Do delays in initiation of home healthcare services following hospital discharge affect patient outcomes?

Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care

STUDY AIM

This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach.

BACKGROUND

Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described.

METHODS

We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements.

RESULTS

We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC.

CONCLUSION

This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study.

APPLICATION

We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Using the Outcome and Assessment Information Set to Measure Patient Health Status in Research: A Systematic Review

OBJECTIVES

To review, evaluate, and synthesize existing literature on how health status changes were measured using the Outcome and Assessment Information Set (OASIS).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Studies were included if they examined the health status of adult patients at 2 or more time points using OASIS, which is a comprehensive assessment tool mandated for home health (HH) patients.

METHODS

A systematic search was conducted in PubMed, CINAHL, Embase, and Scopus. The methodological quality of the included studies was appraised using the National Institutes of Health quality assessment tool.

RESULTS

The initial search yielded 1587 citations, resulting in 27 eligible studies published between 2005 and 2022. All included studies were retrospective cohort studies, with overall quality ranging from good to fair. These studies primarily targeted patients with heart failure, with sample sizes between 40 and 6,637,497 and mean ages of 61.2 to 82.4 years. OASIS version C was the most used version, comparing health status at admission and discharge. Patient health status outcomes encompassed functional (n = 24), physiological (n = 6), emotional/behavioral (n = 4), and cognitive (n = 2) outcomes. Various techniques were employed for scale standardization, compositing individual scores, measuring changes, and reporting outcomes. The predominant methods for assessing change included the corrected Likert scale for standardization, composite change scores for change calculation, and continuous outcomes for reporting.

CONCLUSION AND IMPLICATIONS

Researchers have used OASIS to assess patient health status changes in functional, physiological, emotional/behavioral, and cognitive outcomes during the HH episode. Variations in OASIS items and assessment methods across studies have been observed. Our findings underscore the need to standardize item application in research, enabling researchers to synthesize evidence effectively and enhance understanding of patient recovery and HH services. For policymakers and health care providers, these insights could inform resource allocation, care planning, and tailored interventions, ultimately improving health care quality and efficiency.

Association Between Hospital Participation in Value-Based Programs and Timely Initiation of Post-Acute Home Health Care, Functional Recovery, and Hospital Readmission After Joint Replacement

OBJECTIVES

This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission.

METHOD

This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission.

RESULTS

Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20-1.26), mobility (OR = 1.15; 95% CI = 1.13-1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15-1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13-1.20) and mobility (OR = 1.26; 95% CI = 1.22-1.30) for hip replacement.

CONCLUSION

Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission.

IMPACT

Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models.

Home health services for minorities in urban and rural areas with Alzheimer's and related dementia

Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.

Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD)

INTRODUCTION

We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD).

METHODS

Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge.

RESULTS

Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA.

DISCUSSION

Black patients are more likely to experience a delay in home health care initiation than White patients.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults

Importance

Home health care is one of the fastest growing postacute services in the US and is increasingly important in the era of coronavirus disease 2019 and payment reform, yet it is unknown whether patients who need home health care are receiving it.

Objective

To examine how often patients referred to home health care at hospital discharge receive it and whether there is evidence of disparities.

Design, Setting, and Participants

This cross-sectional study used Medicare data regarding the postacute home health care setting from October 1, 2015, through September 30, 2016. The participants were Medicare fee-for-service and Medicare Advantage beneficiaries who were discharged alive from a hospital with a referral to home health care (2 379 506 discharges). Statistical analysis was performed from July 2019 to June 2020.

Exposures

Hospital referral to home health care.

Main Outcomes and Measures

Primary outcomes included whether discharges received their first home health care visit within 14 days of hospital discharge and the number of days between hospital discharge and the first home health visit. Differences in the likelihood of receiving home health care across patient, zip code, and hospital characteristics were also examined.

Results

Among 2 379 506 discharges from the hospital with a home health care referral, 1 358 697 patients (57.1%) were female, 468 762 (19.7%) were non-White, and 466 383 (19.6%) were dually enrolled in Medicare and Medicaid; patients had a mean (SD) age of 73.9 (11.9) years and 4.1 (2.1) Elixhauser comorbidities. Only 1 284 300 patients (54.0%) discharged from the hospital with a home health referral received home health care services within 14 days of discharge. Of the remaining 1 095 206 patients (46.0%) discharged, 37.7% (896 660 discharges) never received any home health care, while 8.3% (198 546 discharges) were institutionalized or died within 14 days without a preceding home health care visit. Patients who were Black or Hispanic received home health at lower rates than did patients who were White (48.0% [95% CI, 47.8%-48.1%] of Black and 46.1% [95% CI, 45.7%-46.5%] of Hispanic discharges received home health within 14 days compared with 55.3% [95% CI, 55.2%-55.4%] of White discharges). In addition, disadvantaged patients waited longer for their first home health care visit. For example, patients living in high-unemployment zip codes waited a mean of 2.0 days (95% CI, 2.0-2.0 days), whereas those living in low-unemployment zip codes waited 1.8 days (95% CI, 1.8-1.8 days).

Conclusions and Relevance

Disparities in the use of home health care remain an issue in the US. As home health care is increasingly presented as a safer alternative to institutional postacute care during coronavirus disease 2019, and payment reforms continue to pressure hospitals to discharge patients home, ensuring the availability of safe and equitable care will be crucial to maintaining high-quality care.

Hospitalization Among Medicare-Reimbursed Skilled Home Health Recipients

This article presents a summary and critique of the published empirical evidence between the years 2002 and 2011 regarding rehospitalization among Medicare-reimbursed, skilled home health recipients. The knowledge gained will be applied to a discussion regarding ACH among geriatric home health recipients and areas for future research. The referenced literature in MEDLINE, PubMed and Cochrane databases was searched using combinations of the following search terms: home care and home health and Medicare combined with acute care hospitalization, rehospitalization, hospitalization, and adverse events and limited to studies conducted in the United States. Twenty-five research studies published in the last eight years investigated hospitalization among patients receiving Medicare-reimbursed, skilled home health. Empirical findings indicate telehomecare can reduce hospitalizations and emergency room use. The identification of risk factors for hospitalization relate to an elder's sociodemographic, clinical and functional status that can be identified upon admission and interventions taken in order to reduce hospitalizations. Disease management, frontloading nurse visits, the structure of home health services and OBQI are also among the interventions identified to reduce hospitalizations. However, the body of evidence is limited by a paucity of research and the over reliance on small sample sizes. Few published studies have explored methods that effectively reduce hospitalization among Medicare-reimbursed skilled home health recipients. Further research is needed to clarify the most effective ways to structure home health services to maximize benefits and reduce hospitalization among this chronically ill geriatric population.