinence, moderate-vigorous physical activity (MVPA) ≤1x/week, and community-initiated HHPT using multinomial logistic regression.

RESULTS

The population prevalence of cognitive impairment was 46.4% (CIND: 27.3%, dementia: 19.1%). The prevalence of cognitive impairment was greater among those with depression (46.7% vs. 39.5%), difficulty walking across the room (58.9% vs. 41.8%), fall history (49.1% vs. 42.9%), MVPA ≤1x/week (50.0% vs. 38.0%), and community-initiated HHPT (55.2% vs. 40.2%). Compared to normal cognitive status, the odds of cognitive impairment were greater for those with MVPA≤1x/week (CIND: aOR = 1.57 [95% CI: 1.05-2.33], dementia: aOR = 2.55 [95% CI: 1.54-4.22]), depression (dementia: aOR = 1.99 [95% CI: 1.19-3.30]), difficulty walking across the room (dementia: aOR = 2.54 [95% CI: 1.40-4.60]), fall history (dementia: aOR = 1.85 [95% CI: 1.20-2.83]), and community-initiated HHPT (dementia: aOR = 1.72 (95% CI: 1.13-2.61]).

CONCLUSION

There is a high prevalence of CIND and dementia in HHPT, and no characteristics had a low prevalence of cognitive impairment. Physical therapists should be ready to identify cognitive impairment and adapt home health service delivery for this vulnerable population of older adults.

Lower-Limb Perfusion and Cardiovascular Physiology Are Significantly Improved in Non-Healthy Aged Adults by Regular Home-Based Physical Activities-An Exploratory Study

Common daily activities including walking might be used to improve cardiovascular health in the presence of disease. Thus, we designed a specific home-based physical activity program to assess cardiovascular indicators in an older, non-active, non-healthy population. Ten participants, with a mean age of 62.4 ± 5.6 years old, were chosen and evaluated twice-upon inclusion (D0), and on day 30 (D30)-following program application. Perfusion was measured in both feet by laser Doppler flowmetry (LDF) and by polarised spectroscopy (PSp). Measurements were taken at baseline (Phase 1) immediately after performing the selected activities (Phase 2) and during recovery (Phase 3). Comparison outcomes between D0 and D30 revealed relevant differences in Phase 1 recordings, namely a significant increase in LDF perfusion (p = 0.005) and a significant decrease in systolic blood pressure (p = 0.008) and mean arterial pressure (MAP) (p = 0.037). A correlation between the increase in perfusion and the weekly activity time was found (p = 0.043). No differences were found in Phase 2, but, in Phase 3, LDF values were still significantly higher in D30 compared with D0. These simple activities, regularly executed with minimal supervision, significantly improved the lower-limb perfusion while reducing participants' systolic pressure and MAP, taken as an important improvement in their cardiovascular status.

Palliative Care Communication Among Home Health Interprofessional Staff: A Randomized Controlled Trial of Feasibility, Acceptability, and Preliminary Effectiveness

Skilled home health care (HH) is the largest and fastest growing long-term care setting in the United States. Patients in HH are served by an interprofessional team, and may have little direct contact with physicians, when discussing their progress, prognosis, and goals of care. Such conversations are part of primary palliative care communication. Evidence on primary palliative care communication training in the non-physician HH interprofessional team is lacking. The objectives of this study were to assess the feasibility, acceptability, and preliminary effectiveness of using a palliative care communication model known as COMFORT© to provide palliative care communication training to HH staff. A randomized controlled trial was conducted at a regional health system in the southeastern U.S. to test online training modules (n = 10) (Group 1) and online training modules plus face-to-face training (n = 8) (Group 2). Measures included training completion rates, staff acceptability ratings, comfort with palliative and end-of-life communication (C-COPE) and moral distress (MMD-HP). Results showed that COMFORT© training was feasible (92%), highly acceptable (>4 on a 6-point scale), and positively correlated with improved C-COPE scores (P = .037). There was no significant difference in moral distress scores pre- and post-intervention or in effectiveness between the groups. However, acceptability of COMFORT© was positively correlated with history of leaving or considering leaving a job due to moral distress (χ 2 = 7.6, P = .02). Preliminary findings from this pilot study suggest that administration of COMFORT© training was feasible, and it was correlated with increased HH staff comfort with palliative care communication.

A Novel Home-Based Medication Management Program and Its Influence on Hospitalization Rates among Home Health Care Recipients

Patients do not take their medicine as prescribed 50% of the time, and of medication-related hospital admissions in the United States, 33% to 69% are due to poor medication adherence, at a cost of approximately $100 billion a year. Continue CareRx (CCRx) is a novel home-based medication management program that includes adherence packaging alongside medication reconciliation, review, and education by clinicians. We hypothesized that home health patients receiving the CCRx service may have a lower hospitalization rate than control home health patients. Between May 1, 2021, and March 31, 2023, 113 home health patients whose insurance covered the program were enrolled in CCRx. Home health patients not eligible for the program due to a noncovered pharmacy insurance benefit made up the control group (n = 21,304), which was matched with the CCRx group on age range (45-99 years old) and gender (67% women). Hospitalization rate was calculated in both groups and compared using generalized estimating equations analysis. The control group had a total of 7015 hospitalizations during the study period during 2,128,738 total managed days, whereas the CCRx group had 21 hospitalizations during 23,622 total managed days. These translated into rates of 1203 hospitalizations per 1000 per year for the control group, and 324 hospitalizations per 1000 per year for the CCRx group. The results showed that there was a significant main effect of group in predicting individual annual hospitalization rate (Wald χ2 = 56.415, P < .01). Specifically, being in the control group was associated with a 43.42-fold increase in the likelihood of a higher hospitalization rate (95% Wald CI for odds ratios: 7.24-230.44). Home health recipients enrolled in CCRx experienced a 73.1% lower hospitalization rate than controls. Making the program more widely available to patients receiving home health care may present a significant opportunity to reduce hospitalizations in this group.

Grab Bar Use Influences Fall Hazard During Bathtub Exit

OBJECTIVE

This study evaluated the hazard (risk of unrecovered balance loss and hazardous fall) and strategies associated with grab bar use, compared to no grab bar use, during unexpected balance loss initiated whilst exiting a bathtub.

BACKGROUND

While independent bathing is critical for maintaining self-sufficiency, injurious falls during bathing transfer tasks are common. Grab bars are recommended to support bathing tasks, but no evidence exists regarding fall prevention efficacy.

METHOD

Sixty-three adults completed a hazardous bathtub transfer task, experiencing an unpredictable external balance perturbation while stepping from a slippery bathtub to a dry surface. Thirty-two were provided a grab bar, while 31 had no grab bar available. Slips and grab bar use were recorded via four video cameras. Slip occurrence and strategy were identified by two independent video coders.

RESULTS

Participants who had a grab bar were 75.8% more likely to recover their balance during the task than those who did not have a grab bar. Successful grab bar grasp was associated with balance recovery in all cases. Attempts to stabilize using other environmental elements, or using internal strategies only, were less successful balance recovery strategies. Grab bar presence appeared to cue use of the environment for stability. Proactive grasp and other strategies modified grasping success.

CONCLUSION

Grab bars appear to provide effective support for recovery from unexpected balance loss. Grab bar presence may instigate development of fall prevention strategies prior to loss of balance.

APPLICATION

Bathroom designs with grab bars may reduce frequency of fall-related injuries during bathing transfer tasks.

Characterization of Safety Events Involving Technology in Primary and Community Care

BACKGROUND

The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings.

OBJECTIVES

To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization.

METHODS

Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event.

RESULTS

Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions.

CONCLUSION

Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.

Examining the use of geriatric standardized patients with baccalaureate nursing students

The need for clinical placements for undergraduate nursing programs heightened during the COVID-19 pandemic as nursing schools across the country faced restrictions with the high-risk geriatric client population. Nursing students experienced increased anxiety levels, decreased learning opportunities, and uncertainties about the decision to enter the workforce as healthcare professionals. In turn, this amplified the need for faculty support and feedback imperative for student success. One method for mitigating the gap between didactic content and clinical placement is using simulation-based learning experiences. The purpose of this observational study was to examine the impact of a newly developed home health geriatric simulation on student satisfaction and self-confidence in learning among 133 senior-level Baccalaureate nursing students from a large public university. Study measures included the National League of Nursing's Self-Confidence in Learning Scale (SCLS) and Simulation Design Scale (SDS). The primary outcome was satisfaction and self-confidence in learning. Higher SDS component scores were significantly correlated with higher SCLS scores (all p = <.0001), indicating that high satisfaction among Baccalaureate nursing students in simulation design relates to increased satisfaction and self-confidence in learning. Study findings support using standardized geriatric simulation scenarios to prepare students to communicate and care for older adults.

High-intensity home health physical therapy among older adult Veterans: A randomized controlled trial

BACKGROUND

Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events.

METHODS

We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization.

RESULTS

There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds.

CONCLUSIONS

Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program.

Needs of persons living with ALS at home and their family caregivers: A scoping review

INTRODUCTION/AIMS

Most persons with amyotrophic lateral sclerosis (ALS) live at home with support of family caregivers, with escalating complexity of care over the trajectory of the disease requiring resources and support to mitigate negative physical, social, and emotional outcomes.

METHODS

This scoping review identifies the home health/home care needs of persons with ALS and their caregivers as a basis for creating a home health medical standard. We used the PRISMA Extension for Scoping Reviews (PRISMA-ScR) to examine studies describing home care needs published between 2011 and 2021.

RESULTS

Our search yielded 481 articles, of which 44 were included with a total of 3592 (9-273) participants. Most studies used a cross-sectional design and 20 (45%) were rated as high quality. We grouped the needs identified as emotional/psychological, assistive devices and technology, information and education, and human resources and professional services. Most studies demonstrated persistent unmet needs and that available interventions were helpful while needs generally were not met proactively, despite the predictable trajectory.

DISCUSSION

This review describes biopsychosocial and equipment interventions over the trajectory of ALS with implications for anticipatory planning by clinicians, as well as policy for coverage of necessary services and supports. Interdisciplinary expert teams could develop consensus around needs across the trajectory and recommended services and supports. To make knowledge more accessible, encourage availability of services, and clarify the need for coverage of services, we aim to develop an expert consensus-based ALS home health medical standard guidance document in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine.

Did Minimum Wage Policy Changes Impact Home Health Workforce?

The shortage of home health aides has been exacerbated in recent years partially because of low wages. Minimum wage (MW) policy changes may alleviate this workforce shortage. This study examined the effects of MW policies on wages and employment of home health aides. We performed a county-level longitudinal analysis using 2012 to 2018 national data. The study cohort included 2,496 counties and focused on all workers in the home health industry. Outcome variables included wages and the employment of home health aides. Key variables of interest included the consumer price index adjusted state MW and a set of variables that captured the effect of the Fair Labor Standards Act (FLSA) extension. This study found that home health aides' hourly wages were $1.00 higher (p = .011) in states that increased their MWs from below $8 to above $10. The FLSA extension was associated with $1.15 higher wages in states with higher MWs (i.e., state MW above $10 in 2014). The FLSA extension was associated with higher employment of home health aides in less-competitive markets, rather than high- or average-competitive markets. This study suggests that state MW increases combined with the FLSA extension may help maintain the current home health workforce and improve their wages.

Disaggregating the dementia monolith: An analysis of variation in Medicare costs and use by dementia subtype

IMPORTANCE

With an aging population, it is necessary to systematically examine variation in costs and use of Medicare services by dementia subtype. We provide the first national estimates for dementia by subtype, and the respective Medicare costs and use.

METHODS

We analyzed Medicare fee-for-service (FFS) claims from 2017 through 2019. The sample included 41 million beneficiaries: 727,700 beneficiaries with a new dementia diagnosis in 2017. We calculated descriptive statistics and conducted generalized linear regression models by subtype of dementia.

RESULTS

Annual Medicare costs for beneficiaries with dementia ranged from $22,840 for frontotemporal dementia to $44,896 for vascular dementia compared to $9,034 for beneficiaries without dementia. Comparing beneficiaries across dementia subtypes, the greatest differences were in the use of home health and hospice care.

CONCLUSIONS

These analyses demonstrate substantial heterogeneity across dementia subtypes, which will be important in developing models of care that improve value for people with dementia.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Home Care in America: The Urgent Challenge of Putting Ethical Care into Practice

Home care is one of the fastest-growing industries in the United States, providing valuable opportunities for millions of older adults and people with disabilities to live at home rather than in institutional settings. Home care workers assist clients with essential activities of daily living, but their wages and working conditions generally fail to reflect the importance of their work. Drawing on the work of Eva Feder Kittay and other care ethicists, we argue that good care involves attending to the needs of another out of a concern for their well-being. Such care should be standard in the home care system. Yet, because of the pervasive racial, gender, and economic inequalities that the home care industry perpetuates, home care workers and their clients cannot reasonably be expected to care about each other. We endorse reforms aimed at enabling home care workers and their clients to form and maintain professional relationships that cultivate care..

Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice?

Background: Medicare home health could be leveraged to care for those near the end of life (EOL), especially for those who cannot access nor desire the Medicare hospice benefit. It is unknown what role home health currently has either preceding or as an alternative to hospice use. Objective: The aim of this study is to compare populations served and visit patterns of Medicare beneficiaries receiving home health/hospice/both near the EOL. Design: Nationally representative cohort study of National Health and Aging Trends Study (NHATS) respondents. Setting/Subjects: A total of 1,057 U.S. decedents in NHATS from 2012 to 2017 with linked Medicare claims were included in this study. Measurements: Measurements included the proportion of decedents who received home health/hospice/both/neither (yes/no) in the last six months of life (EOL) and mean number of visits by discipline (nurse/therapist [physical/occupational speech-language pathologist]/social worker/home health aide) per 30 eligible days at home for home health/hospice/both at the EOL. The primary independent variable was the clinician discipline providing services (nurse/therapist/social worker/aide). Results: In our sample, 19.9% received home health only, 25.8% hospice only, 18.8% both, and 35.6% neither at the EOL. These populations varied in their demographic, region, and clinical characteristics. Decedents who received home health only compared with hospice only were younger (44.1% over age 85 vs. 58.4%), members of a racially/ethnically diverse group (19.7% vs. 10.9%), and with less disability (37.2% required no assistance with activities of daily living vs. 22.7%), all p values <0.05. In adjusted models, those receiving home health versus hospice received similar numbers of visits per 30 days (average 5.4/30 vs. 6.6/30), while those receiving both received more visits (10.5/30). Home health provided more therapy visits, while hospice provided more social work and aide visits. Conclusions: More than one in three Medicare decedents nationwide received home health at the EOL. Home health has the potential to serve a population not reached by hospice and improve the quality of end-of-life care.

Home Health Care Is Associated With an Increased Risk of Emergency Department Visit, Readmission, and Cost of Care Without Reducing Risk of Complication Following Total Hip Arthroplasty: A Propensity-Score Analysis

BACKGROUND

Home health services have long been implemented for patients to receive additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complications and health care utilizations. The aim of this investigation was to determine if patients assigned home health services exhibited lower rates of medical and surgical complications, health care utilizations, and costs of care following total hip arthroplasty.

METHODS

A large national database was retrospectively reviewed to identify all primary total hip arthroplasty patients from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home under self-care. We compared medical and surgical complication rates, emergency room visits, readmissions, and 90-day costs of care between the groups. Multivariate regression analyses were performed to determine the independent effect of home health services on all outcomes. There were 7,243 patients who received home health services and were matched to 72,430 patients who were discharged home under self-care.

RESULTS

Patients who received home health services had higher rates of emergency department visits at 30 days (Odds Ratio [OR] R statistical programming software v 3.6.1 [Lucent Technologies, New Providence, RJ] 1.1544; P = .002) as well as increased readmissions at 30 days (OR 1.137; P = .039); complication rates were similar between groups. Episode-of-care costs for home health patients were higher than those discharged under self-care ($14,236.97 versus $12,817.12; P < .001).

CONCLUSION

Patients assigned home health care services exhibited higher costs of care without decreased risk of complications and had increased risk of early returns to the emergency department and readmissions.

Understanding the student's experience of community health nursing simulations

OBJECTIVES

The purpose of this study was to explore nursing students' experiences after completing community health nursing simulation encounters.

METHODS

The study used a descriptive qualitative design. Through conventional content analysis, the research team analyzed the experiences of 73 nursing students after participating in community health nursing simulation encounters. The data come from nursing students' responses to three post-simulation qualitative questions.

RESULTS

Nursing students identified both positive aspects (simulation as a great learning method, useful in understanding community health nurses' roles, faculty's role in facilitating an effective learning environment) and opportunities for improvement (needing for clear objectives, expectations, and roles).

CONCLUSIONS

Community health nursing simulation encounters can be a powerful educational method to help students experience and understand the roles of community health nurses.

IMPLICATIONS FOR INTERNATIONAL AUDIENCE

Augmentation of the pre-brief component will further improve students' simulation experiences.

The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

Background

The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood.

Objectives

Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic.

Research design

Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020.

Subjects

Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses.

Measures

Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset.

Results

During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (-3.9%, CI [-5.2%, -2.7%]) or to home (-2.8% CI [-4.4%, -1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics.

Conclusions

Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.

Managing Alzheimer's Dementia with Homecare in an African American Family During the COVID Pandemic

In the US, over 95 million people have been infected with COVID and over 1 million have died. 10% of Californians are infected with COVID with higher rates reported among Latinx, Pacific Islanders, and low-income people. Higher death rates have been reported among African Americans. People living with Alzheimer's Disease (AD) are also more likely to be infected with COVID. African Americans with AD have three times the COVID rate of Whites. Homecare workers who care for moderate to severe AD in home and community settings are frontline essential workers who manage complex AD-related problems like incontinence. Little is known about communication and problem-solving processes between homecare workers and families of people with AD to manage continence at home. This report describes the challenges facing homecare workers illustrated by an African American family caring for a relative with advanced AD during pandemic.

Applying Restorative Environments in the Home Office While Sheltering-in-Place

OBJECTIVE

The objective of this review was to spotlight specific methods for people working from home to apply restorative environment research to improve productivity and mental health during shelter-in-place.

BACKGROUND

The COVID-19 pandemic has led to sheltering-in-place and telework. While necessary, these strategies may lead to negative consequences such as social isolation and worse performance. However, nature environments have been shown to have a variety of positive effects in several different settings, including improved attention, positive affect, and increased job satisfaction, and these may be translated to the home workspace setting.

METHOD

This provides a narrative review of the environmental psychology literature, describing articles involving nature in a task performance or stress context and how it has been applied. It then moves on to discuss how these findings could possibly be applied in the context of workers during the COVID-19 pandemic.

RESULTS

Although beneficial results are mixed, the review found a variety of relatively simple and cost-effective methods that could assist workers during the COVID-19 pandemic, including taking a break in nature and implementing nature in the workspace.

APPLICATION

The application of restorative environment research could be an efficient way of mitigating the negative psychological effects due to at-home sheltering and telework in order to combat COVID-19.

COVID-19 Exacerbated Long-standing Challenges for the Home Care Workforce

The purpose of this study was to understand staffing challenges faced by home care (including home health) agencies due to the COVID-19 pandemic and the policies and practices put into place by the federal government, state governments, and home care agencies themselves to mitigate these challenges. This study included a review of federal and state policy changes enacted in reaction to the pandemic from March through December 2020, a review of home care agency practices described in media reports, peer-reviewed literature, and gray literature focused on responses to workforce challenges encountered during the pandemic, and interviews with a variety of stakeholders. Some of the challenges encountered were entirely new and resulted directly from the pandemic. In other cases, the pandemic worsened long-standing challenges in the industry. States and the federal government addressed some of these issues through changes to policies, regulations, and guidance. Home care agencies also responded with changes to their own policies and practices.

Assessing and Building Clinical Competence in Occupational Therapists Treating Patients with Neurodegenerative Disease: A Community of Practice Study

Communities of practice (CoPs) can be an effective means by which to efficiently build skills, knowledge, and competence for occupational therapists. The objective of this study was to assess changes in clinical competence for occupational therapists treating patients with neurodegenerative diseases (NDD) after participating in a CoP. A cohort of home health occupational therapists was recruited to participate in a seven-week CoP focused on treating patients with NDD. A single group pretest posttest mixed methods design was used to measure changes in clinical competence of the participants through a validated self-report assessment tool and a qualitative analysis of treatment summaries. Thirteen occupational therapists participated in the study. There were significant changes in pretest and post-test knowledge, beliefs, and action scores, indicating a positive change in the participants' competence to treat patients with NDD. Qualitative findings support positive changes in clinical competence through increased knowledge, confidence, and use of interventions aimed at optimizing occupational performance for this population. In summary, the CoP was an effective method for building clinical competence for treating patients with NDD with this cohort of occupational therapists.

Home Health Care in Medicare-Aged Patients is Associated With Increased Early Emergency Visits, Readmissions, and Costs Following Total Knee Arthroplasty

BACKGROUND

Home health services are utilized in order to provide at-home care following total knee arthroplasty (TKA). The purpose of this study is to determine whether patients receiving home health services post-operatively had lower rates of complications, emergency room visits, and readmissions as well as to determine if home health provided value by reducing total episode-of-care costs.

METHODS

The PearlDiver database was retrospectively reviewed to identify all primary TKA patients over 65 years old from 2010 to 2018. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home under self-care. We compared complication rates, emergency room visits, readmissions, and 90-day episode-of-care claims costs between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on emergency department (ED) visits and hospital readmissions.

RESULTS

Of the 185,444 TKA patients discharged home, 15,849 (8.5%) received home health services. Patients who received home health services had higher rates of ED visits at 2 weeks (3.3% vs 2.8%, P = .014) and 3 months (7.1% vs 6.5%, P = .038) as well as increased readmissions at 2 weeks (0.9% vs 0.7%, P = .028); complication rates were similar between groups (11.4% vs 10.9%, P = .159). Episode-of-care costs for home health patients were higher than those discharged under self-care ($24,266 vs $22,539, P < .001).

CONCLUSION

Home health services do not appear to provide value as they are associated with significantly increased costs and do not lower the rates of complications, ED visits, or readmissions following TKA.

Home health utilization association with discharge to community for people with dementia

Introduction

The objective of this study was to identify home health utilization factors associated with successful discharge to community after home health care for patients with and without Alzheimer's disease and related dementias (ADRD).

Methods

This was a retrospective study of 100% national Medicare home health data files (2016 to 2017). Multilevel logistic regression was used to study the relationship of home health utilization with a modified definition of successful discharge to community (M-SDC) after home health (no readmission or discharge within 30 days). Significant interactions were identified using backward selection. The associations between domains were examined in a model stratified by ADRD, with and without controlling for mobility, self-care, and caregiver assistance.

Results

The cohort consisted of 535,691 patients, 18.0% with ADRD. The overall M-SDC rate was 92.1%. The likelihood of M-SDC was increased when physical therapy services were provided, episodes of care were longer than 15 days, and the total number of therapy visits was greater than 10. The likelihood of M-SDC decreased when speech therapy, nursing, and home health aide services were provided and when patients were discharged early. When controlling for mobility, self-care, and caregiver support, length of home health episode was the only characteristic that showed a significant interaction with ADRD.

Discussion

The results of this study indicate that the provision of physical therapy services and moderate lengths of care and volume of visits are associated with increased likelihood of M-SDC. A decreased likelihood of M-SDC when speech therapy, nursing, and home health aide services are delivered may be a proxy indicator of patient acuity and disease severity and needs to be further investigated. An important next step in understanding home health access and outcomes for people with ADRD is to examine the impact of the Patient-Driven Groupings Model on home health utilization characteristics, especially length of episodes.

Highlights

Most people remain in the community after discharge from home health.Likelihood of modified successful discharge to community (M-SDC) increased with physical therapy, longer episodes, and more than 10 visits.Likelihood of M-SDC decreased with speech therapy, skilled nursing, home health aide visits, and early discharge.Longer home health episodes increased likelihood of M-SDC for people with Alzheimer's disease and related dementias.

Transitions from Home Health to Hospice: The Role of Agency Affiliation

Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.

Patient cognitive impairment associated with higher home health care delivery costs

OBJECTIVE

To assess whether home health agencies incur significantly higher care delivery costs for patients with cognitive impairment across three timeframes relevant to home health payment policy.

DATA SOURCES

Linked Medicare home health claims and patient assessments, National Health and Aging Trends Study (NHATS), and home health agency cost reports for a nationally representative sample of Medicare beneficiaries receiving home health between 2011 and 2016.

STUDY DESIGN

We modeled care delivery costs incurred by the home health agency as a function of patient cognitive impairment using multivariable, propensity score-adjusted, generalized linear models.

DATA COLLECTION/EXTRACTION METHODS

We identified NHATS participants who experienced an index home health episode between 2011 and 2016 (n = 1214; weighted n = 5,856,333) and linked their NHATS survey data to standardized patient assessment and claims data for the episode, as well as cost report data for the home health agency that provided care.

PRINCIPAL FINDINGS

Across the first 30, 60, and 120 days of caring for a patient with cognitive impairment, we estimate additional costs of care to the home health agency of $186.19 (p = 0.02), $282.46 (p = 0.01), and $740.91 (p = 0.04), respectively.

CONCLUSIONS

Home health agencies incur significantly higher costs when caring for a patient with cognitive impairment. As patient cognitive function is not considered in the most recent Medicare home health reimbursement model, agencies may be disincentivized from providing care to those with cognitive impairment. Policy makers and researchers should carefully monitor home health access among Medicare beneficiaries with cognitive impairment and further investigate the inclusion of patient cognitive function in future risk adjustment models.

Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis

BACKGROUND

Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care.

OBJECTIVE

To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks.

DESIGN

Semi-structured interviews.

PARTICIPANTS

Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center.

APPROACH

Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives.

KEY RESULTS

Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work.

CONCLUSIONS

Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans.

Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors

Patients with primary or secondary central nervous system (CNS) malignancies benefit from utilization of palliative care (PC) in addition to other supportive services, such as home health and social work. Guidelines propose early initiation of PC for patients with advanced cancers. We analyzed a cohort of privately insured patients with malignant brain or spinal tumors derived from the Optum Clinformatics Datamart Database to investigate health disparities in access to and utilization of supportive services. We introduce a novel construct, "provider patient racial diversity index" (provider pRDI), which is a measure of the proportion of non-white minority patients a provider encounters to approximate a provider's patient demographics and suggest a provider's cultural sensitivity and exposure to diversity. Our analysis demonstrates low rates of PC, home health, and social work services among racial minority patients. Notably, Hispanic patients had low likelihood of engaging with all three categories of supportive services. However, patients who saw providers categorized into high provider pRDI (categories II and III) were increasingly more likely to interface with supportive care services and at an earlier point in their disease courses. This study suggests that prospective studies that examine potential interventions at the provider level, including diversity training, are needed.

Unmet Caregiving Needs Among Sepsis Survivors Receiving Home Health Care: The Need for Caregiver Training

Unmet needs for family caregiver assistance threaten patient outcomes during Medicare home health care (HHC). Sepsis survivors represent a growing proportion of the HHC patient population, but little is known regarding their risk for unmet caregiving needs. We describe prevalence and underlying cause of unmet caregiving needs for sepsis survivors receiving HHC, using HHC patient assessment data for 85,851 older sepsis survivors receiving post-acute HHC in 2013-2014. Unmet caregiving needs were most common for assistance with Activities of Daily Living (ADLs) (28%) and medication administration (27%). Caregivers' need for training accounted for more than three-fourths of all unmet caregiving needs. Those who experienced decline/no improvement in cognitive function were more likely to experience unmet caregiving needs. Findings highlight the potential value of expanding family caregiver training to improve HHC outcomes for sepsis survivors and indicate that caregivers of sepsis survivors with poor cognitive function may benefit most.

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.

Understanding Caregiving and Caregivers: Supporting Children and Youth With Special Health Care Needs at Home

Caregiving encompasses the nurturing, tasks, resources, and services that meet the day-to-day needs of children and youth with special health care needs (CYSHCN) at home. Many gaps exist in the strategies currently offered by the health care system to meet the caregiving needs of CYSHCN. The work of family caregivers of CYSHCN is known to be extensive, but it is so poorly understood that it has been described as "invisible". This invisibility leads to poor communication and gaps in understanding between professional health care providers and family caregivers. To address these gaps, health care researchers must work with family caregivers to incorporate their expertise on caregiving and create meaningful and sustainable research partnerships. A growing body of research is attempting to remedy the problem of caregiving invisibility and lay better foundations for successful integration between health care settings, family caregiving, professional caregiving, and community supports for families of CYSHCN. We identify high-priority gaps in CYSHCN caregiving research and propose research questions that are designed to accelerate growth in evidence-based understanding of the work of family caregivers of CYSHCN and how best to support them.

Association of Dementia Severity and Caregiver Support With Early Discharge From Home Health

INTRODUCTION

The objective of this study was to examine the relationship between dementia severity and early discharge from home health.

METHODS

This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health.

RESULTS

The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs.

DISCUSSION

The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.

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.

Consumer preferences for health insurance, in the wake of covid-19: Ranked features and customer segments

The current study is conceptualized to assess the perception of the general population towards health insurance providers and the policy features, to segment them based on their attitudes. The mixed-method design is used in this study. One fifty health insurance users response were analyzed. The data analysis technique includes focus group discussion, henry garret ranking method, factor analysis and cluster analysis. This study concludes that health insurance providers needs to devise insurance policies incorporating the features of home health, telemedicine and income protection features. The existing users should be offered customization option due to covid-19 to prevent customer switch.

Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia

OBJECTIVES

Hospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia.

DESIGN

Retrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to 2016.

SETTING AND PARTICIPANTS

We identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment.

METHODS

We calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage).

RESULTS

Of the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population.

CONCLUSIONS AND IMPLICATIONS

One-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.

Discharge Practices for Children with Home Mechanical Ventilation across the United States. Key-Informant Perspectives

Rationale: In 2016, the American Thoracic Society released clinical practice guidelines for pediatric chronic home invasive ventilation pertaining to discharge practices and subsequent management for patients with invasive ventilation using a tracheostomy. It is not known to what extent current U.S. practices adhere to these recommendations.Objectives: Hospital discharge practices and home health services are not standardized for children with invasive home mechanical ventilation (HMV). We assessed discharge practices for U.S. children with HMV.Methods: A survey of key-informant U.S. clinical providers of children with HMV, identified with purposeful and snowball sampling, was conducted. Topics included medical stability, family caregiver training, and discharge guidelines. Close-ended responses were analyzed using descriptive statistics. Responses to open-ended questions were analyzed using open coding with iterative modification for major theme agreement.Results: Eighty-eight responses were received from 157 invitations. Eligible survey responses from 59 providers, representing 44 U.S. states, included 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. A minority, 22 (39%) reported that their institution had a standard definition of medical stability; the dominant theme was no ventilator changes 1-2 weeks before discharge. Nearly all respondents' institutions (94%) required that caregivers demonstrate independent care; the majority (78.4%) required two trained HMV caregivers. Three-fourths described codified discharge guidelines, including the use of a discharge checklist, assurance of home care, and caregiver training. Respondents described variable difficulty with obtaining durable medical equipment, either because of insurance or durable-medical-equipment company barriers.Conclusions: This national U.S. survey of providers for HMV highlights heterogeneity in practice realities of discharging pediatric patients with HMV. Although no consensus exists, defining medical stability as no ventilator changes 1-2 weeks before discharge was common, as was having an institutional requirement for training two caregivers. Identification of factors driving heterogeneity, data to inform standards, and barriers to implementation are needed to improve outcomes.

Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia

OBJECTIVE

To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia.

DATA SOURCES

100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016.

STUDY DESIGN

Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients.

DATA COLLECTION/EXTRACTION METHODS

We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back.

PRINCIPAL FINDINGS

Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings.

CONCLUSIONS

Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF.

Grief and Loss During Care Transitions: Experiences of Direct Care Workers

Direct Care Workers (DCW) provide both personal care to patients and emotional support to patients and caregivers in hospice and palliative care. DCWs often develop close ties and are then expected to work with new clients immediately following a care transition, with little or no time to grieve. A qualitative pilot study (n = 24) was conducted to explore the experience of DCWs during care transitions. Data was collected via focus groups and individual interviews. Thematic analysis was used. Results suggest DCWs managed their experiences (n = 19), by anticipating and accepting grief and loss (n = 21), employing personal coping strategies (n = 19), and saying good-bye (n = 15). Relational factors impacted the experience of care transitions (n = 22), including building and maintaining the relationship (n = 14), and the strength of perceived connections (n = 15). Increased organizational support and training to help address grief and loss will better support DCWs and the direct care workforce.

Comparing Receipt of Prescribed Post-acute Home Health Care Between Medicare Advantage and Traditional Medicare Beneficiaries: an Observational Study

BACKGROUND

Medicare Advantage (MA) covers more than 1/3rd of all Medicare beneficiaries. MA plans are required to provide the same benefits as Traditional Medicare (TM), but can impose utilization management tools to control costs.

OBJECTIVE

To assess differences between TM and MA enrollees in the probability of receiving prescribed post-acute home health (HH) care and to describe MA plan characteristics associated with HH receipt.

DESIGN

Retrospective cross-sectional analysis of claims data, HH patient assessment data, and MA plan data from 2011 to 2017.

PARTICIPANTS

Medicare beneficiaries aged 66 and older with an incident hospitalization for joint replacement, pneumonia, chronic obstructive pulmonary disease, stroke, urinary tract infection, septicemia, acute renal failure, or congestive heart failure.

MAIN MEASURES

Receipt of prescribed HH as indicated by a HH discharge code and corresponding HH patient assessment within 14 days of hospital discharge.

KEY RESULTS

There were 2,723,245 beneficiaries prescribed HH at discharge (68% TM, 32% MA). About 75% of TM enrollees and 62% of MA enrollees received prescribed post-acute HH. In adjusted analyses, MA enrollees had an -11.7 percentage point (pp) (95% confidence interval (CI): -16.8, -6.5) lower probability of receiving HH compared with TM enrollees. In adjusted analyses, HMO enrollees in plans with cost sharing (- 8.4 pp; 95% CI: - 14.3, - 2.5), referrals (- 3.7 pp; 95% CI: - 6.1, - 1.2), and pre-authorization (- 5.1 pp; 95% CI: - 8.3, - 2.0) were less likely to receive prescribed HH. In adjusted analyses, PPO enrollees in plans with cost sharing were -7.0 pp (95% CI: - 12.7, - 1.4) less likely to receive HH, but there was no difference for those with referrals (1.1 pp; 95% CI, - 1.5, 3.7) or pre-authorization (1.6 pp; 95% CI: - 0.6, - 3.9).

CONCLUSIONS

Among Medicare beneficiaries, MA enrollees were less likely to receive prescribed post-acute HH compared with TM. As enrollment in MA continues to grow, it is important to examine how differences in utilization relate to outcomes.

Framing the front door: co-creating a home health care assessment of service need for children with disabilities

This paper details the co-creation of a home health assessment tool for children with disabilities in the context of state-level systems change from traditional Medicaid to Medicaid managed care. A community based, sequential, mixed methods design was used to co-develop the assessment. A process evaluation highlighted community members' experiences with Medicaid managed care. Community members identified issues related to appropriateness of items and loss of services and recommended a dual assessment process to address concerns. Results indicated that 72% of items functioned well. Community members felt that organizational policies and the accuracy of clinical information obtained during assessment processes led directly to loss of services. Co-creating the assessment with caregivers of children with disabilities led to a comprehensive, person-centered, and holistic tool. The process buttressed several concrete systems and policy actions to improve home health care for children with disabilities in Medicaid managed care.

"There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19

The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.

Pre-Existing Inequality: The Impact of COVID-19 on Medicare Home Health Beneficiaries

There is significant data on the adverse impact of COVID-19 on persons who were poor, minorities, had compromised physical or mental health, or other vulnerabilities prior to the COVID-19 pandemic. A significant portion of the overall Medicare population has such vulnerabilities. The Medicare home health beneficiary population is even more vulnerable than the overall Medicare population based on gender, race, income level, living alone status, and number of chronic conditions. A literature review indicates there is only 1 study on the impact of COVID-19 in Medicare home health on home care workers and none on the impact on home health beneficiaries. The current study is a qualitative study based on interviews of a convenience sample of 48 home care nurses from 9 different home health agencies in New York City between April 1 and August 31, 2020. Six major themes emerged: need for social service supports increased; loneliness and depression increased among patients; physical and mental health conditions became exacerbated; substance use and abuse increased; evidence of domestic violence against patients increased; and there was a limited amount of staff and equipment to care for patients.

Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives

BACKGROUND

Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.

OBJECTIVE

To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.

DESIGN

Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.

PARTICIPANTS

A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers.

MAIN MEASURES

A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition.

KEY RESULTS

The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.

CONCLUSIONS

Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.