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Che RP, Cheung MC. Factors Associated with the Utilization of Home and Community-Based Services (HCBS) Among Older Adults: A Systematic Review of the Last Decade. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2024:1-27. [PMID: 38616618 DOI: 10.1080/01634372.2024.2342455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
Home and community-based services (HCBS) for older adults have been promoted worldwide to address the growing problems of aging. This systematic review included 59 studies published from 2013 to 2023 to explore factors influencing the utilization of HCBS among older adults. The review identified 15 common factors grouped into four levels of influence: individual, inter-relationship, community, and social contextual levels. The findings suggest that HCBS utilization is a dynamic process influenced by multiple factors at different levels. Gerontological social work should incorporate ecological thinking to improve practice and strengthen caregiver-recipient relationships.
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Affiliation(s)
- Run-Ping Che
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Mei-Chun Cheung
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong SAR, China
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Kimmey L, Wysocki A, Forrow LV, Anderson M, Nyweide DJ. Effects of Home-Based Primary Care on Hospital Use for High-Need Medicare Patients: an Observational Study. J Gen Intern Med 2024; 39:19-26. [PMID: 37526814 PMCID: PMC10817875 DOI: 10.1007/s11606-023-08328-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND High-need, high-cost Medicare patients can have difficulties accessing office-based primary care. Home-based primary care (HBPC) can reduce access barriers and allow a clinician to obtain valuable information not obtained during office visit, possibly leading to reductions in hospital use. OBJECTIVE To determine whether HBPC for high-need, high-cost patients reduces hospitalizations and Medicare inpatient expenditures. DESIGN We conducted a matched retrospective cohort study using a difference-in-differences analysis to examine patients 2 years before and 2 years after their first home visit (HBPC group). PARTICIPANTS The study included high-need, high-cost fee-for-service Medicare patients without prior HBPC use, of which 55,303 were new HBPC recipients and 156,142 were matched comparison patients. INTERVENTION Receipt of at least two HBPC visits and, within 6 months of the index HBPC visit, a majority of a patient's primary care visits in the home. MAIN MEASURES Total and potentially avoidable hospitalizations and Medicare inpatient expenditures. KEY RESULTS HBPC reduced total hospitalization rates, but the marginal effects were not statistically significant: a reduction of 11 total hospitalizations per 1000 patients in the first year (- 0.6%, p = 0.19) and 14 in the second year (- 0.7%, p = 0.16). However, HBPC reduced potentially avoidable hospitalization rates in the second year. The estimated marginal effect was a reduction of 6 potentially avoidable hospitalizations per 1000 patients in the first year (- 1.6%, p = 0.16) and 11 in the second (- 3.1%, p = 0.01). The estimated effect of HBPC was a small decrease in inpatient expenditures of $24 per patient per month (- 1.1%, p = 0.10) in the first year and $0 (0.0%, p = 0.99) in the second. CONCLUSIONS After high-need, high-cost patients started receiving HBPC, they did not experience fewer total hospitalizations or lower inpatient spending but may have had lower rates of potentially avoidable hospitalizations after 2 years.
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Affiliation(s)
| | | | | | | | - David J Nyweide
- Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation, Baltimore, MD, USA
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3
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Reckrey JM, Zhao D, Stone RI, Ritchie CS, Leff B, Ornstein KA. Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults. J Am Med Dir Assoc 2023; 24:1002-1006.e2. [PMID: 37084771 PMCID: PMC10330360 DOI: 10.1016/j.jamda.2023.03.016] [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: 01/06/2023] [Revised: 03/08/2023] [Accepted: 03/11/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVES Describe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS Homebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n = 974). METHODS Use of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, ≥40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS. RESULTS Approximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind. CONCLUSIONS AND IMPLICATIONS Although home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.
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Affiliation(s)
| | - Duzhi Zhao
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robyn I Stone
- LeadingAge LTSS Center@UMass Boston, Washington, DC, USA
| | | | - Bruce Leff
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Mather H, Kleijwegt H, Bollens-Lund E, Liu B, Garrido MM, Kelley AS, Leff B, Ritchie CS, Ornstein KA. The heterogeneity of the homebound: A latent class analysis of a national sample of homebound older adults. J Am Geriatr Soc 2023; 71:2163-2171. [PMID: 36876755 DOI: 10.1111/jgs.18295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics. MATERIALS AND METHODS Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression. RESULTS We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%). CONCLUSIONS This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population.
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Affiliation(s)
- Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hannah Kleijwegt
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bian Liu
- Department of Population Health Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa M Garrido
- Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Transformative Geriatrics Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Palliative Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
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O'Reilly-Jacob M, Perloff J, Srinivasan M, Alvarez M, Hoyt A. State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis. J Gerontol Nurs 2023; 49:11-17. [PMID: 37126015 DOI: 10.3928/00989134-20230414-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].
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Ankuda CK, Ornstein KA, Leff B, Rajagopalan S, Kinosian B, Brody AA, Ritchie CS. Defining a taxonomy of Medicare-funded home-based clinical care using claims data. BMC Health Serv Res 2023; 23:120. [PMID: 36747175 PMCID: PMC9900204 DOI: 10.1186/s12913-023-09081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND As more Americans age in place, it is critical to understand care delivery in the home. However, data on the range of home-based services provided by Medicare is limited. We define a taxonomy of clinical care in the home funded through fee-for-service Medicare and methods to identify receipt of those services. METHODS We analyzed Fee-for-service (FFS) Medicare claims data from a nationally-representative cohort of older adults, the National Health and Aging Trends Study (NHATS), to identify home-based clinical care. We included 6,664 NHATS enrollees age ≥ 70 and living in the community, observed an average of 3 times each on claims-linked NHATS surveys. We examined provider and service type of home-based clinical care to identify a taxonomy of 5 types: home-based medical care (physician, physician assistant, or nurse practitioner visits), home-based podiatry, skilled home health care (SHHC), hospice, and other fee-for-service (FFS) home-based care. We further characterized home-based clinical care by detailed care setting and visit types. RESULTS From 2011-2016, 17.8%-20.8% of FFS Medicare beneficiaries age ≥ 70 received Medicare-funded home-based clinical care. SHHC was the most common service (12.8%-16.1%), followed by other FFS home-based care (5.5%-6.5%), home-based medical care (3.2%-3.9%), and hospice (2.6%-3.0%). Examination of the other-FFS home-based care revealed imaging/diagnostics and laboratory testing to be the most common service. CONCLUSIONS We define a taxonomy of clinical care provided in the home, serving 1 in 5 FFS Medicare beneficiaries. This approach can be used to identify and address research and clinical care gaps in home-based clinical care delivery.
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Affiliation(s)
- Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Kinosian
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA
- NYU Grossman School of Medicine, New York, NY, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, USA.
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7
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Franzosa E, Kim P, Reckrey JM, Zhang M, Xu E, Aldridge MD, Federman AD, Ornstein KA. Care Disruptions and End-Of-Life Care Experiences Among Home-Based Primary Care Patients During the COVID-19 Pandemic in New York City: A Retrospective Chart Review. Am J Hosp Palliat Care 2023; 40:225-234. [PMID: 35775300 PMCID: PMC9253522 DOI: 10.1177/10499091221104732] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC's multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
- Geriatric Research, Education, and
Clinical Center (GRECC), James J. Peters
VA Medical Center, Bronx, NY, USA
| | - Patricia Kim
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Jennifer M. Reckrey
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Meng Zhang
- Department of Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Emily Xu
- Department of Medical Education,
Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Melissa D. Aldridge
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Alex D. Federman
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
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Leff B, Ritchie C, Ciemins E, Dunning S. Prevalence of use and characteristics of users of home-based medical care in Medicare Advantage. J Am Geriatr Soc 2023; 71:455-462. [PMID: 36222194 DOI: 10.1111/jgs.18085] [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: 03/31/2022] [Revised: 09/07/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Home-based medical care (HBMC) is longitudinal medical care provided by physicians, advanced practice providers, and, often, inter-professional care teams to patients in their homes. Our objective is to determine the prevalence of HBMC among older adults (≥65) insured by a Medicare Advantage (MA) plan and compare characteristics of those who receive HBMC to those who do not. METHODS Study used de-identified medical claims and enrollment records for MA beneficiaries during calendar years 2017 and 2018 linked with socioeconomic status data in the OptumLabs Data Warehouse. We defined a cohort of MA beneficiaries age ≥65 receiving HBMC for at least 2 months during 2017-2018, described the cohort using demographic, utilization, and comorbidity data and compared it to a 5% random sample of a population of MA beneficiaries age ≥65 not receiving HBMC (No HBMC). RESULTS Overall, 1.45% of the study cohort age ≥65 received HBMC. Compared to No HBMC (n = 132,147), those receiving HBMC (n = 38,800) were more likely to be: older (46.6% vs. 11.9% age 85+); female (70.8% vs. 58.5%); Black (12.3% vs. 11.3%); urban (90.3% vs. 81.3%); experience hospitalization (38.0% vs. 13.3%), emergency department visit (58.3% vs. 26.9%), ambulance trip (44.1% vs. 9.6%), skilled nursing facility (37.6% vs. 6.4%), or hospice care admission (21.1% vs. 3.5%). They also were more likely to experience a wide range of chronic conditions including dementia (58.1% vs. 5.2%), morbidity burden (Charlson score 3.4 vs. 1.8), and serious illness (77.1% vs. 29.5%). All comparisons p < 0.0001. CONCLUSIONS MA beneficiaries who received HBMC are older, experience greater chronic and serious illness burden, and higher levels of facility-based care than those who did not receive HBMC. MA plans need strategies to identify patients that would benefit from HBMC and develop approaches to deliver such care to this impactful, often invisible population.
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Affiliation(s)
- Bruce Leff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Transformative Geriatrics Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Ciemins
- Analytics Department, AMGA (American Medical Group Association), Alexandria, Virginia, USA
| | - Stephan Dunning
- Outset Medical, Health Economics and Market Access, San Jose, California, USA
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Schweiger L, Vranas KC, Furuno JP, Hansen L, Slatore CG, Sullivan DR. Association of Patient-Centered Elements of Care and Palliative Care Among Patients With Advanced Lung Cancer. Am J Hosp Palliat Care 2023; 40:18-26. [PMID: 36191296 PMCID: PMC9772174 DOI: 10.1177/10499091221130944] [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] [Indexed: 12/24/2022] Open
Abstract
CONTEXT Palliative care (PC) is associated with improved quality of life, survival, and decreased healthcare use at the end of life among lung cancer patients. However, the specific elements of palliative care that may contribute to these benefits are unclear. OBJECTIVES To evaluate the associations of PC and its setting of delivery with prescriptions of symptom management medications, advance care planning (ACP), hospice enrollment, and home health care (HHC) receipt. METHODS Retrospective, cohort study of patients with advanced stage (IIIB/IV) lung cancer in the Veterans Health Administration (VA) diagnosed from 2007-2013; with follow-up through 2017. Propensity score methods were used with inverse probability of treatment weighting and logistic regression modeling, adjusting for patient and tumor characteristics. RESULTS Among 23 142 patients, 57% received PC. Compared to non-receipt of PC, PC in any setting (inpatient or outpatient) was associated with increased prescriptions of pain medications (Adjusted Odds Ratio (aOR) = 1.63, 95% CI: 1.45-1.83), constipation regimen with pain medications (aOR = 2.04, 95% CI: 1.63-2.54), and antidepressants (aOR = 1.78, 95% CI: 1.52-2.09). PC was also associated with increased ACP (aOR = 1.52, 95% CI: 1.37-1.67) and hospice enrollment (aOR = 1.39, 95% CI:1.31-1.47), and decreased HHC (aOR = 0.79, 95% CI: 0.70-.90) compared to non-receipt of PC. Receipt of PC in outpatient settings was associated with increased prescriptions of pain medications (aOR = 2.54, 95% CI: 2.13-3.04) and antidepressants (aOR = 1.76, 95% CI: 1.46-2.12), and hospice enrollment (aOR = 2.09, 95% CI: 1.90-2.31) compared to receipt of PC in inpatient settings. CONCLUSIONS PC is associated with increased use of symptom management medications, ACP, and hospice enrollment, especially when delivered in outpatient settings. These elements of care elucidate potential mechanisms for improved outcomes associated with PC and provide a framework for a primary palliative care approach among non-palliative care clinicians.
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Affiliation(s)
- Liana Schweiger
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System; Portland, OR
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania; Philadelphia, PA
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System; Portland, OR
| | - Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Knight Cancer Institute, Oregon Health & Science University; Portland, OR
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System; Portland, OR
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Knight Cancer Institute, Oregon Health & Science University; Portland, OR
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Reckrey JM, Kim PS, Zhao D, Zhang M, Xu E, Franzosa E, Ornstein KA. Care disruptions among the homebound during the COVID-19 pandemic: An analysis of the role of dementia. J Am Geriatr Soc 2022; 70:3585-3592. [PMID: 35997146 PMCID: PMC9539366 DOI: 10.1111/jgs.18008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Seriously ill people with dementia living at home may be particularly vulnerable to disruptions in their care during times of crisis. The study sought to describe care experiences of those receiving home-based primary care in New York City during the COVID-19 pandemic and compare the experiences of people with and without dementia. METHODS We conducted a retrospective review of all electronic medical record notes between March 1, 2020 and December 30, 2020 among a sample of home-based primary care recipients (n = 228), including all deaths that occurred in the spring of 2020. Drawing from administrative records and using an abstraction tool that included both structured (e.g., documented COVID-19 exposure) and unstructured (e.g., text passage describing caregiver burden) data, we identified salient COVID-19 related care experiences and identified and categorized major disruptions in care. RESULTS Both people with and without dementia experienced significant disruptions of paid caregiving, family caregiving, and home-based services during the COVID-19 pandemic. While the paid caregivers of people with dementia reported more burden to the home-based primary care team as compared to people without dementia, we found little evidence of differences in quantity or type of COVID-19 related disruptions relative to dementia status. DISCUSSION While those with dementia have distinct care needs, our findings emphasize the way that dementia may be one piece of a larger clinical picture of serious illness. In order to support all patients with high care needs in crisis, we need to understand the interdependence of clinical care, long-term care, and family caregiving support for older adults and view dementia within the larger context of serious illness and care need.
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Affiliation(s)
- Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patricia S. Kim
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Duzhi Zhao
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Meng Zhang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Xu
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Geriatric Research, Education, and Clinical Center (GRECC), James J. Peters Veterans Administration, Bronx, New York, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Reckrey JM, Leff B, Kumar RG, Yee C, Garrido MM, Ornstein KA. Home, but Not Homebound: A Prospective Analysis of Persons Living With Dementia. J Am Med Dir Assoc 2022; 23:1648-1652.e1. [PMID: 35063398 PMCID: PMC9294063 DOI: 10.1016/j.jamda.2021.12.029] [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: 07/13/2021] [Revised: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Homebound persons living with dementia may have increased difficulty accessing needed care in the community. This study identifies factors associated with becoming homebound among a national sample of Medicare beneficiaries with newly identified dementia. DESIGN Prospective cohort analysis. SETTING AND PARTICIPANTS We used the National Health and Aging Trends Study (NHATS) 2011-2018 to identify community-dwelling older adults at the time of a new dementia diagnosis (n = 939). Dementia status was determined based on cognitive testing and self and proxy reporting. METHODS We compared characteristics of homebound (ie, those who never or rarely left home) and non-homebound participants at the time of dementia identification. Among non-homebound participants, we used a Fine-Gray subdistribution hazard model to identify factors associated with becoming homebound over follow-up (median follow-up 4 years), accounting for competing risks of death and moving to a nursing home. RESULTS 20% of individuals with newly identified dementia were homebound and this group was more functionally impaired, medically complex, and socioeconomically disadvantaged as compared to the non-homebound. Over time, depression [subhazard ratio (SHR) 2.19, 95% CI 1.36, 3.54], living in an assisted living facility (SHR 2.60, 95% CI 1.35, 4.97), and Hispanic ethnicity (SHR 1.91, 95% CI 1.05, 3.47) were associated with becoming homebound. CONCLUSIONS AND IMPLICATIONS Most adults are not homebound at the time of dementia diagnosis. Identifying and addressing modifiable factors like depression may slow progression to homebound status and enable persons living with dementia to access needed care in the community. In order to accommodate diverse individual and family preferences for long-term care, robust systems of home-based clinical and long-term care are necessary for those who do become homebound.
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Affiliation(s)
| | - Bruce Leff
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raj G Kumar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cynthia Yee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melissa M Garrido
- Boston University School of Public Health, Boston, MA, USA; Boston VA Healthcare System, Boston, MA, USA
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12
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Liu B, Ritchie CS, Ankuda CK, Perez-Benzo G, Osakwe ZT, Reckrey JM, Salinger MR, Leff B, Ornstein KA. Growth of Fee-for-Service Medicare Home-Based Medical Care Within Private Residences and Domiciliary Care Settings in the U.S., 2012-2019. J Am Med Dir Assoc 2022; 23:1614-1620.e10. [PMID: 36202531 PMCID: PMC10214620 DOI: 10.1016/j.jamda.2022.06.014] [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: 05/18/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Home-based medical care (HBMC) delivers physician or advanced practice provider-led medical services for patients in private residences and domiciliary settings (eg, assisted living facilities, group/boarding homes). We aimed to examine the time trends in HBMC utilization by care settings. DESIGN Analyses of HBMC utilization at the national and state levels during the years 2012-2019. SETTING AND PARTICIPANTS With Medicare public use files, we calculated the state-level utilization rate of HBMC among fee-for-service (FFS) Medicare beneficiaries, measured by visits per 1000 FFS enrollees, in private residences and domiciliary settings, both separately and combined. METHODS We assessed the trend of HBMC utilization over time via linear mixed models with random intercept for state, adjusting for the following state-level markers of HBMC supply and demand: number of HBMC providers, state ranking of total assisted living and residential care capacity, and the proportion of FFS beneficiaries with dementia, dual eligibility for Medicaid, receiving home health services, and Medicare Advantage. RESULTS Total HBMC visits in the United States increased from 3,911,778 in 2012 to 5,524,939 in 2019. The median (interquartile range) state-level HBMC utilization rate per 1000 FFS population was 67.6 (34.1-151.3) visits overall, 17.3 (7.9-41.9) visits in private residences, and 47.7 (23.1-86.6) visits in domiciliary settings. The annual percentage increase of utilization rates was significant for all care settings in crude models (3%-8%), and remained significant for overall visits and visits in domiciliary settings (2%-4%), but not in private residences. CONCLUSIONS AND IMPLICATIONS The national-level growth in HBMC from 2012-2019 was largely driven by a growth of HBMC occurring in domiciliary settings. To meet the needs of a growing aging population, future studies should focus efforts on policy and payment issues to address inequities in access to HBMC services for homebound older adults, and examine drivers of HBMC growth at regional and local levels.
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Affiliation(s)
- Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Claire K Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Grace Perez-Benzo
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maggie R Salinger
- Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Sloane PD, Eleazer GP, Phillips SL, Batchelor F. Removing the Financial Barriers to Home-Based Medical Care for Frail Older Persons. J Am Med Dir Assoc 2022; 23:1611-1613. [PMID: 36202530 DOI: 10.1016/j.jamda.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/06/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Philip D Sloane
- Cecil G. Sheps Center for Health Services Research and Departments of Family Medicine and Internal Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - G Paul Eleazer
- George E. Wahlen Department of Veterans Affairs Medical Center, University of Utah School of Medicine, and Geriatrics Research, Education and Clinical Center, Salt Lake City, UT, USA
| | - Steven L Phillips
- Geriatric Specialty Care of Nevada and Pine Park Health, Reno, NV, USA
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14
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DiTommaso MJ, Mohammad NF. Expansion of a House Calls Program for Patients With Dementia During COVID-19. J Gerontol Nurs 2022; 48:21-25. [PMID: 36169292 DOI: 10.3928/00989134-20220908-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Homebound older adults with dementia have increased health care use, hospitalization rates, and mortality risk, which are associated with considerable health care costs. A large, unmet need for individuals with dementia is home-based medical care. Although our institution has had a primary care program for homebound patients since 2019, we did not have an analogous program for patients with dementia before the coronavirus disease 2019 (COVID-19) pandemic. However, with increased health risks and challenges associated with the pandemic, we rapidly expanded the program to include facility-based older adults with dementia. We incorporated telemedicine and home-based visits to effectively provide patient-centered care that was aligned with their goals and preferences, and we describe a program example of how we provided care during a COVID-19 outbreak in a large facility. Further research is needed to capture potential cost savings and hospitalization rates for persons with dementia who receive home-based medical care. [Journal of Gerontological Nursing, 48(10), 21-25.].
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15
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Datta R, Fried T, O’Leary JR, Zullo AR, Allore H, Han L, Juthani-Mehta M, Cohen A. National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship. Open Forum Infect Dis 2022; 9:ofac453. [PMID: 36147594 PMCID: PMC9487603 DOI: 10.1093/ofid/ofac453] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Over 7 million older Americans are homebound. Managing infections in homebound persons presents unique challenges that are magnified among persons living with dementia (PLWD). This work sought to characterize antibiotic use in a national cohort of PLWD who received home-based primary care (HBPC) through the Veterans Health Administration. Methods Administrative data identified veterans aged ≥65 years with ≥2 physician home visits in a year between 2014 and 2018 and a dementia diagnosis 3 years before through 1 year after their initial HBPC visit. Antibiotics prescribed orally, intravenously, intramuscularly, or by enema within 3 days of an HBPC visit were assessed from the initial HBPC visit to death or December 31, 2018. Prescription fills and days of therapy (DOT) per 1000 days of home care (DOHC) were calculated. Results Among 39 861 PLWD, the median age (interquartile range [IQR]) was 85 (78-90) years, and 15.0% were Black. Overall, 16 956 (42.5%) PLWD received 45 122 prescription fills. The antibiotic use rate was 20.7 DOT per 1000 DOHC. Telephone visits and advanced practice provider visits were associated with 30.9% and 42.0% of fills, respectively. Sixty-seven percent of fills were associated with diagnoses for conditions where antibiotics are not indicated. Quinolones were the most prescribed class (24.3% of fills). The overall median length of therapy (IQR) was 7 (7-10) days. Antibiotic use rates varied across regions. Within regions, the median annual antibiotic use rate decreased from 2014 to 2018. Conclusions Antibiotic prescriptions were prevalent in HBPC. The scope, appropriateness, and harms of antibiotic use in homebound PLWD need further investigation.
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Affiliation(s)
- Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terri Fried
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R O’Leary
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Heather Allore
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Manisha Juthani-Mehta
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew Cohen
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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16
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Han YH, Yoo SH, Lee SY, Hwang IY, Kim KH, Cho B, Kim MS, Choi W, Kim Y. The Medical Needs and Characteristics of Cancer and Progressive Neurologic Disease Patients Who Use Home-Based Medical Care in Korea: A Retrospective Study for 2011-2020. J Am Med Dir Assoc 2022; 23:1634-1641.e2. [PMID: 35926572 DOI: 10.1016/j.jamda.2022.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/08/2022] [Accepted: 06/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the needs and characteristics of patients with cancer and neurologic disorders requiring home-based medical care (HBMC). DESIGN Retrospective observational study. SETTING AND PARTICIPANTS Patients receiving HBMC on discharge from a tertiary hospital in Korea during 2011-2020. METHODS Patients were classified into 3 disease groups: cancer, progressive neurologic disorders (NR), and others. Characteristics and medical needs were assessed in each disease group. Medical needs were categorized based on functional items requiring support or management at the time of registration: respiratory, feeding, urinary system, drain tube, central catheter, wound, medication, and other. Patients with multiple medical needs were assigned to multiple categories. Patients who used HBMC for more than 3 months were defined as long-term users; their characteristics were evaluated in the same way. RESULTS Of the total 655 patients, 47.0% (308) had cancer and 17.3% (113) were NR patients. Among all patients, 78.8% were partially dependent (44.0%) or completely dependent (34.8%) in daily activities, and there were more dependent patients in the NR group (80.5%) than cancer (26.6%). Patients with cancer needed central catheter management the most (43.5%), followed by wound care (36.7%), feeding support (35.1%), and drain tube management (22.1%). NR patients required feeding support the most (80.5%), followed by respiratory support (43.4%), wound care (41.6%), and urinary system support (19.5%). Of all patients, 30.2% (198) were long-term users (NR, 37.9%; cancer, 35.4%). Long-term users were common among patients who needed respiratory support (59.4%), feeding support (48.75), and urinary system support (34.6%). CONCLUSIONS AND IMPLICATIONS Homebound patients with cancer and progressive neurologic disorders need medical services at home after discharge. Patients who need feeding and respiratory support usually use HBMC for more than 3 months. Further studies are needed to design an optimal HBMC that continuously provides medical services to patients with serious illnesses living at home.
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Affiliation(s)
- Yo Han Han
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - In Young Hwang
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyae Hyung Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Belong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Sun Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Wonho Choi
- Center for Palliative care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yejin Kim
- Center for Palliative care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
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17
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Miller RK, Morgan-Gouveia MD, DeCherrie LV. Medical Training in Home Care Medicine: The Time is Now. J Gen Intern Med 2022; 37:2302-2305. [PMID: 35710677 PMCID: PMC9202974 DOI: 10.1007/s11606-022-07514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/25/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Rachel K Miller
- Division of Geriatric Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, and Geriatrics and Extended Care Program, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
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18
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Chan KT, Marsack-Topoleswki C, LaFave S, Ratnayake M, Graves J, Fenski D, Jones L. Teaching Note-Supporting Homebound Older Adults and Caregivers Through Integrative Service Learning. JOURNAL OF SOCIAL WORK EDUCATION 2022; 59:1249-1257. [PMID: 38143590 PMCID: PMC10746131 DOI: 10.1080/10437797.2022.2045238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/26/2023]
Abstract
The Supporting Older Adults & Caregivers: Integrative Service Learning (SOCIAL) partnership trains undergraduate social work students to provide practical home-based support for older adults with chronic illness and their family caregivers, serving as a pipeline for future leaders in older adult care. More than 2 million older adults are homebound, and 5 million need help leaving their homes due to physical limitations from chronic conditions or cognitive impairments. Family members often assume daily caregiving tasks to assist their loved ones, navigate health care systems, and provide much needed emotional support. The challenges of caregiving are further compounded by the problems associated with insufficient health care professionals who are trained to work with older adults. Integrative service learning models can provide home-based support to older adults while offering valuable, hands-on learning experiences for students. In this teaching note, we acknowledge a need for developing an educational pipeline that can provide training opportunities for students to work with older adults and their caregivers at home. We provide an example of an integrative service-learning model which offers valuable pedagogical experiences to baccalaureate students along with strategies for curriculum building, community engagement, research and evaluation, and program sustainability.
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Affiliation(s)
- Keith T. Chan
- Silberman School of Social Work at Hunter College, New York, NY
| | | | - Sarah LaFave
- Johns Hopkins University, Baltimore, MD
- Lori’s Hands, Newark, DE
| | | | - Jillian Graves
- School of Social Work, Eastern Michigan University, Ypsilanti, MI, USA
| | - Diane Fenski
- School of Social Work, Eastern Michigan University, Ypsilanti, MI, USA
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19
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Ritchie C, Leff B. Home-Based Care Reimagined: A Full-Fledged Health Care Delivery Ecosystem Without Walls. Health Aff (Millwood) 2022; 41:689-695. [PMID: 35500180 DOI: 10.1377/hlthaff.2021.01011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The COVID-19 pandemic exposed the dangers of tying health care delivery to brick-and-mortar health care facilities. Both before and, more intensely, during the pandemic, health systems have struggled to support high-need patients, especially those unable to engage with virtual technology or needing urgent care in the home. The pandemic has highlighted an ongoing need to create a distributed health care delivery ecosystem centered in patients' homes and the community. This age-friendly ecosystem would initially focus on high-need patients, expand access, improve equity, and be of high value. It would integrate episodic and longitudinal care and expand to serve broader populations as it matures. We briefly describe the evidence base for home-based care models that constitute this ecosystem, define the guiding principles underlying it, and discuss what will be required to build out and scale it.
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Affiliation(s)
- Christine Ritchie
- Christine Ritchie , Massachusetts General Hospital and Harvard University, Boston, Massachusetts
| | - Bruce Leff
- Bruce Leff, Johns Hopkins University, Baltimore, Maryland
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20
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Ornstein KA, Liu SH, Husain M, Ankuda CK, Bollens-Lund E, Kelley AS, Garrido MM. Prospective assessment of dementia on transitions in homeboundness using multistate Markov models. J Am Geriatr Soc 2022; 70:1117-1126. [PMID: 34951008 PMCID: PMC8986556 DOI: 10.1111/jgs.17631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/26/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions. METHODS Using 2011-2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community-dwelling Medicare beneficiaries. Homebound status (independent, semi-homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self-report. Transition probabilities across states were assessed using a multistate Markov model. RESULTS Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two-fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia. DISCUSSION Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home-based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care.
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Affiliation(s)
- Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Shelley H. Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Mohammed Husain
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Claire K. Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Amy S. Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
- James J Peters Veterans Affairs Medical Center, Bronx, NY
| | - Melissa M. Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Boston VA Healthcare System, Boston, MA
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21
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Boyd ND, Naasan G, Harrison KL, Garrett SB, D’Aguiar Rosa T, Pérez-Cerpa B, McFarlane S, Miller BL, Ritchie CS. Characteristics of people with dementia lost to follow-up from a dementia care center. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5628. [PMID: 34590336 PMCID: PMC8740544 DOI: 10.1002/gps.5628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/06/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify the prevalence and characteristics of people living with dementia (PLWD) lost to follow-up (LTFU) from a specialized dementia care clinic and to understand factors influencing patient follow-up status. METHODS We conducted a retrospective chart review of PLWD seen at a dementia care clinic 2012-2017 who were deceased as of 2018 (n = 746). Participants were evaluated for follow-up status at the time of death. Generalized linear regression was used to analyze demographic and diagnostic characteristics by follow-up status. Text extracted from participant medical records was analyzed using qualitative content analysis to identify reasons patients became LTFU. RESULTS Among PLWD seen at a dementia care clinic, 42% became LTFU before death, 39% of whom had chart documentation describing reasons for loss to follow-up. Increased rates of LTFU were associated with female sex (risk ratio 1.27, [95% confidence interval 1.09-1.49]; p = 0.003), educational attainment of high school or less (1.34, [1.13-1.61]; p = 0.001), and death in a long-term care facility (1.46, [1.19-1.80]; p = 0.003). Commonly documented reasons for not returning for care at the clinic included switching care to another provider (42%), logistical difficulty accessing care (26%), patient-family decision to discontinue care (24%), and functional challenges in accessing care (23%). CONCLUSIONS PLWD are LTFU from specialized memory care at high rates. Attention to care coordination, patient-provider communication, and integrated use of alternative care models such as telehealth are potential strategies to improve care.
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Affiliation(s)
- Nicole D. Boyd
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Georges Naasan
- University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Department of Neurology, Department of Medicine, University of California San Francisco, San Francisco, California, USA,Department of Neurology, Mount Sinai Hospitals, Ichan School of Medicine, New York City, New York, USA
| | - Krista L. Harrison
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA,University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Sarah B. Garrett
- University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Talita D’Aguiar Rosa
- University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Brenda Pérez-Cerpa
- University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Hospital Civil de Guadalajara (Hospital Civil Fray Antonio Alcade), Guadalajara, Jalisco, Mexico
| | - Shamiel McFarlane
- University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA
| | - Bruce L. Miller
- University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Department of Neurology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Christine S. Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA,University of California San Francisco / Global Brain Health Institute, San Francisco, California, USA,Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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22
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Nguyen HQ, Vallejo JD, Macias M, Shiffman MG, Rosen R, Mowry V, Omotunde O, Hong B, Liu ILA, Borson S. A mixed-methods evaluation of home-based primary care in dementia within an integrated system. J Am Geriatr Soc 2021; 70:1136-1146. [PMID: 34936090 DOI: 10.1111/jgs.17627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/07/2021] [Accepted: 12/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND No prior studies have examined the effects of home-based primary care (HBPC) in persons living with dementia (PLWD), within an ecosystem of serious illness care in an integrated healthcare system. Our objectives were to compare the characteristics of PLWD receiving HBPC and their hospital utilization and end-of-life care, with those of a matched comparison group, and to understand the experiences of family caregivers of PLWD receiving HBPC. METHODS This mixed-methods study used a retrospective observational cohort design with PLWD receiving HBPC (n = 287) from 2015 to 2020 and a strata-matched comparison group (n = 861), and qualitative phone interviews with 16 HBPC family caregivers in 2020. Inverse probability of treatment weighting propensity score-adjusted models were used to compare time-to-first hospital-based utilization and, for decedents, home palliative and hospice care and place of death. Care experience was captured through caregiver interviews. RESULTS Patients receiving HBPC had a similar risk of hospital utilization [adjusted hazard ratio, 1.06 (95% CI: 0.89-1.26), p = 0.51] as a matched non-HBPC comparison group after a median follow-up of 199 days. However, HBPC decedents (n = 159) were more likely to receive home palliative care or hospice [rate ratio, RR: 1.23 (95% CI: 1.07-1.42), p < 0.01] and to die at home [RR: 1.66 (95% CI: 1.35-2.05), p < 0.001] than were non-HBPC decedents (n = 423). Caregivers reported that HBPC provided coordinated, continuous, and convenient care that was aligned with families' priorities and goals; however, some expressed unmet needs, especially for help paying for personal care and medical supplies/equipment, and a desire for clearer communication about program operations and more quality oversight for contract services. CONCLUSIONS Although HBPC for PLWD was associated with a similar risk of hospital utilization compared to a matched non-HBPC comparison group, HBPC resulted in more patient-centered end-of-life care for decedents. Prospective studies of HBPC that further elicit and address unmet needs are warranted.
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Affiliation(s)
- Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jessica D Vallejo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Mayra Macias
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Romina Rosen
- Woodland Hills Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Velda Mowry
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Omotayo Omotunde
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Benjamin Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Family Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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23
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Ornstein KA, Ankuda CK, Leff B, Rajagopalan S, Siu AL, Harrison KL, Oh A, Reckrey JM, Ritchie CS. Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism. J Am Geriatr Soc 2021; 70:1127-1135. [PMID: 34936087 DOI: 10.1111/jgs.17621] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/22/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access. METHODS Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia. RESULTS Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas. CONCLUSION Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.
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Affiliation(s)
- Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, The Center for Transformative Geriatric Research, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Anna Oh
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco VA Health Care System, San Francisco, California, USA
| | - Jennifer M Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
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24
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Gorbenko K, Franzosa E, Masse S, Brody AA, Sheehan O, Kinosian B, Ritchie CS, Leff B, Ripp J, Ornstein KA, Federman AD. "I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York. Home Health Care Serv Q 2021; 40:1-15. [PMID: 34301160 PMCID: PMC8783921 DOI: 10.1080/01621424.2021.1935383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.
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Affiliation(s)
- Ksenia Gorbenko
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute of Health Care Delivery Science, Mount Sinai Health System, New York, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
| | - Sybil Masse
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Orla Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Ripp
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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25
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Zimbroff RM, Ornstein KA, Sheehan OC. Home-based primary care: A systematic review of the literature, 2010-2020. J Am Geriatr Soc 2021; 69:2963-2972. [PMID: 34247383 DOI: 10.1111/jgs.17365] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although more than seven million older adults struggle or are unable to leave their homes independently, only a small minority access home-based primary care (HBPC). Despite substantial growth of HBPC, fueled by growing evidence supporting positive patient outcomes and cost savings, the population remains dramatically underserved and many evidence gaps still exist around scope of practice and key issues in care delivery and quality. Understanding the current state of the field is critical to the delivery of high-quality home-based care. METHODS We conducted a systematic search of the peer-reviewed literature on HBPC, published between January 2010 and January 2020, using Medline, CINAHL, Embase, Web of Science, and Scopus online libraries. All studies were evaluated by two members of the research team, and key findings were extracted. RESULTS The initial search yielded 1730 unique studies for screening. Of these initial results, 1322 were deemed not relevant to this review. Of the 408 studies deemed potentially relevant, 79 were included in the study. Researchers identified five overarching themes: the provision of HBPC, the composition of care teams, HBPC outcomes, the role of telehealth, and emergency preparedness efforts. CONCLUSION The need and desire for growth of HBPC has been highlighted by the recent COVID-19 pandemic. Current research on HBPC finds a diverse scope of practice, successful use of interdisciplinary teams, positive outcomes, and increasing interest in telehealth with many areas ripe for further research.
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Affiliation(s)
- Robert M Zimbroff
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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26
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Federman AD, Leff B, Brody AA, Lubetsky S, Siu AL, Ritchie CS, Ornstein KA. Disruptions in Care and Support for Homebound Adults in Home-Based Primary Care in New York City During the COVID-19 Pandemic. Home Healthc Now 2021; 39:211-214. [PMID: 34190705 PMCID: PMC8345896 DOI: 10.1097/nhh.0000000000000983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Homebound older adults are a highly vulnerable population, yet little is known about their experiences with healthcare during the COVID-19 pandemic. We interviewed patients in home-based primary care (HBPC) in New York City by telephone in May and June of 2020. Interviews covered social supports, household activities, self-care, and medical care, and asked participants to compare current with prepandemic experiences. Among 70 participants, 37% were Black and 32% were Hispanic. Disruptions in the home included greater difficulty accessing paid caregivers (13.9%) and food (35.3%) than before the pandemic, and unaddressed household chores (laundry, 81.4%; food preparation, 11.4%). Black study participants were more likely than White and Hispanic participants to report disruptions in accessing medical care (13 [50.0%] vs. 3 [14.3%] vs. 6 [27.3%], respectively, p = 0.02), as well as food preparation and medication taking. Black patients in HBPC are at risk of disparities in healthcare and social support during the COVID-19 pandemic.
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27
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Osakwe ZT, Kim RS, Obioha CU, Osborne JC, Harun N, Saint Fleur-Calixte R. Impact of state scope-of-practice laws on nurse practitioner-provided home visits. Geriatr Nurs 2021; 42:674-680. [PMID: 33823425 DOI: 10.1016/j.gerinurse.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/01/2022]
Abstract
Millions of older Americans receive nurse practitioner (NP)-provided home based primary care (HBPC). Little is known about how state scope-of- practice (SOP) laws may impact use of NP-home visits. Using 2017 Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File (PUF), we examined the impact of state SOP laws on the use of NP-home visits. The PUF file was merged with the 2017 American Community Survey to assess area-level median income. Over 4.4 million home visits were provided to 1.6 million Medicare beneficiaries. NPs represented the largest share of providers (47.5%). In states with restricted SOP laws, compared to NPs, physicians and physician assistants had higher odds of providing HBPC. In states with reduced SOP laws, compared to NPs, physicians and PAs had decreased odds of providing HBPC. Our study provides evidence that SOP restrictions are associated with decreased utilization of NP-provided HBPC.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health at Adelphi University, 1 South Avenue, Garden City, NY, 11530, United States.
| | - Ryung S Kim
- Department of Epidemiology and Population, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States.
| | - Chinedu U Obioha
- College of Nursing and Public Health at Adelphi University, 1 South Avenue, Garden City, NY, 11530, United States.
| | - Jennel C Osborne
- Harriet Rothkopf Heilbrunn School of Nursing, Long Island University, 1 University Plaza, Brooklyn, NY 11201-5372, United States.
| | - Nafin Harun
- Center for Health workforce Studies, School of Public Health, University of Albany, SUNY, 1 University Place, Ste 220/Rensselaer, NY 12144, United States.
| | - Rose Saint Fleur-Calixte
- Department of Community Health and Social Medicine, CUNY School of Medicine, Townsend Harris Hall, Suite 313, 160 Covent Avenue, NY 10031, United States.
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28
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Yao N, Mutter JB, Berry JD, Yamanaka T, Mohess DT, Cornwell T. In Traditional Medicare, Modest Growth In The Home Care Workforce Largely Driven By Nurse Practitioners. Health Aff (Millwood) 2021; 40:478-486. [PMID: 33646879 DOI: 10.1377/hlthaff.2020.00671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Little is known about the characteristics of the workforce providing home-based medical care for traditional (fee-for-service) Medicare beneficiaries. We found that the number of participating home care providers in traditional Medicare increased from about 14,100 in 2012 to around 16,600 in 2016. Approximately 4,000 providers joined or reentered that workforce annually, and 3,000 stopped or paused participation. The number of home visits that most participants provided each year remained below 200. Only 0.7 percent of physicians in Medicare provided fifty or more home visits annually, with little change over the course of five years. In contrast, the number of home-visiting nurse practitioners almost doubled, and the average number of home visits they made increased each year. Despite generally low overall participation of traditional Medicare providers in home-based care, the workforce has seen modest but steady growth, driven primarily by increasing nurse practitioner participation. Additional stimuli may be necessary to ensure workforce adequacy and stability.
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Affiliation(s)
- Nengliang Yao
- Nengliang (Aaron) Yao is the Cheeloo Scholar Professor in Healthcare Management and Nursing at Shandong University, in Jinan, Shandong, China. He is also the part-time research director of the Home Centered Care Institute, in Schaumburg, Illinois, and a part-time research scientist for the Section of Geriatric Medicine at the University of Virginia, in Charlottesville, Virginia
| | - Justin B Mutter
- Justin B. Mutter is section head of geriatric medicine at the University of Virginia School of Medicine and a fellow at the Institute for Advanced Studies in Culture, University of Virginia
| | - James D Berry
- James D. Berry is the chief of the Division of ALS and Motor Neuron Diseases and director of the Neurological Clinical Research Institute at Massachusetts General Hospital, in Boston, Massachusetts
| | - Takashi Yamanaka
- Takashi Yamanaka is the chair of the Department of Home Care Medicine at the University of Tokyo, in Bunkyo City, Tokyo, Japan
| | - Denise T Mohess
- Denise T. Mohess is the medical director and section chief of Geriatrics in the Inova Health System, in Fairfax, Virginia
| | - Thomas Cornwell
- Thomas Cornwell is the executive chairman of the Home Centered Care Institute and is the senior medical director of Village Medical at Home, in Chicago, Illinois
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29
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Brant LCC, Pinheiro PC, Machado IE, Correa PRL, Santos MR, Ribeiro ALP, Tupinambás U, Santiago CF, Souza MDFM, Malta DC, Passos VMA. The impact of COVID-19 pandemic course in the number and severity of hospitalizations for other natural causes in a large urban center in Brazil. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000054. [PMID: 36962251 PMCID: PMC10021898 DOI: 10.1371/journal.pgph.0000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022]
Abstract
The COVID-19 pandemic may indirectly impact hospitalizations for other natural causes. Belo Horizonte is a city with 2.5 million inhabitants in Brazil, one of the most hardly-hit countries by the pandemic, where local authorities monitored hospitalizations daily to guide regulatory measures. In an ecological, time-series study, we investigated how the pandemic impacted the number and severity of public hospitalizations by other natural causes in the city, during 2020. We assessed the number and proportion of intensive care unit (ICU) admissions and in-hospital deaths for all-natural causes, COVID-19, non-COVID-19 natural causes, and four disease groups: infectious, respiratory, cardiovascular, and neoplasms. Observed data from epidemiological week (EW) 9 (first diagnosis of COVID-19) to EW 48, 2020, was compared to the mean for the same EW of 2015-2019 and differences were tested by Wilcoxon rank-sum test. The five-week moving averages of the studied variables in 2020 were compared to that of 2015-2019 to describe the influence of regulatory measures on the indicators. During the studied period, there was 54,722 hospitalizations by non-COVID-19 natural causes, representing a 28% decline compared to the previous five years (p<0.001). There was a concurrent significant increase in the proportion of ICU admissions and deaths. The greater reductions were simultaneous to the first social distancing decree or occurred in the peak of COVID-19 hospitalizations, suggesting different drivers. Hospitalizations by specific causes decreased significantly, with greater increase in ICU admissions and deaths for infectious, cardiovascular, and respiratory diseases than for neoplasms. While the first reduction may have resulted from avoidance of contact with healthcare facilities, the second reduction may represent competing causes for hospital beds with COVID-19 after reopening of activities. Health policies must include protocols to address hospitalizations by other causes during this or future pandemics, and a plan to face the rebound effect for elective deferred procedures.
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Affiliation(s)
- Luisa C C Brant
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Pedro C Pinheiro
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Isis E Machado
- School of Medicine, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
| | | | | | - Antonio L P Ribeiro
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Unaí Tupinambás
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Deborah C Malta
- Nursing School, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Valéria M A Passos
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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30
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Ornstein KA, Garrido MM, Bollens-Lund E, Reckrey JM, Husain M, Ferreira KB, Liu SH, Ankuda CK, Kelley AS, Siu AL. The Association Between Income and Incident Homebound Status Among Older Medicare Beneficiaries. J Am Geriatr Soc 2020; 68:2594-2601. [PMID: 32776512 PMCID: PMC7722026 DOI: 10.1111/jgs.16715] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022]
Abstract
IMPORTANCE A large and growing population of older adults with multimorbidity, cognitive impairment, and functional disability live in the community, but many never or rarely leave their homes. Being homebound is associated with decreased access to medical services, poor health outcomes, and increased mortality. Yet, it is unknown what factors, in particular socioeconomic factors, are associated with new onset of homebound status. OBJECTIVE To evaluate the association between income and risk of becoming homebound. DESIGN Observational cohort study using 2011 to 2018 data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries aged 65 years and older. SETTING Population-based study in the United States. PARTICIPANTS A total of 7,042 initially nonhomebound community-dwelling older adults. EXPOSURE Total annual household income at baseline (in 2011) measured via self-report. OUTCOME Annual measure of homebound status, defined as leaving home an average of 1 d/wk or less. RESULTS Over 7 years, 15.81% of older adults in the lowest income quartile (≤$15,003) became homebound, compared with only 4.64% of those in the highest income quartile (>$60,000). In a competing risks analysis accounting for risks of death and nursing home admission, and adjusted for clinical and demographic characteristics, those in the lowest income quartile had a substantially higher subhazard of becoming homebound than those in the highest income quartile (1.65; 95% confidence interval = 1.20-2.29). Moreover, we see evidence of a gradient in risk of homebound status by income quartile. CONCLUSION AND RELEVANCE Our work demonstrates that financial resources shape the risk of becoming homebound, which is associated with negative health consequences. In the context of existing income disparities, more support is needed to assist older adults with limited financial resources who wish to remain in the community.
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Affiliation(s)
- Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Boston VA Healthcare System, Boston, Massachusetts, USA
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohammed Husain
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katelyn B Ferreira
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shelley H Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Claire K Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Albert L Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
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