Identifying Critical Factors in Determining Discharge Readiness from Skilled Home Health: An Interprofessional Perspective

Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study

Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care

BACKGROUND/OBJECTIVES

Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services.

DESIGN

Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File.

SETTING

AL facilities and Medicare HH agencies in the United States.

PARTICIPANTS

741,926 Medicare HH admissions of AL residents in 2017.

MEASUREMENTS

Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission.

RESULTS

Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)).

CONCLUSION

For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Patients' and caregivers' perspectives in determining discharge readiness from home health

There are no national, empirically derived clinical decision support tools to assist the interprofessional home health team in determining readiness for discharge from skilled home health. Eliciting patient and family caregiver perspectives around readiness for home health discharge is integral to developing tools that address their needs in this decision-making process. The purpose of this study was to describe the factors home health patients and their family caregivers perceive as critical when determining readiness for discharge from services. A qualitative descriptive study was conducted among skilled home health recipients and their family caregivers who were either recently discharged or recertified for additional care from two different Medicare-certified skilled home health agencies. Nine themes emerged: self-care ability, functional status, status of condition(s) and symptoms, presence of a caregiver, support for the caregiver, connection to community resources/support, safety needs of the home environment addressed, adherence to the prescribed regimen, and care coordination.

The Role of Social, Economic, and Physical Environmental Factors in Care Planning for Home Health Care Recipients

Social, economic, and environmental factors contribute to patients' recovery following hospitalization. However, little is known about how home health nurses make decisions based on their assessment of these factors. The purpose of the current study was to explore the nonclinical factors that home health nurses evaluate and describe how these factors influence care planning decisions. Semi-structured interviews conducted with 20 visiting nurses from three home health agencies were analyzed using conventional content analysis. Three nonclinical factor themes emerged: Social Support, Home Environment and Neighborhood, and Finances and Insurance Barriers. Nurses' assessments guided them to include family caregivers in the plan of care, evaluate their own safety to complete home visits, and refer patients to useful resources. Findings highlight the role of home health nurses in supporting older adults with limited resources and the need to address the social determinants of health across the care continuum. [Research in Gerontological Nursing, 13(3), 130-137.].

Caregivers' Perceptions Managing Functional Needs Among Older Adults Receiving Post-Acute Home Health Care

Caregivers play important roles in managing the physical functioning (PF) needs of older adults transitioning home after a hospitalization. Training and support of caregivers in the post-acute home health care (HHC) setting should incorporate caregivers' perspectives. To explore caregivers' experiences managing PF needs in the post-acute HHC setting, semi-structured telephone interviews of 20 caregivers were conducted. Conventional content analysis revealed patient-, caregiving task-, caregiver-, and home environment-related themes consistent with the Theory of Dependent Care. Caregivers highlighted the dynamics and contributors of PF needs for older patients in the post-acute HHC setting and depicted the enormity of caregiving tasks needed to manage older patients' PF needs. Caregivers also described their perceived roles and challenges in managing PF deficits, including a sense of isolation when they were the sole caregiver. Findings from this research can guide nursing efforts to target caregiver training and support during this critical care transition. [Res Gerontol Nurs. 2019; 12(4):174-183.].

How home health nurses plan their work schedules: A qualitative descriptive study

AIMS AND OBJECTIVES

To describe how home health nurses plan their daily work schedules and what challenges they face during the planning process.

BACKGROUND

Home health nurses are viewed as independent providers and value the nature of their work because of the flexibility and autonomy they hold in developing their work schedules. However, there is limited empirical evidence about how home health nurses plan their work schedules, including the factors they consider during the process and the challenges they face within the dynamic home health setting.

DESIGN

Qualitative descriptive design.

METHODS

Semi-structured interviews were conducted with 20 registered nurses who had >2 years of experience in home health and were employed by one of the three participating home health agencies in the mid-Atlantic region of the United States. Data were analysed using conventional content analysis.

RESULTS

Four themes emerged about planning work schedules and daily itineraries: identifying patient needs to prioritise visits accordingly, partnering with patients to accommodate their preferences, coordinating visit timing with other providers to avoid overwhelming patients, and working within agency standards to meet productivity requirements. Scheduling challenges included readjusting the schedule based on patient needs and staffing availability, anticipating longer visits, and maintaining continuity of care with patients.

CONCLUSION

Home health nurses make autonomous decisions regarding their work schedules while considering specific patient and agency factors, and overcome challenges related to the unpredictable nature of providing care in a home health setting. Future research is needed to further explore nurse productivity in home health and improve home health work environments.

RELEVANCE TO CLINICAL PRACTICE

Home health nurses plan their work schedules to provide high quality care that is patient-centered and timely. The findings also highlight organisational priorities to facilitate continuity of care and support nurses while alleviating the burnout associated with high productivity requirements.