Experiences of Veterans, Caregivers, and VA Home-Based Care Providers before, during, and Post-Hurricane Ian

On 28 September 2022, Hurricane Ian pummeled parts of south Florida. Disaster and climate change research has shown that disasters exacerbate inequalities, especially amongst older and physically vulnerable people. Florida has a large population of Veterans managing multiple chronic health conditions and receiving long-term care in-home from Veterans Health Administration (VA) programs, including Home Based Primary Care and Medical Foster Home. To describe how VA staff provided high quality care during and after the hurricane, and how Veterans and caregivers accessed needed healthcare and supports post-hurricane, we conducted a site visit to Lee County, Florida area in May 2023, conducting N = 25 interviews with VA staff, Veterans, and caregivers. Findings from qualitative thematic analysis showed that while some Veterans and caregivers experienced significant challenges during and after the hurricane, including displacement and difficulty accessing oxygen, they felt highly supported by VA care teams. Staff efforts post-hurricane focused on improving care coordination in anticipation of future disasters, especially around communicating with Veterans and their caregivers, and a VA workgroup formed to implement changes. As climate change causes more severe hazard events, lessons learned from this project can better support healthcare staff, older adults, and their caregivers before and after major disasters.

Exploring the Needs and Requirements of Informal Caregivers of Older Adults With Cognitive Impairment From Sensor-Based Care Solutions: Multimethod Study

BACKGROUND

With the increase in the older adult population, sensor-based care solutions that can monitor the deviations in physical, emotional, and physiological activities in real-time from a distance are demanded for prolonging the stay of community-dwelling older adults with cognitive impairment. To effectively develop and implement these care solutions, it is important to understand the current experiences, future expectations, perceived usefulness (PU), and communication needs of the informal caregivers of older adults with cognitive impairment regarding such solutions.

OBJECTIVE

This comprehensive study with informal caregivers of older adults with cognitive impairment aims to (1) highlight current experiences with (if any) and future expectations from general sensor-based care solutions, (2) explore PU specifically toward unobtrusive sensing solutions (USSs), (3) determine the information communication (IC) needs and requirements for communicating the information obtained through USSs in different care scenarios (fall, nocturnal unrest, agitation, and normal daily life), and (4) elicit the design features for designing the interaction platform in accordance with the persuasive system design (PSD) model.

METHODS

A multimethod research approach encompassing a survey (N=464) and in-depth interviews (10/464, 2.2%) with informal caregivers of older adults with cognitive impairment was used. The insights into past experiences with and future expectations from the sensor-based care solutions were obtained through inductive thematic analysis of the interviews. A convergent mixed methods approach was used to explore PU and gather the IC needs from USSs by using scenario-specific questions in both survey and interviews. Finally, the design features were elicited by using the PSD model on the obtained IC needs and requirements.

RESULTS

Informal caregivers expect care infrastructure to consider centralized and empathetic care approaches. Specifically, sensor-based care solutions should be adaptable to care needs, demonstrate trust and reliability, and ensure privacy and safety. Most informal caregivers found USSs to be useful for emergencies (mean 4.09, SD 0.04) rather than for monitoring normal daily life activities (mean 3.50, SD 0.04). Moreover, they display variations in information needs including mode, content, time, and stakeholders involved based on the care scenario at hand. Finally, PSD features, namely, reduction, tailoring, personalization, reminders, suggestions, trustworthiness, and social learning, were identified for various care scenarios.

CONCLUSIONS

From the obtained results, it can be concluded that the care scenario at hand drives PU and IC design needs and requirements toward USSs. Therefore, future technology developers are recommended to develop technology that can be easily adapted to diverse care scenarios, whereas designers of such sensor-driven platforms are encouraged to go beyond tailoring and strive for strong personalization while maintaining the privacy of the users.

[Survey on Visiting Nurses' Awareness of the Roles of Pharmacists in Pediatric in-Home Care]

In recent years, there has been an urgent need to build a pediatric in-home care system with multiple occupations. This study aims to clarify the role of pharmacists in this system by investigating what visiting nurses' expectation from them. A self-administered questionnaire survey was conducted, targeting nurses enrolled in 10 home-visit nursing facilities. Responses were received from 51 nurses at six facilities, and the questionnaire collection rate was 42.5%. The primary role of the pharmacists that nurses regarded was the management of prescribed oral medications such as "mixing powders, single-dose packages at each time" and "sorting and summarizing each time medicine packages are taken." Other roles included providing information based on the drug's physicochemical properties such as "the tube gets clogged easily when the medicine is administered" and "do not crush the medicine when administering it." The findings of this study are novel because they revealed that pharmacists need to perform pharmaceutical assessments on the influences of changes in children's physical condition and the presence or absence of effects of drugs, and share information in real time. They also need to participate in a conference at discharge. For the first time, this study revealed the roles of pharmacists expected by nurses in pediatric in-home care. However, further knowledge or training are required, especially in terms of the relationship between the symptoms in children and the medicine administered, for pharmacists to effectively practice their roles.

Association Between In-Home Treatment and Engagement in Psychosocial Services Among Medicaid-Enrolled Youth

OBJECTIVE

Prior studies have identified low rates of engagement in mental health (MH) services in clinic settings among children enrolled in Medicaid. Yet, little is known about whether the delivery of in-home MH treatment (in which the clinician travels to the child's home) improves engagement for this population. This study examines the association between the delivery of in-home psychosocial treatment and engagement in services among Medicaid-enrolled youth.

METHOD

We used 2010 to 2014 Georgia Medicaid claims data to identify 53,508 children and adolescents (aged 5-17 years) with a MH diagnosis that initiated new psychosocial treatment. We estimated regression models controlling for covariates to examine the relationship of the receipt of any in-home psychosocial treatment in the home setting with 3 outcome measures of engagement: receipt of at least 4 psychosocial visits during the first 12 weeks; total number of psychosocial visits during the first 12 weeks; and total duration of service use.

RESULTS

Those who received any in-home psychosocial treatment (compared to those who did not) had 4.3 times the odds (odds ratio = 4.3, 95% CI = 4.0, 4.7) of receiving at least 4 visits during the first 12 weeks, had 4.5 (95% CI = 4.3, 4.7) more predicted visits during the first 12 weeks, and had a longer treatment episode duration (mean rate ratio = 1.54, 95% CI = 1.48,1.59).

CONCLUSION

Although many Medicaid-enrolled youth do not receive a sufficient number of MH services to achieve positive outcomes, our findings suggest that providing in-home psychosocial treatment can improve service engagement and potentially help address this challenge.

Novel in-home COVID-19 vaccination program for vulnerable populations using public-private collaboration

Background

The continued emergence of new COVID-19 variants highlights the importance of vaccination in the effort to reduce disease transmission and burden. The objective of this study is to evaluate the processes and outcomes associated with a novel in-home COVID-19 vaccination program aimed at vaccinating high-risk populations in New York, USA.

Methods

To evaluate program processes, we described the program itself and reflected on some key lessons learned. To evaluate program outcomes, we analyzed data reported by vaccine recipients. These outcomes included the percentage of vaccine recipients that successfully received the full course of vaccinations, and the demographic and health characteristics of vaccine recipients. We additionally assessed demographic differences in motivations for receiving in-home care, using chi-squared tests to assess statistical significance. Data were collected and reported via dynamic online intake forms.

Results

The median age of vaccine recipients was 79 ± SD 9.0 years. The oldest vaccine recipient was 107 years old. Of those with non-missing data, more than half of vaccine recipients were female (63%), identified as part of a racial/ethnic minority (66%), reported an annual income of < $25,000 (58%), and received a high school degree or less (68%). Most vaccine recipients reported having one or more health conditions associated with increased risk of severe COVID-19 disease (72%). Vaccine recipients were most likely to report receiving in-home vaccination because they were home-bound due to disability. Motivations for receiving in-home vaccination differed by demographic subgroup.

Conclusion

The population receiving vaccinations from this in-home care delivery program comprised seniors who were mostly female and non-white, indicated socioeconomic vulnerability, and reported one or more COVID-related health conditions; this signified that the program met its goal of vaccinating those most at risk for severe COVID-19 disease.

Caring for Homebound Veterans during COVID-19 in the U.S. Department of Veterans Affairs Medical Foster Home Program

The onset of the COVID-19 pandemic made older, homebound adults with multiple chronic conditions increasingly vulnerable to contracting the virus. The United States (US) Department of Veterans Affairs (VA) Medical Foster Home (MFH) program cares for such medically complex veterans residing in the private homes of non-VA caregivers rather than institutional care settings like nursing homes. In this qualitative descriptive study, we assessed adaptations to delivering safe and effective health care during the early stages of the pandemic for veterans living in rural MFHs. From December 2020 to February 2021, we interviewed 37 VA MFH care providers by phone at 16 rural MFH programs across the US, including caregivers, program coordinators, and VA health care providers. Using both inductive and deductive approaches to thematic analysis, we identified themes reflecting adaptations to caring for rural MFH veterans, including care providers rapidly increased communication and education to MFH caregivers while prioritizing veteran safety. Telehealth visits also increased, MFH veterans were prioritized for in-home COVID-19 vaccinations, and strategies were applied to mitigate the social isolation of veterans and caregivers. The study findings illustrate the importance of clear, regular communication and intentional care coordination to ensure high-quality care for vulnerable, homebound populations during crises like the COVID-19 pandemic.

The Determinants of Informal, Formal, and Mixed In-Home Care in the Canadian Context

Objective: This study employed the behavioral model of service utilization to assess the impact of social support and other predisposing, enabling, and health need factors on the receipt of informal, formal, and/or combination of both types of in-home care. Method: The study utilized data from the 2008-2009 Canadian Community Health Survey and focused on individuals aged 45 and older with one or more functional limitations (N = 5,898). Results: A broad array of predisposing and enabling factors influenced the receipt of care both directly and indirectly through health-related needs for care. Different types of support were influential including affectionate support, positive social interaction, and tangible assistance. Discussion: Findings support the utility of the behavioral model of service utilization to examine the determinants of in-home care arrangements. Findings also point to the need to broaden our focus on the importance of support networks beyond their direct involvement in the provision of care itself.

A Preliminary Qualitative Evaluation of an In-home Geriatric Care Elective Experience for Third-year Medical Students

Introduction: The aging population is growing quickly and has a higher prevalence of comorbid and chronic diseases. A majority of this group resides in the home setting. The purpose of this study was to examine the attitudes of third-year medical students following a pilot component of an internal medicine clerkship, consisting of four in-home visits with geriatric patients.

Methods: A qualitative study design, utilizing focus groups, was used to assess general themes in students’ responses regarding their attitudes to geriatrics, the field of geriatrics and the in-home care pilot program.

Results: Twelve students participated in three focus group sessions. Six themes were identified across all focus group sessions. These included 1) distinct advantages to the home setting, 2) more time for relationship building, 3) increased insight to the aging process, 4) increased compassion, 5) suggestions for program improvement, and 6) future quality of care.

Conclusion: The results demonstrate that students found the program to be of value to their medical education. Students developed positive attitudes and compassion for the elderly community. The insight they gained during this program may allow them to understand their role in caring for increasing numbers of aging patients in future populations. Suggestions made by the students showed their perceived value of the program and desire for it to continue for future students. Future studies should utilize validated tools and more longitudinal study designs to assess temporal changes in attitudes.

An evaluation of the effectiveness of engaging Canadian clients as partners in in-home care

This exploratory quasi-experimental evaluation assessed the effectiveness of the use of a concrete discussion guide to promote organisation-wide application of a partnering approach to engage older home-care clients with chronic disease/disabilities as care partners. A post-test-only design with an independent pre-test sample was used to compare selected outcomes with those of standard in-home care. The theoretically informed discussion guide portrayed how to go about the process of empowering partnering by using language and open-ended conversational leads to construct partnering, partnering effort and health as a resource for everyday living through social interaction. The discussion guide was provided to all providers for use with all clients in one home-care programme in Ontario, Canada and this organisation was compared with a similar but geographically distanced organisation, also in Ontario. Seven hundred and ninety-one randomly selected clients (mean age = 72.5 years) receiving 3+ months of in-home care for chronic conditions/disabilities from the two home-care programmes between September 2007 and May 2010 completed a researcher-administered questionnaire at either baseline, 1 year or 2 years. Instruments included the Client's Partnering Experience, Health-Promoting Partnering Effort, a modified version of Locus of Authority in Decision-Making, the Medical Outcomes Survey Self-Rated Health Scale, Health and Social Services Utilization and a modified Functional Independence Measure. Analysis of covariance revealed that the use of the concrete discussion guide to promote organisation-wide application of a partnering approach achieved significantly greater client partnering experience and health-promoting partnering effort over time than did the usual approach to in-home-care interactions. Using the discussion guide enhanced client/provider partnering, hence, interdependence, contributing positively to promoting clients' health as a resource for everyday living.