Impact of Home Health Care on Health Care Resource Utilization Following Hospital Discharge: A Cohort Study

Disparities in Infection Risk Among Home Health Care Patients: A Study Using Area Deprivation Index

OBJECTIVE

To examine the association between neighborhood deprivation and infection-related hospitalizations among home health care (HHC) patients across different rurality levels.

DESIGN

Retrospective observation analysis of 2019 national data sets, including Medicare data linked to 2019 Area Deprivation Index (ADI) data and Rural-Urban Continuum Codes (RUCCs).

SETTING AND PARTICIPANTS

The sample includes 3,656,810 HHC patients from 8135 HHC agencies nationwide. Patients were predominantly White (77.6%), with an average age of 80 years, and mostly female (61.7%). The sample included 24% dual-eligible patients and those living in large metropolitan (53.8%), small metro (30.2%), rural adjacent (11.4%), and remote rural areas (4.6%).

METHODS

Hospital admissions due to infection were identified through International Classification of Diseases, Tenth Revision (ICD-10), codes. Neighborhood deprivation was measured by the 2019 ADI. Patients were stratified by RUCC (large metro, small metro, rural adjacent, or remote rural). Within each rurality stratum, ADI quartiles were constructed, with higher quartiles indicating greater neighborhood deprivation. Multivariable logistic regression was conducted, adjusting for multiple-level variables.

RESULTS

As neighborhood deprivation increased, there was a rise in the proportion of dual-eligible, female, Black, and Hispanic patients, whereas the proportion of White patients decreased, especially in rural areas. Rural areas with higher ADI rankings showed lower quality metrics and reduced health care resources. Higher ADI quartiles were significantly associated with increased infection risks after adjusting for covariates, but this was only observed in remote rural areas, not in urban areas.

CONCLUSIONS AND IMPLICATIONS

The findings highlight significant policy and clinical implications for remote rural areas. Policymakers should increase investments in rural health infrastructure, enhance telehealth, improve transportation services, and offer incentives for health care providers to practice in these areas. The nonsignificant association between neighborhood deprivation and infection outcomes in metropolitan areas may stem from the ADI's limited sensitivity to urban contexts, highlighting the need for more nuanced indices that better capture urban socioeconomic challenges.

Characteristics and Readmission Risks Following Sepsis Discharges to Home

OBJECTIVE

To examine the characteristics and risk factors associated with 30-day readmissions, including the impact of home health care (HHC), among older sepsis survivors transitioning from hospital to home.

RESEARCH DESIGN

Retrospective cohort study of the Medical Information Mart for Intensive Care (MIMIC)-IV data (2008-2019), using generalized estimating equations (GEE) models adjusting for patient sociodemographic and clinical characteristics.

SUBJECTS

Sepsis admission episodes with in-hospital stays, aged over 65, and discharged home with or without HHC were included.

MEASURES

The outcome was all-cause hospital readmission within 30 days following sepsis hospitalization. Covariates, including the primary predictor (HHC vs. Home discharges), were collected during hospital stays.

RESULTS

Among 9115 sepsis admissions involving 6822 patients discharged home (66.8% HHC, 33.2% Home), HHC patients, compared with those discharged without services, were older, had more comorbidities, longer hospital stays, more prior hospitalizations, more intensive care unit admissions, and higher rates of septic shock diagnoses. Despite higher illness severity in the HHC discharges, both groups had high 30-day readmission rates (30.2% HHC, 25.2% Home). GEE analyses revealed 14% higher odds of 30-day readmission for HHC discharges after adjusting for risk factors (aOR: 1.14; 95% CI: 1.02-1.27; P=0.02).

CONCLUSIONS

HHC discharges experienced higher 30-day readmission rates than those without, indicating the need for specialized care in HHC settings for sepsis survivors due to their complex health care needs. Attention to sepsis survivors, regardless of HHC receipt, is crucial given the high readmission rates in both groups. Further research is needed to optimize postacute care/interventions for older sepsis survivors.

Race and Ethnicity, Neighborhood Social Deprivation and Medicare Home Health Agency Quality for Persons Living With Serious Illness

OBJECTIVE

Examine the relationship between race and ethnicity and area-level social deprivation and Medicare home health care (HHC) agency quality for seriously ill older adults receiving HHC.

METHODS

A linear probability fixed effects model analyzed the association between patient-level predictors and HHC agency quality (star-rating), controlling for neighborhood level fixed effects. Linear mixed regression modeled the relationship between area-level social deprivation and receiving care from a high-quality HHC agency. An interaction term between race and social deprivation index quartiles examined whether racial disparities in accessing high-quality HHC agencies depended on the level of neighborhood social deprivation.

RESULTS

The final sample consisted of 213 491 Medicare beneficiaries. Reduced access to high-quality HHC was associated with identifying as Black (1.2 % point lower, P < .001), having Medicaid (5.5 % point lower, P < .0001), and living in a neighborhood with high social deprivation (6.5% point lower, P < .001). The effect of race on access to high-quality HHC persisted regardless of the level of neighborhood social deprivation.

CONCLUSIONS

For people living with serious illness, living in areas with higher social deprivation is associated with lower-quality HHC. Patient race and ethnicity has a consistent effect reducing access to high-quality HHC agencies, regardless of neighborhood. Future research must investigate ways to improve access to high-quality HHC for racial and ethnic historically marginalized populations who are seriously ill, especially in areas of high social deprivation. This includes understanding what policies, organizational structures, or care processes impede or improve access to high-quality care.

Discharge Disposition after Total Hip Arthroplasty: A 10-Year Analysis of Trends and Predictors of Nonhome Discharge (2011-2021)

BACKGROUND

Total hip arthroplasty (THA) practices are evolving under the influence of the current value-based healthcare system and bundled payment models. This study aimed to (1) evaluate national trends in discharge disposition and postoperative outcomes after THA, (2) compare discharge cohorts on episode-of-care parameters, and (3) determine predictors of nonhome discharge from 2011 to 2021.

METHODS

The National Surgical Quality Improvement Program database was queried for THA data from 2011 to 2021. A total of 328,380 patients undergoing THA were identified between 2011 and 2021. Of these patients, 276,710 were discharged home and 51,670 were discharged to nonhome locations. Trends of annual discharge disposition, healthcare utilization parameters, and proxies for postoperative complications were reported. A multivariable logistic regression analysis was conducted to identify potential risk factors for nonhome discharge.

RESULTS

The percentage of patients who were discharged to home increased from 70.20% in 2011 to 92.42% in 2021. In those discharged to home, 30-day readmission rates, 30-day major complication rates, length of stay, any wound complications, and need for transfusion all decreased within the past decade. The percentage of patients who were discharged to nonhome locations decreased from 29.80% in 2011 to 7.58% in 2021. In this group, major complication rates within 30 days, length of stay, and need for mechanical ventilation increased from 2011 to 2021. Greater age, female sex, body mass index of <18.5, race, smoking, higher comorbidity burden, and functional status were associated with greater odds ratios of nonhome discharge.

CONCLUSION

Home discharge after THA has increased substantially over the past decade, with more than 90% of patients now being discharged home. However, a small subset of higher-risk patients still requires nonhome discharge and experience worse outcomes. Focused efforts based on known discharge risk factors may allow implementing perioperative optimization strategies to further improve outcomes in this population.

Characteristics and hospitalization of people living with dementia after home healthcare: A nationwide cohort study

The need for home healthcare (HHC) is increasing among people living with dementia (PLWD) to achieve their desire to age. This study aimed to investigate the determinants of hospitalization among PLWD receiving HHC. This retrospective cohort study used data from the National Health Insurance Research Database of Taiwan from 2007 to 2017. The primary outcome was subsequent hospitalization after HHC for PLWD. Using multivariate Poisson regression, baseline and follow-up HHC-related characteristics were examined as covariates and influencing factors. A total of 95,831 PLWD received HHC (mean age: 80.2 years), and 81.7% had at least one subsequent hospitalization during the follow-up period. Regarding baseline characteristics, prior admission was the strongest determinant of subsequent hospitalization, especially being admitted three to six months before HHC use (aRR = 1.47, 95% confidence interval [CI] 1.39-1.56, P < .001), followed by dementia duration from diagnosis to index date more than 3.5 years (aRR = 1.22, 95% CI 1.19-1.24). Among HHC-related characteristics, a higher frequency of HHC visits (more than 2 counts/month) (aRR = 4.81, 95% CI 4.63-5.00) and visits by both physicians and nurses (aRR = 2.03, 95% CI 1.98-2.07) were associated with a higher risk of hospitalization. Our findings suggest that prior admission, longer dementia duration from diagnosis to the index date, and frequency of HHC were positively associated with increased hospitalization. Future interventions and strategies can focus on these factors to decrease hospitalization among PLWD receiving HHC.

Frontloaded Home Health Physical Therapy Reduces Hospital Readmissions Among Medicare Fee-for-Service Beneficiaries

OBJECTIVE

The purpose of this paper is to determine a claims-based definition of frontloaded home health physical therapy (HHPT) and examine the effect of frontloaded HHPT visits on all-cause 30-day hospital readmissions.

METHODS

This study used a retrospective analysis of Medicare fee-for-service claims from older adults (≥65 years) in the National Health and Aging Trends Study (2011-2017) with ≥1 HHPT visit within 30 days of a hospitalization (n = 1344 hospitalizations; weighted n = 7,727,384). An exploratory analysis of home health claim distribution was conducted to determine definitions of frontloaded HHPT. Generalized linear models were then used to examine the relationship between hospital readmission and each definition of frontloading.

RESULTS

Four definitions of frontloaded HHPT were identified: ≥2 HHPT visits in the first week after discharge; ≥3 visits in the first week; ≥4 visits in the first 2 weeks; and ≥ 5 visits in the first 2 weeks. The adjusted risk of readmission was lower for older adults receiving frontloaded HHPT in the first week: (risk ratio [RR] for ≥2 vs <2 visits = 0.57; 95% CI = 0.41-0.79; RR for ≥3 vs <3 visits = 0.39; 95% CI = 0.22-0.72). The reduction in risk of readmission was even greater for older adults receiving ≥4 versus <4 HHPT visits (RR = 0.32; 95% CI = 0.21-0.48) and ≥ 5 versus <5 HHPT visits (RR = 0.27; 95% CI = 0.14-0.50) within the first 2 weeks. The effect of HHPT frontloading was greater for patients hospitalized with surgical versus medical diagnoses and for patients with diagnoses targeted by the Hospital Readmissions Reduction Program.

CONCLUSION

Frontloaded HHPT reduces 30-day hospital readmissions among Medicare beneficiaries. Additional research is needed to determine the optimal number of visits and those most likely to benefit from frontloaded HHPT.

IMPACT

Frontloaded HHPT can be an effective approach for reducing 30-day hospital readmissions among Medicare beneficiaries.

LAY SUMMARY

This study found that providing home health physical therapist visits early and often after hospital discharge decreases the risk that patients will be readmitted over the next 30 days.

Dimensions and components of hospital-at-home care: a systematic review

BACKGROUND AND AIM

Hospital-at-home (HaH) care is known as a healthcare delivery approach providing acute care services at home as an alternative to traditional hospital care. This study aimed to explore the dimensions and components of HaH care.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The databases including ScienceDirect, Scopus, PubMed, the Cochrane library, the Web of Science Core Collection, and the Wiley online library were searched for articles on HaH care dimensions and components of from early 2000 to February 19, 2024. The inclusion criteria of the study included articles published in the English language, and and those pertaining to various dimensions and components of HaH care. The quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and data were analysed using the framework analysis method.

RESULTS

A total of 4078 articles were retrieved. After screening and quality assessment, 179 articles were included in the review, identifying 88 dimensions and components of HaH care across seven main categories: benefits, challenges and obstacles, facilitators, management-related factors, medical conditions, factors associated with patients and their families, and factors associated with caregivers. The common components included cost savings (n = 30), patient and family satisfaction (n = 23), reduction in re-admissions (n = 13), medication management (n = 12), communication, coordination, and cooperation among healthcare teams, patients, and families (n = 12), preferences of patients and families (n = 12), and education of patients, families, and healthcare teams (n = 10).

CONCLUSION

Based on the results, HaH includes many and diverse dimensions and components. So, healthcare policymakers and planners are urged to consider the dimensions and components of HaH care including benefits, challenges and obstacles, facilitators, management-related factors, medical conditions, factors associated with patients and their families, and factors associated with caregivers when developing models and programs to ensure effective outcomes following implementation.

Home health care is associated with an increased risk of readmission and cost of care without reducing risk of complication following shoulder arthroplasty: a propensity-score analysis

BACKGROUND

Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services.

METHODS

A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA 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 without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes.

RESULTS

A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P = .0328) and 90 days (OR 1.215; P = .0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P < .001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P < .001).

CONCLUSION

Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation.

Experiences of workplace violence among healthcare workers in home care settings: A qualitative systematic review

AIMS

The aims of this systematic review were to obtain a comprehensive understanding of healthcare workers' experiences who were subjected to workplace violence in the home care environment and identify their specific support needs.

BACKGROUND

Workplace violence toward healthcare workers has been a prevalent and ongoing issue. With the expansion of home care services, more emphasis should be placed on maintaining a safe in-home care environment for healthcare workers. Understanding healthcare workers' experience of workplace violence is crucial for developing effective interventions.

METHODS

A systematic search was conducted in 10 databases from their inception date until January 2022. Primary qualitative studies were included. Two reviewers performed screening of studies, methodological quality assessment, and data extraction and analysis independently. The two-step approach by Sandelowski and Barroso on meta-summary and meta-synthesis was used. This qualitative systematic review was reported according to the PRISMA guidelines.

RESULTS

Eight studies were included. Three themes were identified: (1) impact of workplace violence, (2) reasons behind tolerating violence, and (3) way forward to prevent violence.

CONCLUSION

Workplace violence is common among healthcare workers in home care settings, yet the support provided to healthcare workers is inadequate. The findings suggest the need for effective interventions and policies to address this grave issue in order to improve the well-being of healthcare workers as it may indirectly affect the care quality provided to patients.

IMPLICATIONS FOR NURSING

Due to the unique nature of home care services, interventions preventing workplace violence must be tailored to the specific home care settings and needs of healthcare workers. Future research should develop and evaluate different interventions to prevent workplace violence in home care settings.

Loss of Independent Living in Patients Undergoing Transcatheter or Surgical Aortic Valve Replacement: A Retrospective Cohort Study

BACKGROUND

The recommendation for transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in patients 65 to 80 years of age is equivocal, leaving patients with a difficult decision. We evaluated whether TAVR compared to SAVR is associated with reduced odds for loss of independent living in patients ≤65, 66 to 79, and ≥80 years of age. Further, we explored mechanisms of the association of TAVR and adverse discharge.

METHODS

Adult patients undergoing TAVR or SAVR within a large academic medical system who lived independently before the procedure were included. A multivariable logistic regression model, adjusting for a priori defined confounders including patient demographics, preoperative comorbidities, and a risk score for adverse discharge after cardiac surgery, was used to assess the primary association. We tested the interaction of patient age with the association between aortic valve replacement (AVR) procedure and loss of independent living. We further assessed whether the primary association was mediated (ie, percentage of the association that can be attributed to the mediator) by the procedural duration as prespecified mediator.

RESULTS

A total of 1751 patients (age median [quartiles; min-max], 76 [67, 84; 23-100]; sex, 56% female) were included. A total of 27% (222/812) of these patients undergoing SAVR and 20% (188/939) undergoing TAVR lost the ability to live independently. In our cohort, TAVR was associated with reduced odds for loss of independent living compared to SAVR (adjusted odds ratio [OR adj ] 0.19 [95% confidence interval {CI}, 0.14-0.26]; P < .001). This association was attenuated in patients ≤65 years of age (OR adj 0.63 [0.26-1.56]; P = .32) and between 66 and 79 years of age (OR adj 0.23 [0.15-0.35]; P < .001), and magnified in patients ≥80 years of age (OR adj 0.16 [0.10-0.25]; P < .001; P -for-interaction = .004). Among those >65 years of age, a shorter procedural duration mediated 50% (95% CI, 28-76; P < .001) of the beneficial association of TAVR and independent living.

CONCLUSIONS

Patients >65 years of age undergoing TAVR compared to SAVR had reduced odds for loss of independent living. This association was partly mediated by shorter procedural duration. No association between AVR approach and the primary end point was found in patients ≤65 years of age.

The association of intraoperative low driving pressure ventilation and nonhome discharge: a historical cohort study

PURPOSE

To evaluate whether intraoperative ventilation using lower driving pressure decreases the risk of nonhome discharge.

METHODS

We conducted a historical cohort study of patients aged ≥ 60 yr who were living at home before undergoing elective, noncardiothoracic surgery at two tertiary healthcare networks in Massachusetts between 2007 and 2018. We assessed the association of the median driving pressure during intraoperative mechanical ventilation with nonhome discharge using multivariable logistic regression analysis, adjusted for patient and procedural factors. Contingent on the primary association, we assessed effect modification by patients' baseline risk and mediation by postoperative respiratory failure.

RESULTS

Of 87,407 included patients, 12,584 (14.4%) experienced nonhome discharge. In adjusted analyses, a lower driving pressure was associated with a lower risk of nonhome discharge (adjusted odds ratio [aOR], 0.88; 95% confidence interval [CI], 0.83 to 0.93, per 10 cm H2O decrease; P < 0.001). This association was magnified in patients with a high baseline risk (aOR, 0.77; 95% CI, 0.73 to 0.81, per 10 cm H2O decrease, P-for-interaction < 0.001). The findings were confirmed in 19,518 patients matched for their baseline respiratory system compliance (aOR, 0.90; 95% CI, 0.81 to 1.00; P = 0.04 for low [< 15 cm H2O] vs high [≥ 15 cm H2O] driving pressures). A lower risk of respiratory failure mediated the association of a low driving pressure with nonhome discharge (20.8%; 95% CI, 15.0 to 56.8; P < 0.001).

CONCLUSIONS

Intraoperative ventilation maintaining lower driving pressure was associated with a lower risk of nonhome discharge, which can be partially explained by lowered rates of postoperative respiratory failure. Future randomized controlled trials should target driving pressure as a potential intervention to decrease nonhome discharge.

Impact of obesity on complications and surgical outcomes after adult degenerative scoliosis spine surgery

OBJECTIVE

To compare perioperative outcomes of obese versus non-obese adult patients who underwent degenerative scoliosis spine surgery.

METHODS

235 patients who underwent thoracolumbar adult spinal deformity (ASD) surgery (≥4 levels) were identified and categorized into two cohorts based on their body mass indices (BMI): obese (BMI ≥30 kg/m²; n = 81) and non-obese (BMI <30 kg/m²; n = 154). Preoperative (demographics, co-morbidities, American Society of Anesthesiologists (ASA) score and modified frailty indices (mFI-5 and mFI-11)), intraoperative (estimated blood loss (EBL) and anesthesia duration), and postoperative (complication rates, Oswestry Disability Index (ODI) scores, discharge destination, readmission rates, and survival) characteristics were analyzed by student's t, chi-squared, and Mann-Whitney U tests.

RESULTS

Obese patients were more likely to be Black/African-American (p < 0.05, OR:4.11, 95% CI:1.20-14.10), diabetic (p < 0.05, OR:10.18, 95% CI:4.38-23.68) and had higher ASA (p < .01) and psoas muscle indices (p < 0.0001). Furthermore, they had greater pre- and post-operative ODI scores (p < 0.05) with elevated mFI-5 (p < 0.0001) and mFI-11 (p < 0.01). Intraoperatively, obese patients were under anesthesia for longer time periods (p < 0.05) with higher EBL (p < 0.05). Postoperatively, while they were more likely to have complications (OR:1.77, 95% CI:1.01 - 3.08), had increased postop days to initiate walking (p < .05) and were less likely to be discharged home (OR:0.55, 95% CI:0.31-0.99), no differences were found in change in ODI scores or readmission rates between the two cohorts.

CONCLUSIONS

Obesity increases pre-operative risk factors including ASA, frailty and co-morbidities leading to longer operations, increased EBL, higher complications and decreased discharge to home. Pre-operative assessment and systematic measures should be taken to improve peri-operative outcomes.

The Cost-Effectiveness of Homecare Services for Adults and Older Adults: A Systematic Review

This study provides an overview of the literature on the cost-effectiveness of homecare services compared to in-hospital care for adults and older adults. A systematic review was performed using Medline, Embase, Scopus, Web of Science, CINAHL and CENTRAL databases from inception to April 2022. The inclusion criteria were as follows: (i) (older) adults; (ii) homecare as an intervention; (iii) hospital care as a comparison; (iv) a full economic evaluation examining both costs and consequences; and (v) economic evaluations arising from randomized controlled trials (RCTs). Two independent reviewers selected the studies, extracted data and assessed study quality. Of the 14 studies identified, homecare, when compared to hospital care, was cost-saving in seven studies, cost-effective in two and more effective in one. The evidence suggests that homecare interventions are likely to be cost-saving and as effective as hospital. However, the included studies differ regarding the methods used, the types of costs and the patient populations of interest. In addition, methodological limitations were identified in some studies. Definitive conclusions are limited and highlight the need for better standardization of economic evaluations in this area. Further economic evaluations arising from well-designed RCTs would allow healthcare decision-makers to feel more confident in considering homecare interventions.

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.

“The Crossover to Hospice”: Perspectives of Home Healthcare Nurses and Social Workers

Background:

Although home healthcare(HHC) clinicians increasingly provide care to a homebound population with advanced illness and high symptom burden,  we know little about how HHC clinicians navigate discussions about hospice with patients and families in this setting.

Objective

We sought to explore perspectives on transition from HHC to hospice among HHC nurses and social workers.

Design

PQualitative study using semi-structured interviews and thematic analysis.

Results:

Fifteen nurses and 3 Social workers participated in the study. Four main themes emerged from the interviews: (1) Regulatory Forces of Hospice and HHC; (2) Structure of HHC; (3) Individual beliefs—Hospice means giving up; and (4) Dynamics of Communication in HHC to Facilitate Transitions to Hospice.

Conclusion

Introducing the option of hospice to patients and families nearing end-of-life in the HHC setting is complex and challenging.  Facilitators of hospice discussions in the HHC setting  include interdisciplinary team-based clinical review, clinical decision support tools to identify patients who are hospice-eligible, and staff training.  These factors provide targets for future interventions.

Barriers to efficient management of in-home care: A qualitative content analysis

AIM

Inefficient management is one of the major barriers to development of in-home care in the society. Accordingly, the present study aims to identify the barriers to efficient management of home care nursing using a qualitative approach.

DESIGN

The present study is a qualitative-descriptive work of research.

METHOD

Data were collected using semi-structured, in-depth, individual interviews with 19 nurses from November 2020 to May 2021. The collected data were analysed using Graneheim and Lundman's method.

RESULTS

The findings of the study were categorized into four main themes, namely lack of effective standards, ineffective interactions, inappropriate cultural/social context and professional issues, and 15 subthemes.

CONCLUSION

In-home care nurses in Iran experience various problems in their practice. Creating an appropriate cultural/social context in Iranian societies, providing the necessary infrastructure, including insurance, providing comprehensive, clear guidelines for in-home care, encouraging teamwork and organizing workshops to promote effective interactions between the personnel and patients can improve the quality of in-home care nursing.

Symptom Burden and Activity of Daily Living (ADL) Dependency Among Home Health care Patients Discharged to Home Hospice

Background: We sought to examine sociodemographic and clinical characteristics present on admission to HHC associated with discharge to hospice. Methods: We used a 5% random sample of 2017 national Outcome and Assessment Information Set (OASIS) data. A Cox proportional hazards regression model was estimated for the primary outcome (discharge to hospice) to examine the associations with sociodemographic and clinical characteristics of HHC patients. Results: Among 489, 230 HHC patients, 4268 were discharged to hospice. The median (interquartile range) length of HHC stay for patients discharged to hospice care was 33 (14-78) days. Compared to White patients, Black, Hispanic, and other race, (hazard ratio [HR] = .50 [95% confidence interval, CI = .44-.57]), (HR = .53 [95% CI = .46-.62]), and (HR = .49 [95% CI = .40-.61], respectively) was associated with shorter time to discharge to hospice care. Clinical characteristics including severe dependence in activities of daily (ADL) (HR = 1.68 [95% CI = 1.01-2.78]), cognitive impairment (HR = 1.10 [95% CI = 1.01-1.20]), disruptive behavior daily (HR = 1.11 [95% CI = 1.02-1.22]), and inability to feed oneself (HR = 4.78, 95% CI = 4.30, 5.31) was associated with shorter time to discharge to hospice. Symptoms of anxiety daily (HR = 1.55 [95% CI = 1.43-1.68]), and pain daily or all the time (HR = 1.54 [95% CI = 1.43-1.64]) were associated with shorter time to discharge to hospice. Conclusions: High symptom burden, ADL dependency, and cognitive impairment on admission to HHC services was associated with greater likelihood of discharge to hospice.

Cultural Factors and Social Changes Affecting Home Healthcare in Iran: A Qualitative Study

In Iran, home healthcare (HHC) is provided in a diverse socio-cultural context. Health professionals’ inadequate knowledge of the socio-cultural factors of the society can lead to poor quality HHC. Even so, the ways these factors influence HHC remain unclear. This study aimed to explore the effects of cultural factors and social changes on HHC in Iran. This qualitative study which follows a conventional content analysis approach was conducted in Tabriz, Iran. Eighteen individuals including nurses, home health directors, physicians, policy-makers, patients, and their families participated in the study. Participants were selected using purposive sampling. Data collection involved focus group discussion (FGD) and 16 semi-structured in-depth interviews. In order to analyze the data, Graneheim and Lundman’s techniques were used and data collection continued until saturation was reached. Five main themes emerged from the data analysis including cultural diversity issues, society’s understanding of HHC, shifting demographics affecting healthcare needs, transitioning from traditional to modern lifeways, and increasing unaffordability of healthcare. Health managers can improve the accessibility and acceptability of HHC services by identifying the socio-cultural needs of the society. Future research should develop and test patients and families’ cultural care models in the HHC setting.

Specialty-Specific Readmission Risk Models Outperform General Models in Estimating Hepatopancreatobiliary Surgery Readmission Risk

BACKGROUND

Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population.

METHODS

Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC).

RESULTS

A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58).

CONCLUSION

HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.

Home health care after discharge is associated with lower readmission rates for patients with acute myocardial infarction

OBJECTIVE

We studied the utilization of home health care (HHC) among acute myocardial infarction (AMI) patients, impact of HHC on and predictors of 30-day readmission.

METHODS

We queried the National Readmission Database (NRD) from 2012 to 2014identify patients with AMI discharged home with (HHC+) and without HHC (HHC-). Linkage provided in the data identified patients who had 30-day readmission, our primary end-point. The probability for each patient to receive HHC was calculated by a multivariable logistic regression. Average treatment of treated weights were derived from propensity scores. Weight-adjusted logistic regression was used to determine impact of HHC on readmission.

RESULTS

A total of 406 237 patients with AMI were discharged home. Patients in the HHC+ cohort (38 215 patients, 9.4%) were older (mean age 77 vs. 60 years P < 0.001), more likely women (53 vs. 26%, P < 0.001), have heart failure (5 vs. 0.5%, P < 0.001), chronic kidney disease (26 vs. 6%, P < 0.001) and diabetes (35 vs. 26%, P < 0.001). Patients readmitted within 30-days were older with higher rates of diabetes (RR = 1.4, 95% CI: 1.37-1.48) and heart failure (RR = 5.8, 95% CI: 5.5-6.2). Unadjusted 30-day readmission rates were 21 and 8% for HHC+ and HHC- patients, respectively. After adjustment, readmission was lower with HHC (21 vs. 24%, RR = 0.89, 95% CI: 0.82-0.96; P < 0.001).

CONCLUSION

In the United States, AMI patients receiving HHC are older and have more comorbidities; however, HHC was associated with a lower 30-day readmission rate.

Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity

Older adults with diabetes are at elevated risk of complications following hospitalization. Home health care services mitigate the risk of adverse events and facilitate a safe transition home. In the United States, when home health care services are prescribed, federal guidelines require they begin within two days of hospital discharge. This study examined the association between timing of home health care initiation and 30-day rehospitalization outcomes in a cohort of 786,734 Medicare beneficiaries following a diabetes-related index hospitalization admission during 2015. Of these patients, 26.6% were discharged to home health care. To evaluate the association between timing of home health care initiation and 30-day rehospitalizations, multivariate logistic regression models including patient demographics, clinical and geographic variables, and neighborhood socioeconomic variables were used. Inverse probability-weighted propensity scores were incorporated into the analysis to account for potential confounding between the timing of home health care initiation and the outcome in the cohort. Compared to the patients who received home health care within the recommended first two days, the patients who received delayed services (3-7 days after discharge) had higher odds of rehospitalization (OR, 1.28; 95% CI, 1.25-1.32). Among the patients who received late services (8-14 days after discharge), the odds of rehospitalization were four times greater than among the patients receiving services within two days (OR, 4.12; 95% CI, 3.97-4.28). Timely initiation of home health care following diabetes-related hospitalizations is one strategy to improve outcomes.

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

BACKGROUND

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

OBJECTIVE

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

RESEARCH DESIGN

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What Factors Predict Adverse Discharge Disposition in Patients Older Than 60 Years Undergoing Lower-extremity Surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) Risk Score

BACKGROUND

Adverse discharge disposition, which is discharge to a long-term nursing home or skilled nursing facility is frequent and devastating in older patients after lower-extremity orthopaedic surgery. Predicting individual patient risk allows for preventive interventions to address modifiable risk factors and helps managing expectations. Despite a variety of risk prediction tools for perioperative morbidity in older patients, there is no tool available to predict successful recovery of a patient's ability to live independently in this highly vulnerable population.

QUESTIONS/PURPOSES

In this study, we asked: (1) What factors predict adverse discharge disposition in patients older than 60 years after lower-extremity surgery? (2) Can a prediction instrument incorporating these factors be applied to another patient population with reasonable accuracy? (3) How does the instrument compare with other predictions scores that account for frailty, comorbidities, or procedural risk alone?

METHODS

In this retrospective study at two competing New England university hospitals and Level 1 trauma centers with 673 and 1017 beds, respectively; 83% (19,961 of 24,095) of patients 60 years or older undergoing lower-extremity orthopaedic surgery were included. In all, 5% (1316 of 24,095) patients not living at home and 12% (2797 of 24,095) patients with missing data were excluded. All patients were living at home before surgery. The mean age was 72 ± 9 years, 60% (11,981 of 19,961) patients were female, 21% (4155 of 19,961) underwent fracture care, and 34% (6882 of 19,961) underwent elective joint replacements. Candidate predictors were tested in a multivariable logistic regression model for adverse discharge disposition in a development cohort of all 14,123 patients from the first hospital, and then included in a prediction instrument that was validated in all 5838 patients from the second hospital by calculating the area under the receiver operating characteristics curve (ROC-AUC).Thirty-eight percent (5360 of 14,262) of patients in the development cohort and 37% (2184 of 5910) of patients in the validation cohort had adverse discharge disposition. Score performance in predicting adverse discharge disposition was then compared with prediction scores considering frailty (modified Frailty Index-5 or mFI-5), comorbidities (Charlson Comorbidity Index or CCI), and procedural risks (Procedural Severity Scores for Morbidity and Mortality or PSS).

RESULTS

After controlling for potential confounders like BMI, cardiac, renal and pulmonary disease, we found that the most prominent factors were age older than 90 years (10 points), hip or knee surgery (7 or 8 points), fracture management (6 points), dementia (5 points), unmarried status (3 points), federally provided insurance (2 points), and low estimated household income based on ZIP code (1 point). Higher score values indicate a higher risk of adverse discharge disposition. The score comprised 19 variables, including socioeconomic characteristics, surgical management, and comorbidities with a cutoff value of ≥ 23 points. Score performance yielded an ROC-AUC of 0.85 (95% confidence interval 0.84 to 0.85) in the development and 0.72 (95% CI 0.71 to 0.73) in the independent validation cohort, indicating excellent and good discriminative ability. Performance of the instrument in predicting adverse discharge in the validation cohort was superior to the mFI-5, CCI, and PSS (ROC-AUC 0.72 versus 0.58, 0.57, and 0.57, respectively).

CONCLUSION

The Adverse Discharge in Older Patients after Lower Extremity Surgery (ADELES) score predicts adverse discharge disposition after lower-extremity surgery, reflecting loss of the ability to live independently. Its discriminative ability is better than instruments that consider frailty, comorbidities, or procedural risk alone. The ADELES score identifies modifiable risk factors, including general anesthesia and prolonged preoperative hospitalization, and should be used to streamline patient and family expectation management and improve shared decision making. Future studies need to evaluate the score in community hospitals and in institutions with different rates of adverse discharge disposition and lower income. A non-commercial calculator can be accessed at www.adeles-score.org.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries

OBJECTIVES

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

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Identifying Targets to Improve Heart Failure Outcomes for Patients Receiving Home Healthcare Services: The Relationship of Functional Status and Pain

Heart failure (HF) is one of the leading causes of rehospitalization in the United States. Due to the complex nature of HF, the provision of Medicare-certified home healthcare services has increased. Medicare-certified home healthcare agencies measure and report patients' outcomes such as functional status, activities of daily living (ADL), and instrumental activities of daily living to the Centers for Medicare and Medicaid Services. These metrics are assessed using the Outcome and Assessment Information Set (OASIS). As a large data set, OASIS has been used to advance care quality in multiple ways including identifying risk factors for negative patient outcomes. However, there is a lack of OASIS analyses to assess the relationship between functional status and the role of other factors, such as pain, in impeding recovery after hospitalization among HF patients. Therefore, the purpose of this study is to identify the relationship between functional status and pain using the OASIS database. Among 489 HF patients admitted to home healthcare, 83% were White, 57% were female, and the median age was 80. Patients who reported daily but not constant activity-interfering pain at discharge demonstrated the least improvement in functional performance as measured by ADLs, whereas patients without activity-interfering pain demonstrated the greatest improvement in ADL performance (p value = 0.0284). Tracking individual patient ADL scores, particularly the frequency of activity-interfering pain, could be a key indicator for clinical focus for patients with HF in the home healthcare setting.

Patient Factors Linked with Return Acute Healthcare Use in Older Adults by Discharge Disposition

OBJECTIVES

Compare patient characteristics by hospital discharge disposition (home without services, home with home healthcare (HHC) services, or post-acute care (PAC) facilities). Examine timing and rates of 30-day healthcare utilization (rehospitalization, emergency department (ED) visit, or observation (OBS) visit) and patient characteristics associated with rehospitalization by discharge location.

DESIGN

Retrospective analysis of hospital administrative and clinical data.

SETTING AND PARTICIPANTS

A total of 3,294 older adult inpatients discharged home with or without HHC services or to a PAC facility.

MEASUREMENTS

Patient-level sociodemographic and clinical characteristics. Number of and time to occurrences of rehospitalization or ED/OBS visit within 30 days of hospital discharge.

RESULTS

Most rehospitalizations and ED/OBS visits occurred within 14 days from hospital discharge. Patients who returned within 24 hours came mostly from inpatient rehabilitation facilities (IRFs). More intense levels of PAC services were linked with higher rehospitalization risk. However, specific predictors differed by discharge location. Being unemployed, being single, and having more comorbidities were most associated with rehospitalization in those who went home with or without services, whereas patients rehospitalized from IRFs were younger, with less chronic illness burden, but greater and recent functional decline. Those discharged with HHC services had more return ED/OBS visits.

CONCLUSIONS

Although sicker patients were referred for more intense levels of PAC services, patients with greater chronic illness burden were still most often rehospitalized. In addition to unique patient differences, rehospitalizations from IRF within 24 hours suggest systems factors are contributory. Most return acute healthcare utilization occurred within 14 days; therefore, interventions should focus on smoothing transitions to all discharge locations. Because predictors of rehospitalization risk differed by discharge disposition, future research is necessary to study approaches aimed at matching patients' care needs with the most suitable PAC services at the right time. J Am Geriatr Soc 68:2279-2287, 2020.

Risk factors for infection in home health care: Analysis of national Outcome and Assessment Information Set data

Patients in home health care (HHC), a rapidly growing healthcare sector, are at high risk for infections. This study aimed to identify risk factors for infections among HHC patients using the Outcome and Assessment Information Set (OASIS) data. We used a 5% random sample of the 2013 national OASIS data. Infections were identified if records indicated that patients were hospitalized or received emergency care for one of three types of infections (respiratory, wound site, and urinary tract infection). Multivariate logistic regression models were used to identify risk factors for each individual infection type. The final analysis included 128,163 patients from 8,255 HHC agencies nationwide. Approximately 3.2% of the patients developed infections during their HHC stay that led to hospitalization or emergency care treatment. We found that associations between demographics and infection risk are specific to the type of infection. In general, a history of multiple hospitalizations in past 6 months, comorbidity, having a severe condition at HHC admission, and impaired physical functioning increased HHC patients' risk of infections. We also identified that HHC patients with caregivers who needed training in providing medical procedure or treatment are at higher risk for wound-site infections. Our findings suggest that patients with underlying medical conditions and limited physical function status are more likely to develop infection. The caregiver's lack of training in providing needed care at home also places HHC patients at high risk for infection. Education for patients and caregivers should be tailored based on their health literacy level to ensure complete understanding.

Functional outcome in home health: Do racial and ethnic minority patients with dementia fare worse?

Objectives

Evaluate the independent and interactive effects of dementia and racial/ethnic minority status on functional outcomes during a home health (HH) admission among Medicare beneficiaries.

Methods

Secondary analysis of data from the Outcome and Assessment Information Set [OASIS] and billing records in a non-profit HH agency in New York. Participants were adults ≥ 65 years old who received HH in CY 2017 with OASIS records at HH admission and HH discharge. Dementia was identified by diagnosis (ICD-10 codes) and cognitive impairment (OASIS: M1700, M1710, M1740). We used OASIS records to assess race/ethnicity (M0140) and functional status (M1800-M1870 on activities of daily living [ADL]). Functional outcome was measured as change in the composite ADL score from HH admission to HH discharge, where a negative score means improvement and a positive score means decline.

Results

The sample included 4,783 patients, among whom 93.9% improved in ADLs at HH discharge. In multivariable linear regression that adjusted for HH service use and covariates (R² = 0.23), being African American (β = 0.21, 95% confidence interval [CI]: 0.06, 0.35, p = 0.005) and having dementia (β = 0.51, 95% CI: 0.41, 0.62, p<0.001) were independently related to less ADL improvement at HH discharge, with significant interaction related to further decrease in ADL improvement. Relative to white patients without dementia, African American patients with dementia (β = 1.08, 95% CI: 0.81, 1.35, p<0.001), Hispanics with dementia (β = 0.92, 95% CI: 0.38, 1.47, p = 0.001) and Asian Americans with dementia (β = 1.47, 95% CI: 0.81, 2.13, p<0.001) showed the least ADL improvement at HH discharge.

Conclusion

Racial/ethnic minority status and dementia were associated with less ADL improvement in HH with independent and interactive effects. Policies should ensure that these patients have equitable access to appropriate, adequate community-based services to meet their needs in ADLs and disease management for improved outcomes.

Skilled Nursing Facility Patients Discharged to Home Health Agency Services Spend More Days at Home

OBJECTIVES

To investigate the association of the utilization of Medicare-certified home health agency (CHHA) services with post-acute skilled nursing facility (SNF) discharge outcomes that included home time, rehospitalization, SNF readmission, and mortality.

DESIGN

Retrospective cohort study.

SETTING

New York State fee-for-service Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care and discharged to the community in 2014.

PARTICIPANTS

A total of 25,357 older adults.

MEASUREMENTS

The outcomes included days spent alive in the community ("home time"), rehospitalization, SNF readmission, and mortality within 30- and 90-day post-SNF discharge periods. The primary independent variables were SNF five-star overall quality rating and receipt of CHHA services within 7 days of SNF discharge. Zero-inflated negative binomial regression and logistic regression models characterized the association of CHHA linkage with home time and other outcomes, respectively.

RESULTS

Following SNF discharge, 17,657 (69.6%) patients received CHHA services. In analyses that adjusted for patient-, market-, and other SNF-level factors, older adults discharged from higher quality SNFs were more likely to receive CHHA services. In analyses that adjusted for patient- and market-level factors, receipt of post-SNF CHHA services was associated with 2.03 and 4.17 (P < .001) more days in the community over 30- and 90-day periods. Receiving CHHA services was also associated with decreased odds for rehospitalization (odds ratio [OR] = .68; P < .001; OR = .91; P = .008), SNF readmission (OR = .36; P < .001; OR = .62; P < .001), and death (OR = .34; P < .001; OR = .63; P < .001) over 30- and 90-day periods, respectively.

CONCLUSION

Among older adults discharged from a post-acute SNF stay, those who received CHHA services had better discharge outcomes. They were less likely to experience admissions to institutional care settings and had a lower mortality risk. Future efforts that examine how the type and intensity of CHHA services affect outcomes would build on this work. J Am Geriatr Soc 68:1573-1578, 2020.

The contribution of hospital-based home health services in pulmonary diseases: Current Practice in Turkey

BACKGROUND

The medical management of chronic respiratory diseases becomes more difficult with the increase in the rate of the elderly population. Monitoring and treating chronic respiratory diseases at home are more comfortable for both the patient and their relatives. Therefore, countries need to develop policies regarding home health services (HHS) according to the state of their social, cultural, and financial infrastructure.

OBJECTIVE

The objective of this study is to show the role and contribution of hospital-based HHS regarding respiratory disorders, and to evaluate the model and its efficiency.

STUDY DESIGN

The design of this study was cross-sectional. Data were obtained from the Ministry of Health of Turkey with official permission. Data were collected for HHS concerning respiratory diseases between 2011 and 2017. Age and sex distribution, the number of recorded patients, the number of visits for pulmonary diseases, the distribution of institutional visits, and the quantitative alterations within the years were investigated.

STUDY POPULATION

The study population was based on patients with respiratory disorders who were given HHS as directed by the Ministry of Health of Turkey.

RESULTS

Between 2011 and 2017, the majority of patients with pulmonary diseases, mostly those with chronic obstructive pulmonary disease, asthma, and lung cancer, visited government hospitals (78%). The number of house visits concerning pulmonary disorders increased nearly ten times, but hospitalization due to respiratory diseases decreased (13.5% in 2011 to 12.9% in 2017).

CONCLUSION

Hospital-based HHS in pulmonary diseases can be considered as an appropriate model for implementation for countries like Turkey, those that have inadequate hospice-type health service infrastructure.

Quantitative thresholds based decision support approach for the home health care scheduling and routing problem

In the domain of Home Health Care (HHC), precise decisions regarding patient's selection, staffing level, and scheduling of health care staff have a significant impact on the efficiency and effectiveness of the HHC system. However, decentralized planning, the absence of well defined decision rules, delayed decisions and lack of interactive tools typically lead towards low satisfaction level among all the stakeholders of the HHC system. In order to address these issues, we propose an integrated three phase decision support methodology for the HHC system. More specifically, the proposed methodology exploits the structure of the HHC problem and logistic regression based approaches to identify the decision rules for patient acceptance, staff hiring, and staff utilization. In the first phase, a mathematical model is constructed for the HHC scheduling and routing problem using Mixed-Integer Linear Programming (MILP). The mathematical model is solved with the MILP solver CPLEX and a Variable Neighbourhood Search (VNS) based method is used to find the heuristic solution for the HHC problem. The model considers the planning concerns related to compatibility, time restrictions, distance, and cost. In the second phase, Bender's method and Receiver Operating Characteristic (ROC) curves are implemented to identify the thresholds based on the CPLEX and VNS solution. While the third phase creates a fresh solution for the HHC problem with a new data set and validates the thresholds predicted in the second phase. The effectiveness of these thresholds is evaluated by utilizing performance measures of the widely-used confusion matrix. The evaluation of the thresholds shows that the ROC curves based thresholds of the first two parameters achieved 67% to 71% accuracy against the two considered solution methods. While the Bender's method based thresholds for the same parameters attained more than 70% accuracy in cases where probability value is small (p ≤ 0.5). The promising results indicate that the proposed methodology is applicable to define the decision rules for the HHC problem and beneficial to all the concerned stakeholders in making relevant decisions.

Impact of a home health care program for disabled patients in Taiwan: A nationwide population-based cohort study

The aim of this study was to evaluate the impact of home health care (HHC) for disabled patients.We conducted a nationwide population-based retrospective cohort study. A total of 5838 disabled patients with HHC were identified to match by propensity score with 15,829 disabled patients without HHC receiving tube or catheter care (tracheostomy tube, nasogastric tube, urinary catheter, cystostomy tube, nephrostomy tube) or stage 3 or 4 pressure sore care from the Taiwanese National Health Insurance Research Database between 2005 and 2009. After 1:1 matching, 2901 subjects in the HHC group and 2901 subjects in the non-HHC group were selected and analyzed. Generalized estimating equations (GEEs) were used to compare the risk of health outcomes (rate of hospitalization and emergency services use) and the healthcare expenditure between the 2 groups.Compared to those in the non-HHC group, the patients in the HHC group had significantly higher risk for hospitalization (odds ratio [OR] = 18.43, 95% confidence interval [CI]: 15.62-21.75, P < .001) and emergency services use (OR = 3.72, 95% CI: 3.32-4.17, P < .001) 1 year before the index date. However, 1 year after the index date, the risk for hospitalization (OR = 1.6, 95% CI: 1.41-1.83, P < .001) and emergency services use (OR = 1.16, 95% CI: 1.04-1.30, P < .05) attenuated significantly. Regarding the comparison of total healthcare expenditure 1 year before and after the index date, our study showed an insignificant decrease of US$1.5 per person per day and a significant increase of US$5.2 per person per day (P < .001) in the HHC and non-HHC groups, respectively.The HHC for disabled patients has a potential role to reduce hospitalization and emergency services use. Besides, the improvement of healthcare quality through HHC was not accompanied by increased healthcare expenditure. The clinical impact of HHC emphasizes the importance for public health officials to promote HHC model to meet the needs of disabled patients.

Changes in vulnerability among older patients with cardiovascular disease in the first 90 days after hospital discharge: A secondary analysis of a cohort study

OBJECTIVES

(1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period.

DESIGN

Secondary analysis of longitudinal data from a cohort study.

PARTICIPANTS AND SETTING

834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121).

OUTCOME

Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching.

RESULTS

Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year.

CONCLUSION

After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge.

Inverse Dose-Response Relationship Between Home Health Care Services and Rehospitalization in Older Adults

OBJECTIVES

(1) To examine the impact of specific services [skilled nursing (SN), physical therapy (PT), occupational therapy (OT), and home health aide (HA)] in Medicare-certified home health care (HHC) on subsequent rehospitalization among older patients during a 60-day HHC episode and (2) to test the moderating effect of functional limitation on these services.

DESIGN

Secondary analysis of data from the Outcome and Assessment Information Set (OASIS) and HHC administrative records of a statewide not-for-profit HHC agency from January 1, 2016, to December 31, 2016.

SETTING AND PARTICIPANTS

Participants were ≥65 years old and were admitted to HHC within 48 hours of hospital discharge.

MEASURES

Outcome was time to rehospitalization during the 60-day HHC episode (ie, number of days). Independent variables were visit intensity (number of visits/week) of SN, PT, OT, and HA, respectively. Functional limitation was measured by a composite score generated from 9 OASIS items on physical function. Multivariate Cox Proportional hazard analyses were conducted. Subgroup analysis (high vs low functional limitation) was conducted to examine the moderating effect of functional limitation on specific HHC services. Ad hoc analysis was conducted to examine potential interaction between specific HHC services that were significantly related to rehospitalization.

RESULTS

The sample included 1377 participants, among whom 11.5% were rehospitalized during the 60-day HHC episode. At the threshold dose of 1 PT or 2 SN visits/week, higher visit intensity significantly reduced the hazard of rehospitalization in these patients by up to 82% for PT (2.30 visits/week; hazard ratio [HR] = 0.18, P value < .001) and 48% for SN visits (2.51 visits/week; HR = 0.52, P value < .05). The effect of PT on reducing the risk of rehospitalization was more pronounced in patients with low versus high functional limitation (2.30 visits/week, HR = 0.08 vs 0.24, both P < .001). SN was only effective in reducing the hazard of rehospitalization in the low functional limitation group (1.70 visits/week, HR = 0.41, P < .05; 2.51 visits/week, HR = 0.29, P < .05), but not in the high functional limitation group (P > .05 at all intensity levels). Visit intensity of HA or OT was not significantly related to rehospitalization.

CONCLUSIONS/RELEVANCE

At a threshold of 1 PT visit or 2 SN visits/week, HHC lowered the risk of rehospitalization in older patients by up to 82% and 48%, respectively. Both PT and SN were more effective in avoiding rehospitalization in patients with low functional limitation than in those with high functional limitation. Older patients should receive enough HHC services (especially PT and SN) to avoid rehospitalizations with consideration of their functional limitation.

Exploration of the administrative aspects of the delivery of home health care services: a qualitative study

BACKGROUND

Because of the variety of services and resources offered in the delivery of home health care, its management is a challenging and difficult task.

OBJECTIVES

The purpose of this study was to explore the administrative aspects of the delivery of home health care services.

METHODS

This qualitative study was conducted based on the traditional content analysis approach in 2015 in Iran. The participants were selected using the purposeful sampling method and data were collected through in-depth semi-structured personal interviews and from discussions in a focus group. The collected data were analyzed using the Lundman and Graneheim method.

RESULTS

23 individuals participated in individual interviews, and the collected data were categorized into the two main themes of policymaking and infrastructures, each of which consisted of some subcategories.

CONCLUSION

Health policymakers could utilize the results of this study as baseline information in making decisions about the delivery of home health care services, taking into account the contextual dimensions of home care services, leading to improvements in home health care services.