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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home. J Am Med Dir Assoc 2024; 25:138-145.e6. [PMID: 37913819 PMCID: PMC10843747 DOI: 10.1016/j.jamda.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester-Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA
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Wang J, Shen JY, Conwell Y, Yu F, Nathan K, Heffner KL, Li Y, Caprio TV. Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes. J Am Geriatr Soc 2023; 71:3768-3779. [PMID: 37671461 PMCID: PMC10841208 DOI: 10.1111/jgs.18555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/07/2023] [Accepted: 07/26/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Antipsychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of antipsychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD. METHODS In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analyzed using logistic (predictors) and linear regression (association with outcome) analyses. RESULTS The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioral and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, antipsychotic use was associated with having less ADL improvement at HHC discharge (β = -0.70, p < 0.001). CONCLUSIONS HHC patients living with ADRD were more likely to use antipsychotics and to experience worse functional outcomes when using antipsychotics. Antipsychotics should be systematically reviewed and, if contraindicated or unnecessary, deprescribed. Efforts are needed to improve HHC patients' access to nonpharmacological interventions and to provide education for caregivers regarding behavioral approaches to manage symptoms in ADRD.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York, USA
| | - Kathi L Heffner
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Home Care, Rochester, New York, USA
- Finger Lakes Geriatric Education Center, Rochester, New York, USA
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks. Clin Ther 2023; 45:947-956. [PMID: 37640614 PMCID: PMC10841554 DOI: 10.1016/j.clinthera.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC. METHODS A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping. FINDINGS Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication. IMPLICATIONS Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Kobi Nathan
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
| | - Thomas V Caprio
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; University of Rochester Home Care, University of Rochester Medical Center, Rochester, New York; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, New York
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Wang J, Shen JY, Yu F, Conwell Y, Nathan K, Shah AS, Simmons SF, Li Y, Ramsdale E, Caprio TV. Medications Associated With Geriatric Syndromes (MAGS) and Hospitalization Risk in Home Health Care Patients. J Am Med Dir Assoc 2022; 23:1627-1633.e3. [PMID: 35490716 PMCID: PMC9547843 DOI: 10.1016/j.jamda.2022.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/18/2022] [Accepted: 03/20/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Polypharmacy is common in home health care (HHC). This study examined the prevalence of medications associated with geriatric syndromes (MAGS), its predictors, and association with subsequent hospitalization in HHC. DESIGN Analysis of HHC electronic medical records, the Outcome and Assessment Information Set (OASIS), and Medicare HHC claims. SETTING AND PARTICIPANTS A total of 6882 adults ≥65 years old receiving HHC in 2019 from a large, not-for-profit home health agency serving multiple counties in New York State. MEASURES MAGS use was identified from active medications reconciled during HHC visits (HHC electronic medical records). MAGS use was operationalized as count and in quartiles. Hospitalization during the HHC episode was operationalized as a time-to-event variable (ie, number of days from HHC admission to hospitalization). We used regression analyses to identify predictors of MAGS use, and survival analyses to examine the association between MAGS and hospitalization. RESULTS Nearly all (98%) of the HHC patients used at least 1 MAGS and 41% of all active medications used by the sample were MAGS. More MAGS use was found in HHC patients who were community-referred, taking more medications, and having more diagnoses, depressive symptoms, and functional limitations. Adjusted for covariates, higher MAGS quartiles were not independently associated with the risk of hospitalization, but higher MAGS quartiles combined with multimorbidity (ie, having ≥10 diagnoses) were associated with a 2.3-fold increase in hospitalization risk (hazard ratio 2.24; 95% confidence interval: 1.61-3.13; P < .001), relative to the lowest quartile of MAGS use and having <10 diagnoses. CONCLUSIONS AND IMPLICATIONS More than 40% of medications taken by HHC patients are MAGS. Multimorbidity and MAGS use collectively increased the risk of hospitalization by up to 2.3 times. HHC clinicians should carefully review patients' medications and use information about MAGS to facilitate discussion about deprescribing with patients and their prescribers.
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Affiliation(s)
- Jinjiao Wang
- Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA
| | - Jenny Y Shen
- University of Rochester Medical Center, Department of Medicine, Rochester, NY, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
| | - Yeates Conwell
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; St. John Fisher College, Wegmans School of Pharmacy, Rochester, NY, USA
| | - Avantika S Shah
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN, USA
| | - Sandra F Simmons
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Erika Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester Medical Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
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Chae S, Song J, Ojo M, Bowles KH, McDonald MV, Barrón Y, Hobensack M, Kennedy E, Sridharan S, Evans L, Topaz M. Factors associated with poor self-management documented in home health care narrative notes for patients with heart failure. Heart Lung 2022; 55:148-154. [PMID: 35597164 PMCID: PMC11021173 DOI: 10.1016/j.hrtlng.2022.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 05/03/2022] [Accepted: 05/07/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with heart failure (HF) who actively engage in their own self-management have better outcomes. Extracting data through natural language processing (NLP) holds great promise for identifying patients with or at risk of poor self-management. OBJECTIVE To identify home health care (HHC) patients with HF who have poor self-management using NLP of narrative notes, and to examine patient factors associated with poor self-management. METHODS An NLP algorithm was applied to extract poor self-management documentation using 353,718 HHC narrative notes of 9,710 patients with HF. Sociodemographic and structured clinical data were incorporated into multivariate logistic regression models to identify factors associated with poor self-management. RESULTS There were 758 (7.8%) patients in this sample identified as having notes with language describing poor HF self-management. Younger age (OR 0.982, 95% CI 0.976-0.987, p < .001), longer length of stay in HHC (OR 1.036, 95% CI 1.029- 1.043, p < .001), diagnosis of diabetes (OR 1.47, 95% CI 1.3-1.67, p < .001) and depression (OR 1.36, 95% CI 1.09-1.68, p < .01), impaired decision-making (OR 1.64, 95% CI 1.37-1.95, p < .001), smoking (OR 1.7, 95% CI 1.4-2.04, p < .001), and shortness of breath with exertion (OR 1.25, 95% CI 1.1-1.42, p < .01) were associated with poor self-management. CONCLUSIONS Patients with HF who have poor self-management can be identified from the narrative notes in HHC using novel NLP methods. Meaningful information about the self-management of patients with HF can support HHC clinicians in developing individualized care plans to improve self-management and clinical outcomes.
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Affiliation(s)
- Sena Chae
- College of Nursing, University of Iowa, 50 Newton Rd, Iowa City, IA 52242, United States.
| | - Jiyoun Song
- Columbia University School of Nursing, New York, NY, United States
| | - Marietta Ojo
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, United States
| | - Kathryn H Bowles
- Department of Biobehavioral Health Sciences Philadelphia PA, Center for Home Care Policy & Research, University of Pennsylvania School of Nursing, Visiting Nurse Service of New York, New York, NY, United States
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, United States
| | - Yolanda Barrón
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, United States
| | - Mollie Hobensack
- Columbia University School of Nursing, New York, NY, United States
| | - Erin Kennedy
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, United States
| | - Sridevi Sridharan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, United States
| | - Lauren Evans
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, United States
| | - Maxim Topaz
- Center for Home Care Policy & Research, Columbia University School of Nursing, Data Science Institute, Columbia University, Visiting Nurse Service of New York, New York, NY, United States
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Wang J, Ying M, Li Y. Home Health Agencies With More Socially Vulnerable Patients Have Poorer Experience of Care Ratings. J Appl Gerontol 2021; 41:661-670. [PMID: 34937402 DOI: 10.1177/07334648211053859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Examine the relationships between dual eligibility and race/ethnicity characteristics of Medicare-Certified Home Health Agencies (CHHAs) and experience of care ratings. METHODS Analysis of 2017 national Consumer Assessment of Healthcare Providers and Systems and matched datasets of 10,906 CHHAs. RESULTS CHHAs with higher concentrations of dual-eligible patients were less likely to have high experience of care ratings for all three domains (e.g., for care delivery, quartile 4 vs. 1: odds ratio [OR] = 0.622, p < .001); CHHAs with higher concentrations of racial/ethnic minorities generally were less likely to have high experience of care ratings in care delivery (e.g., Black: quartile 4 vs. 1: OR = 0.418, p<0.001), communication (e.g., Black: quartile 4 vs. 1: OR = 0.316, p<0.001), and specific care issues (e.g., Hispanic: quartile 4 vs. 1: OR = 0.397, p < .001). DISCUSSION CHHAs with greater concentrations of dual-eligible patients and racial/ethnic minorities were more likely to have poor experience of care ratings.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, NY, USA
| | - Meiling Ying
- Department of Public Health Sciences, University of Rochester, NY, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, NY, USA
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Niculescu I, Arora T, Iaboni A. Screening for depression in older adults with cognitive impairment in the homecare setting: a systematic review. Aging Ment Health 2021; 25:1585-1594. [PMID: 32677506 DOI: 10.1080/13607863.2020.1793899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Previous systematic reviews have examined depression screening in older adults with cognitive impairment (CI) in outpatient and inpatient clinics, nursing homes, and residential care. Despite an increasing number of older adults with CI receiving care in their homes, less is known about best depression screening practices in homecare. The objective of this review is to identify evidence-based practices for depression screening for individuals with CI receiving homecare by assessing tool performance and establishing the current evidence for screening practices in this setting. METHODS This review is registered under PROSPERO (ID: CRD42018110243). A systematic search was conducted using MEDLINE, EMBASE, Health and Psychosocial Abstracts, PsycINFO and CINAHL. The following criteria were used: assessment of depression at home in older adults (>55 years) with CI, where performance outcomes of the depression screening tool were reported. RESULTS Of 5,453 studies, only three met eligibility criteria. These studies evaluated the Patient Health Questionnaire (n = 236), the Geriatric Depression Scale (n = 79) and the Mental Health Index (n = 1,444) in older adults at home with and without CI. Psychometric evaluation demonstrated moderate performance in the subsamples of people with CI. CONCLUSION At present, there is insufficient evidence to support best practices in screening for depression in people with CI in homecare.
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Affiliation(s)
- Iulia Niculescu
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Rehabilitation Sciences, University of Toronto, Toronto, Canada
| | - Twinkle Arora
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Andrea Iaboni
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Rehabilitation Sciences, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
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Wang J, Ying M, Temkin-Greener H, Caprio TV, Yu F, Simning A, Conwell Y, Li Y. Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care. J Am Geriatr Soc 2021; 69:1231-1239. [PMID: 33394506 PMCID: PMC8127345 DOI: 10.1111/jgs.17005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services. DESIGN Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File. SETTING AL facilities and Medicare HH agencies in the United States. PARTICIPANTS 741,926 Medicare HH admissions of AL residents in 2017. MEASUREMENTS Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission. RESULTS Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)). CONCLUSION For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.
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Affiliation(s)
| | - Meiling Ying
- University of Rochester, Department of Public Health Sciences, NY
| | | | - Thomas V. Caprio
- University of Rochester Medical Center, Department of Medicine, NY
- University of Rochester Medical Home Care, NY
- Finger Lakes Geriatric Education Center, NY
| | - Fang Yu
- Arizona State University, College of Nursing and Health Innovation, AZ
| | - Adam Simning
- University of Rochester, Department of Public Health Sciences, NY
- University of Rochester Medical Center, Department of Psychiatry, NY
| | - Yeates Conwell
- University of Rochester Medical Center, Department of Psychiatry, NY
| | - Yue Li
- University of Rochester, Department of Public Health Sciences, NY
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Wang J, Yu F, Cai X, Caprio TV, Li Y. Functional outcome in home health: Do racial and ethnic minority patients with dementia fare worse? PLoS One 2020; 15:e0233650. [PMID: 32453771 PMCID: PMC7250428 DOI: 10.1371/journal.pone.0233650] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/09/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Jinjiao Wang
- School of Nursing, University of Rochester, Rochester, NY, United States of America
- * E-mail:
| | - Fang Yu
- School of Nursing, University of Minnesota, Minneapolis, MN, United States of America
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States of America
| | - Thomas V. Caprio
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
- University of Rochester Medical Home Care, Rochester, NY, United States of America
- Finger Lakes Geriatric Education Center, Rochester, NY, United States of America
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, NY, United States of America
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Martínez-Linares JM, Andújar-Afán FA, Martínez-Yébenes R, López-Entrambasaguas OM. A Qualitative View of Homecare Support Workers on Unmet Health Needs of People with Dependency. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093166. [PMID: 32370123 PMCID: PMC7246884 DOI: 10.3390/ijerph17093166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 11/16/2022]
Abstract
Background: Longevity and population growth generate an increase in the number of people with dependency, who require homecare assistance to meet their health needs. Homecare support workers provide this care in Spain, and they may have unique insights into the unmet health needs of those receiving homecare assistance. The aim of this study was to determine the unmet health needs of people with dependency based on the perspective of homecare support workers. Methods: Qualitative exploratory-descriptive study. Through convenience sampling, homecare support workers from a Spanish province were selected, following inclusion and exclusion criteria. Four focus groups, transcription and thematic analyses were performed using Atlas.ti. Coding triangulation was carried out, applying criteria for scientific rigour. Results: The six themes obtained were classified into the material, psychoemotional, socioeconomical and psychosocial needs of people with dependency from the point of view of homecare support workers, along with the contributions of improvements and the need of these professionals for continuous training. Conclusions: People with dependency need complex technical assistance, materials, psychological attention due to their situation, and more effective assessments of their health and disability status. Homecare support workers perceive themselves to be essential in these assessments. They ask for psychological assistance, due to the emotional burden of their work, and believe this help would contribute to improving the quality of their service. Homecare support workers perceive that they are capable of performing their job, although they believe that some delegated activities are beyond their levels of competency.
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Wang J, Caprio TV, Simning A, Shang J, Conwell Y, Yu F, Li Y. Association Between Home Health Services and Facility Admission in Older Adults With and Without Alzheimer's Disease. J Am Med Dir Assoc 2019; 21:627-633.e9. [PMID: 31879184 DOI: 10.1016/j.jamda.2019.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/24/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To evaluate the association between home health (HH) services, including skilled nursing (SN), physical therapy (PT), occupational therapy, social work (SW), and homemaking aide assistance with the hazard of unplanned facility admissions among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). DESIGN Analysis of the Outcome and Assessment Information Set and billing records. SETTING A not-for-profit HH agency serving multiple counties in New York State. PARTICIPANTS Adults ≥65 years old who received HH from January 1, 2017 to December 31, 2017. MEASURES Outcome was time from HH start of care to an unplanned facility admission of any type, including the hospital, nursing home, and rehabilitation facility. Independent variables included weekly intensity (visits/week, hours/week) of SN, PT, occupational therapy, SW, and, homemaking aide assistance separately. ADRD was identified by diagnosis (International Classification of Diseases, Tenth Revision codes in billing records) and cognitive impairment assessment (Outcome and Assessment Information Set). RESULTS Of the sample (N = 6153), 14.9% had an unplanned facility admission. In multivariable Cox proportional hazard models that adjusted for time-varying effects of HH intensity and covariates, receiving the highest intensity of SN (3.3 visits of 2.78 hours per week) and PT (2.5 visits of 2 hours per week) was related to up to a 54% and 86% decrease, respectively, in the hazard of unplanned facility admission among patients with ADRD (n = 1525), and decreases of 56% and 90%, respectively, among patients without ADRD (n = 4628). Receiving any SW was related to 40% decreased in the hazard of facility admission in patients without ADRD only. Other HH services were not consistently related to the risk of facility admission. CONCLUSIONS AND IMPLICATIONS Receiving a higher intensity of SN and PT was associated with reduced hazards of unplanned facility admission among HH patients with and without ADRD. Policies should ensure that patients with ADRD receive a sufficient amount and appropriate mix of HH services.
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Affiliation(s)
- Jinjiao Wang
- School of Nursing, University of Rochester, Rochester, NY.
| | - Thomas V Caprio
- Department of Medicine, University of Rochester Medical Center, Rochester, NY; University of Rochester Medical Home Care, Rochester, NY; Finger Lakes Geriatric Education Center, NY
| | - Adam Simning
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | | | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Fang Yu
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, NY
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Wang J, Liebel DV, Yu F, Caprio TV, Shang J. Inverse Dose-Response Relationship Between Home Health Care Services and Rehospitalization in Older Adults. J Am Med Dir Assoc 2018; 20:736-742. [PMID: 30579919 DOI: 10.1016/j.jamda.2018.10.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Jinjiao Wang
- University of Rochester, School of Nursing, Rochester, NY.
| | | | - Fang Yu
- University of Minnesota, School of Nursing, Minneapolis, MN
| | - Thomas V Caprio
- University of Rochester Medical Center, Rochester, NY; University of Rochester Medical Home Care, Rochester, NY; Finger Lakes Geriatric Education Center, Rochester, NY
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