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Tsui EK, Reckrey JM, Franzosa E, LaMonica M, Gassama S, Boerner K. Awareness, Acceptance, Avoidance: Home Care Aides' Approaches to Death and End-of-Life Care. Omega (Westport) 2024; 89:550-566. [PMID: 35245148 DOI: 10.1177/00302228221078348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Death and dying are woven throughout the work of home care aides, and yet the care they provide at the end of life (EOL) remains poorly understood. This is due in part to the multiple circumstances under which aides provide EOL care. In this paper, we elucidate the EOL care experiences of aides working in home care agencies in New York City. We conducted in-depth interviews with 29 home care aides, and we analyzed these data using inductive, team-based methods. Our findings show that aides may not be aware of or accept a client's EOL status, and they may avoid EOL care. These conditions shape EOL care, and we detail the committed forms of care aides provide when they are aware and accepting. We recommend improved training, support systems, and policy change to enhance aides' contributions to EOL care, while protecting aides' health and well-being.
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Affiliation(s)
- Emma K Tsui
- Department of Community Health & Social Sciences, CUNY Graduate School of Public Health & Health Policy, 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
| | - 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
| | - Marita LaMonica
- Department of Community Health & Social Sciences, CUNY Graduate School of Public Health & Health Policy, New York, NY, USA
| | - Seedoumuktar Gassama
- Department of Community Health & Social Sciences, CUNY Graduate School of Public Health & Health Policy, New York, NY, USA
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts Boston, Boston, MA, USA
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Wexler MG, Watman D, Perez S, Ankuda C, Reckrey JM. "It shouldn't be like this": Family caregivers navigating insurance for family members with dementia. J Am Geriatr Soc 2024; 72:1453-1459. [PMID: 38280225 PMCID: PMC11090749 DOI: 10.1111/jgs.18779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/08/2023] [Accepted: 12/17/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Almost 11.3 million family caregivers of people with dementia must navigate the health insurance landscape to meet the complex medical and long-term care needs of their family members. This study explores factors that influence family caregivers' decisions about insurance and how these choices affect the care and support people with dementia receive. METHODS Semi-structured interviews were conducted from June 2022 to January 2023 with 15 family caregivers of people with dementia dual eligible for Medicaid and Medicare and enrolled in home-based primary care in New York City. A set of open-ended questions were asked exploring caregivers' perspectives on navigating insurance plans. Interviews were recorded, transcribed, and analyzed using thematic analysis with both deductive and inductive coding. RESULTS Analysis revealed three major themes: (1) challenges of Medicaid enrollment, (2) making do with existing insurance, and (3) mistrust of the insurance system. Initial enrollment in Medicaid compounded the stress of adjusting to caregiving. The enrollment process was impacted by clinical factors, financial factors, and input from providers and social workers; however, caregivers could not identify a centralized system for obtaining insurance information and support. Once Medicaid was in place, participants described advocating on behalf of their family member within the constraints of their current insurance plans (Medicare and Medicaid) and ensuring they had the necessary knowledge to understand their family member's coverage. Participants voiced a need for ongoing vigilance to ensure their family members received needed care and support. CONCLUSION The challenges family caregivers experience when navigating insurance for their family members with dementia contribute to caregiver burden. Robust and centralized professional support for family members both immediately after a family member's dementia diagnosis and as the disease progresses could increase caregivers' capacity to make insurance decisions that best support their family members with dementia.
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Affiliation(s)
| | - Deborah Watman
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sasha Perez
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Claire Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Reckrey JM, McKendrick K, Morrison RS, Osakwe ZT, Ornstein KA, Aldridge M. Variation in Hospice Aide Care by Residential Setting. J Palliat Med 2024. [PMID: 38647702 DOI: 10.1089/jpm.2023.0585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data from Medicare beneficiaries in the United States enrolled in the Medicare Current Beneficiary Survey (MCBS) who died between 2010 and 2019 and had hospice claims and available residential setting data in MCBS (n = 1,915). Analysis: Decedent hospice aide use was compared by residential settings; multivariable models controlling for sociodemographic, clinical/functional, and hospice characteristics examined factors associated with hospice aide care in different residential settings. Results: Hospice aide visits were least common in the community setting (64.4% vs. 76.6% vs. 72.6% with any hospice aide visits in community, assisted living, and nursing home, respectively, p = 0.001). In adjusted models, factors associated with hospice aide visits did not significantly differ by residential settings. Conclusions: Despite staff providing hands-on support in assisted livings and nursing homes, hospice aide visits were more common in residential as opposed to community settings, and factors associated with hospice aide visits were similar among settings. To maximize the potentially positive impact of hospice aides on overall care, additional work is needed to understand when hospice aides are used and how hospice aides collaborate with families and care teams. This will help to ensure that hospice care is appropriately tailored to individual care needs in all residential settings.
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Affiliation(s)
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zainab Toteh Osakwe
- Adelphi University College of Nursing and Public Health, New York, New York, USA
| | | | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Burgdorf JG, Ritchie CS, Reckrey JM, Liu B, McDonough C, Ornstein KA. Drivers of Community-Entry Home Health Care Utilization Among Older Adults. J Am Med Dir Assoc 2024; 25:697-703.e2. [PMID: 37931897 PMCID: PMC10990820 DOI: 10.1016/j.jamda.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES A growing proportion of Medicare home health (HH) patients are "community-entry," meaning referred to HH without a preceding hospitalization. We sought to identify factors that predict community-entry HH use among older adults to provide foundational information regarding care needs and circumstances that may prompt community-entry HH referral. DESIGN Nationally representative cohort study. SETTING AND PARTICIPANTS Health and Retirement Study (HRS) respondents who were aged ≥65 years, community-living, and enrolled in Medicare between 2012 and 2018 (n = 11,425 unique individuals providing 27,026 two-year observation periods). METHODS HRS data were linked with standardized HH patient assessments. Community-entry HH utilization was defined as incurring one or more HH episode with no preceding hospitalization or institutional post-acute care stay (determined via assessment item indicating institutional care within 14 days of HH admission) within 2 years of HRS interview. Weighted, multivariable logistic regression was used to model community-entry HH use as a function of individual, social support, and community characteristics. RESULTS The overall rate of community-entry HH utilization across observation periods was 13.4%. Older adults had higher odds of community-entry HH use if they were Medicaid enrolled [adjusted odds ratio (aOR) = 1.49, P = .001], had fair or poor overall health (aOR = 1.48, P < .001), 3+ activities of daily living limitations (aOR = 1.47, P = .007), and had fallen in the past 2 years (aOR = 1.43, P < .001). Compared with those receiving no caregiver help, individuals were more likely to use community-entry HH if they received family or unpaid help only (aOR = 1.81, P < .001), both family and paid help (aOR = 2.79, P < .001), or paid help only (aOR: 3.46, P < .001). CONCLUSIONS AND IMPLICATIONS Findings indicate that community-entry HH serves a population with long-term care needs and coexisting clinical complexity, making this an important setting to provide skilled care and prevent avoidable health care utilization. Results highlight the need for ongoing monitoring of community-entry HH accessibility as this service is a key component of home-based care for a high-need subpopulation.
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Affiliation(s)
- Julia G Burgdorf
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Catherine McDonough
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Center for Equity in Aging, Johns Hopkins School of Nursing, Baltimore, MD, USA.
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Osakwe ZT, Bollens-Lund E, Wang Y, Ritchie CS, Reckrey JM, Ornstein KA. Clinician Perception of Likelihood of Death in the Next Year Is Associated With 1-Year Mortality and Hospice Use Among Older Adults Receiving Home Health Care. J Palliat Med 2024; 27:481-486. [PMID: 38346312 PMCID: PMC10998701 DOI: 10.1089/jpm.2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 04/06/2024] Open
Abstract
Background: Given the complex care needs of older adults receiving home health care (HHC), it is important for HHC clinicians to identify those with limited prognosis who may benefit from a transition to hospice care. Objectives: To assess the association between HHC clinician-identified likelihood of death and (1) 1-year mortality, and (2) hospice use. Methods: Prospective cohort study from the National Health and Aging Trends Study (NHATS) waves 2011-2018, linked to the Outcomes and Assessment Information Set (OASIS) HHC assessment and Medicare data among 915 community-dwelling NHATS respondents. HHC clinician-identified likelihood of death/decline was determined using OASIS item M1034. Multivariable logistic regression was used to assess the association between clinician-identified likelihood of death/decline and 1-year mortality and hospice use. Results: HHC clinicians identified 42% of the sample as at increased risk of decline or death. One year mortality was 22.3% (n = 548), and 15.88% (n = 303) used hospice within 12 months of HHC. HHC clinician-perceived likelihood of death/decline was associated with greater odds of 1-year mortality (odds ratio [OR], 6.57; confidence interval (95% CI), 2.56-16.90) and was associated with greater likelihood of hospice use (OR, 1.61; 95% CI, 1.00-2.62). Conclusion: HHC clinician perception of patients' risk of death or decline is associated with 1-year mortality. A better understanding of HHC patients at high risk for mortality can facilitate improved care planning and identification of homebound older adults who may benefit from hospice.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, New York, USA
| | - Evan Bollens-Lund
- Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, New York, New York, USA
| | - Yihan Wang
- Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, New York, New York, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer M. Reckrey
- Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, New York, New York, USA
| | - Katherine A. Ornstein
- Center for Equity in Aging, Johns Hopkins University, School of Nursing, Baltimore, Maryland, USA
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Reckrey JM, Russell D, Fong MC, Burgdorf JG, Franzosa EC, Travers JL, Ornstein KA. Home Care Worker Continuity in Home-Based Long-Term Care: Associated Factors and Relationships With Client Health and Well-Being. Innov Aging 2024; 8:igae024. [PMID: 38505005 PMCID: PMC10946305 DOI: 10.1093/geroni/igae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 03/21/2024] Open
Abstract
Background and Objectives Despite the importance of provider continuity across healthcare settings, continuity among home care workers who provide hands-on long-term care is understudied. This project describes home care worker continuity, identifies factors associated with increased continuity, and examines associations between continuity and client outcomes. Research Design and Methods We conducted a retrospective cohort study of clients receiving Medicaid-funded home-based long-term care (n = 3,864) using insurance plan and home care agency data from a large nonprofit organization. We estimated home care worker continuity for clients between 6-month clinical assessments using Bice-Boxerman scores. We then used generalized estimating equations to model associations between home care worker continuity and (1) client characteristics (e.g., cognitive impairment), and (2) client functional, health, and psychosocial outcomes. Results While home care worker continuity was lowest for clients receiving the most weekly care hours, a range of continuity existed across all levels of care need. Those who were male, older, Asian/Pacific Islander/Native American, cognitively impaired, and functionally impaired had lower continuity. Higher home care worker continuity was significantly associated (p < .05) with fewer falls, a higher likelihood of functional improvement/stabilization, and fewer depressive symptoms. Discussion and Implications The finding that home care worker continuity is associated with the health and well-being of home-based long-term care clients underscores the importance of building high-quality relationships in long-term care. Continued efforts are necessary to understand and advance home care worker continuity and to identify other aspects of the home care experience that benefit those receiving long-term care at home.
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - David Russell
- VNS Health Center for Home Care Policy & Research, New York City, New York, USA
- Department of Sociology, Appalachian State University, Boone, North Carolina, USA
| | - Mei-Chia Fong
- L&M Policy Research, Washington, District of Columbia, USA
| | - Julia G Burgdorf
- VNS Health Center for Home Care Policy & Research, New York City, New York, USA
| | - Emily C Franzosa
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- James J. Peters VA Medical Center, Bronx, New York, USA
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Osakwe ZT, Calixte R, Bubu OM, Reckrey JM. Association Between Documented Severe Pain and Cognitive Impairment in Home Health Care Patients: Results from the National Outcome and Assessment Information Set Data. J Palliat Med 2023; 26:1662-1670. [PMID: 37751588 PMCID: PMC10714109 DOI: 10.1089/jpm.2023.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 09/28/2023] Open
Abstract
Background: Despite the growing importance of home health care (HHC) in the care of older adults with cognitive impairment, limited evidence exists about factors associated with documented severe pain among older adults receiving HHC. Methods: This secondary data analysis used a 5% random national sample of the 2017 national Outcome and Assessment Information Set (OASIS) data. Multivariable Poisson regression model was used to examine the association between documented severe pain, cognitive impairment, and a range of sociodemographic, clinical, and cognitive factors. Results: HHC patients (n = 183,038) were mean age 79.7 years, 61.7% female, and 78.6% non-Hispanic White. In multivariable models, cognitive impairment was associated with lower likelihood of documented severe pain (prevalence ratio [PR] = 0.96, confidence interval [CI] = [0.94-0.98]). Other factors independently associated with less documented severe pain included Hispanic ethnicity (PR = 0.92, CI = [0.89-0.95]), the oldest (≥85 years) groups (PR = 0.65, CI = [0.63-0.66]), male patients (PR = 0.83, CI = [0.82-0.85]), those with a formal diagnosis of Alzheimer's Disease Related Dementias (PR = 0.67, CI = [0.65-0.69]), and patients with verbal- and speech-related difficulty (PR = 0.83, CI = [0.80-0.86]). Patients with history of falls (PR = 1.18, CI = [1.16-1.20]), positive screen on the Patient Health Questionnaire-2 (PR = 1.36, CI = [1.31-1.41]), shortness of breath (PR = 1.14, CI = [1.12-1.14]), anxiety daily (PR = 1.16, CI = [1.14-1.18]), and anxiety daily or more often (PR = 1.40, CI = [1.37-1.43]) were more likely to have documented severe pain. Conclusions: HHC patients with cognitive impairment were less likely to have documented severe pain even with a range of sociodemographic, clinical, functional, and cognitive characteristics were considered. These findings may reflect a link between cognitive impairment missed opportunities for clinicians to provide pain management. Tailored interventions are needed to better assess and manage pain in this vulnerable group of HHC patients.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, New York, USA
| | - Rose Calixte
- Department of Epidemiology and Biostatistics, SUNY Downstate Health Sciences, University, Brooklyn, New York, USA
| | - Omonigho Michael Bubu
- Department of Psychiatry and Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Reckrey JM, Kleijwegt H, Morrison RS, Nothelle S, Kelley AS, Ornstein KA. Paid Care for People with Functional Impairment and Serious Illness: Results from the Health and Retirement Study. J Gen Intern Med 2023; 38:3355-3361. [PMID: 37349637 PMCID: PMC10681964 DOI: 10.1007/s11606-023-08262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Paid caregivers (e.g., home health aides) care for individuals living at home with functional impairment and serious illnesses (health conditions with high risk of mortality that impact function and quality of life). OBJECTIVE To characterize those who receive paid care and identify factors associated with receipt of paid care in the context of serious illness and socioeconomic status. DESIGN Retrospective cohort study. PARTICIPANTS Community-dwelling participants ≥ 65 years enrolled in the Health and Retirement Study (HRS) between 1998 and 2018 with new-onset functional impairment (e.g., bathing, dressing) and linked fee-for-service Medicare claims (n = 2521). MAIN MEASURES Dementia was identified using HRS responses and non-dementia serious illness (e.g., advanced cancer, end-stage renal disease) was identified using Medicare claims. Paid care support was identified using HRS survey report of paid help with functional tasks. KEY RESULTS While about 27% of the sample received paid care, those with both dementia and non-dementia serious illnesses in addition to functional impairment received the most paid care (41.7% received ≥ 40 h of paid care per week). In multivariable models, those with Medicaid were more likely to receive any paid care (p < 0.001), but those in the highest income quartile received more hours of paid care (p = 0.05) when paid care was present. Those with non-dementia serious illness were more likely to receive any paid care (p < 0.001), but those with dementia received more hours of care (p < 0.001) when paid care was present. CONCLUSIONS Paid caregivers play a significant role in meeting the care needs of those with functional impairment and serious illness and high paid care hours are common among those with dementia in particular. Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill throughout the income spectrum.
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Affiliation(s)
| | | | | | | | - Amy S Kelley
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, MD, USA
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Burgdorf JG, Mroz TM, Reckrey JM, Barrón Y, Ryvicker M. Prevalence and predictors of incident ADRD diagnosis following a Medicare home health episode. Alzheimers Dement 2023; 19:3936-3945. [PMID: 37057687 PMCID: PMC10523879 DOI: 10.1002/alz.13061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Home health (HH) may be an important source of care for those with early-stage/undiagnosed Alzheimer's Disease and Related Dementias (ADRD), but little is known regarding prevalence or predictors of incident ADRD diagnosis following HH. METHODS Using 2010-2012 linked Master Beneficiary Summary File (MBSF) and HH assessment data for 40,596 Medicare HH patients, we model incident ADRD diagnosis within 1 year of HH via multivariable logistic regression. RESULTS Among HH patients without diagnosed ADRD, 10% received an incident diagnosis within 1 year. In adjusted models, patients were three times more likely to receive an incident ADRD diagnosis if they had HH clinician-reported impaired overall cognition (compared to patients without reported impairment) and twice as likely if they were community-referred (compared to hospital-referred patients). DISCUSSION There is a pressing need to develop tailored HH clinical pathways and protect access to community-referred HH to support community-living older adults with early-stage/undiagnosed ADRD.
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Affiliation(s)
- Julia G. Burgdorf
- Center for Home Care Policy & Research at VNS Health, 220 E. 42 St, 6 Floor, New York, NY 10017
| | - Tracy M. Mroz
- Department of Rehabilitation Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356490, Seattle, WA 98195-6490
| | - Jennifer M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place Box 1216, New York NY 10029
| | - Yolanda Barrón
- Center for Home Care Policy & Research at VNS Health, 220 E. 42 St, 6 Floor, New York, NY 10017
| | - Miriam Ryvicker
- Center for Home Care Policy & Research at VNS Health, 220 E. 42 St, 6 Floor, New York, NY 10017
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Xu EL, Kim PS, Yee C, Zhang M, Reckrey JM, Lubetsky S, Zhao D, Ornstein KA, Franzosa E. "I Depend on Her for Everything": A Retrospective Chart Review of Home Care Worker Service Disruptions for Homebound Older Adults During the COVID-19 Pandemic. J Appl Gerontol 2023; 42:561-570. [PMID: 36283965 PMCID: PMC9597284 DOI: 10.1177/07334648221135584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022] Open
Abstract
Home care workers played critical roles in meeting the complex medical and social needs of homebound adults during COVID-19, yet their contributions remain underappreciated. This study characterizes home care workers' roles during COVID-19 and examines how home care disruptions impacted homebound individuals and caregivers. Using a qualitative analysis of electronic medical records among a randomly sampled subset of homebound patients in a home-based primary care practice, we found that home care workers were essential in meeting existing and new needs of homebound individuals. Insufficient home care worker services, including unstable schedules and inadequate hours of paid care, became particularly disruptive, leading to risks for patients and their caregivers. Given their integral role on care teams, home care workers must be a policy focus to prepare for emergent situations and ensure that homebound individuals have access to high quality, stable home care.
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Affiliation(s)
- Emily L Xu
- Department of Medical Education, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricia S Kim
- Brookdale Geriatric Research, Education and Clinical Center, New York, NY, USA
| | - Cynthia Yee
- Brookdale Geriatric Research, Education and Clinical Center, New York, NY, USA
| | - Meng Zhang
- Department of Internal Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jennifer M Reckrey
- Brookdale Geriatric Research, Education and Clinical Center, New York, NY, USA
| | - Sara Lubetsky
- Brookdale Geriatric Research, Education and Clinical Center, New York, NY, USA
| | - Duzhi Zhao
- Brookdale Geriatric Research, Education and Clinical Center, New York, NY, USA
| | | | - Emily Franzosa
- Brookdale Geriatric Research, Education and Clinical Center, New York, NY, USA
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12
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Reckrey JM, Perez S, Watman D, Ornstein KA, Russell D, Franzosa E. The Need for Stability in Paid Dementia Care: Family Caregiver Perspectives. J Appl Gerontol 2023; 42:607-616. [PMID: 35512123 PMCID: PMC9636070 DOI: 10.1177/07334648221097692] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Paid caregivers (e.g., home health aides, home care workers) provide essential care to people with dementia living at home; this study explored family caregiver perspectives on the role and impact of paid caregivers in home-based dementia care. We conducted semi-structured interviews with family caregivers (n = 15) of people with advanced dementia who received long-term paid care at home in New York between October 2020 and December 2020. We found that given the vulnerability resulting from advanced dementia, family caregivers prioritized finding the "right" paid caregivers and valued continuity in the individual providing care. The stable paid care that resulted improved outcomes for both the person with advanced dementia (e.g., eating better) and their family (e.g., ability to work). Those advocating for high quality, person-centered dementia care should partner with policymakers and home care agencies to promote the stability of well-matched paid caregivers for people with advanced dementia living at home.
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Affiliation(s)
| | - Sasha Perez
- 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deborah Watman
- 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Emily Franzosa
- 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.,20071James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
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13
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Fabius CD, Reckrey JM. The Time is Now: Spotlighting the Home Care Workforce Providing Essential Support to Older Adults. J Appl Gerontol 2023; 42:512-513. [PMID: 36647583 DOI: 10.1177/07334648221150308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Chanee D Fabius
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Franzosa E, Wyte-Lake T, Tsui EK, Reckrey JM, Sterling MR. Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies. J Am Med Dir Assoc 2022; 23:1990-1996. [PMID: 36343702 PMCID: PMC9634621 DOI: 10.1016/j.jamda.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.
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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,Address correspondence to Emily Franzosa DrPH, Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY
| | - Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Emma K. Tsui
- Graduate School of Public Health and Health Policy, City University of New York, 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,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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Reckrey JM, Ornstein KA, McKendrick K, Tsui EK, Morrison RS, Aldridge M. Receipt of Hospice Aide Visits Among Medicare Beneficiaries Receiving Home Hospice Care. J Pain Symptom Manage 2022; 63:503-511. [PMID: 34954065 PMCID: PMC8930441 DOI: 10.1016/j.jpainsymman.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Hospice aides provide essential direct care to hospice patients, yet there is minimal research examining hospice aide visits. OBJECTIVES describe the prevalence and frequency of hospice aide visits, and 2) evaluate patient, community, and hospice characteristics associated with these visits. METHODS Longitudinal cohort study of Medicare Current Beneficiary Survey (MCBS) participants who died between 2010-2018 and received routine hospice care in the 6 months prior to death (n = 674). We characterized prevalence and frequency of hospice aide visits over time and used generalized linear modelling to identify factors associated with visits. RESULTS 64% of hospice enrollees received hospice aide visits and average visit frequency (1.3 per week) remained stable throughout enrollment. The only patient characteristic associated with receipt of hospice aide visits was primary hospice diagnosis (respiratory diagnosis vs. dementia: OR 0.372, P = 0.040). Those living in community-based residential housing and those cared for by hospices with aides employed as staff were more likely to receive any hospice aide visits (OR 2.331, P = 0.047 and OR 4.612, P = 0.002, respectively.) CONCLUSION: Hospice aide visits are a common component of hospice care, but visit frequency does not increase as death approaches. Receipt of hospice aide visits was primarily associated with community and hospice agency (rather than patient) characteristics. Future work is needed to ensure that hospice aides are integrated in the hospice interdisciplinary team and that access to hospice aide visits is meaningfully driven by patient and family needs, rather than the practice norms and business models of individual hospice agencies.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York.
| | - Katherine A Ornstein
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Emma K Tsui
- CUNY Graduate School of Health and Health Policy (E.K..T.), New York, New York
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
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20
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Reckrey JM, Li L, Zhan S, Wolff J, Yee C, Ornstein KA. Caring Together: Trajectories of Paid and Family Caregiving Support to Those Living in the Community With Dementia. J Gerontol B Psychol Sci Soc Sci 2022; 77:S11-S20. [PMID: 35034123 PMCID: PMC9122661 DOI: 10.1093/geronb/gbac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Paid caregivers (e.g., home health aides) often work with family caregivers to support persons living with dementia at home. We identify (a) unique trajectories of paid and family caregiving support among persons living with dementia with high care needs and (b) factors associated with these trajectories. METHODS We used group-based multiple trajectory modeling to identify distinct trajectories of paid and family caregiving hours among National Health and Aging Trends Study respondents with dementia who died or moved to a nursing home (n = 334, mean follow-up 5.5 years). We examined differences between trajectory groups and identified factors associated with group membership using generalized estimating equation modeling. RESULTS A 3-group model best fit our data: (a) "low/stable care" (61.3% of respondents) with stable, low/no paid care and moderate family care, (b) "increasing paid care" with increasing, moderate paid and family care, and (c) "high family care" with increasing, high family care and stable, low paid care. While both the "increasing paid care" and "high family care" groups were more functionally impaired than the "low/stable care" group, the "high family care" group was also more likely to be non-White and experience multiple medical comorbidities, depression, and social isolation. DISCUSSION Study findings highlight the importance of considering unique arrangements in dementia care. Receipt of paid care was not only determined by patient care needs. Creating equitable access to paid care may be a particularly important way to support both persons living with dementia and their family caregivers as care needs grow.
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Affiliation(s)
- Jennifer M Reckrey
- Address correspondence to: Jennifer M. Reckrey, MD, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1216, New York, NY 10029, USA. E-mail:
| | - Lihua Li
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA,Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Serena Zhan
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jennifer Wolff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cynthia Yee
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA,Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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21
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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22
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Reckrey JM, Boerner K, Franzosa E, Bollens-Lund E, Ornstein KA. Paid Caregivers in the Community-Based Dementia Care Team: Do Family Caregivers Benefit? Clin Ther 2021; 43:930-941. [PMID: 33972126 DOI: 10.1016/j.clinthera.2021.03.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/18/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Older adults with dementia often rely on both paid caregivers (ie, home health aides, personal care attendants, other direct care workers) and family caregivers (ie, spouses, children, other unpaid individuals) to remain in the community. This study conceptualizes paid caregivers as part of the collaborative dementia care team and examines the association between receipt of paid care and primary family caregiver experience. METHODS Using data from 3 waves (2011, 2015, and 2017) of the National Health and Aging Trends Study linked to the National Study of Caregiving, community-dwelling Medicare beneficiaries aged ≥67 years with advanced dementia (n = 338 observations) were identified. Primary family caregiver experiences were compared among those with zero, part-time (<40 hours/week), and full-time (≥40 hours/week) paid care, and multivariable models were used to evaluate the associations between full-time paid care and family caregiver strain (eg, being overwhelmed due to caregiving) and activity restriction (eg, being unable to work for pay due to caregiving). FINDINGS About one half of the community-dwelling older adults with advanced dementia received paid care: 30% had part-time paid care and 18% had full-time paid care. The experiences of family caregivers of those receiving part-time and no paid care were not significantly different. After adjusting for family caregiver and care recipient characteristics, receipt of full-time paid care was associated with a nearly 70% reduced odds of having activity restrictions due to caregiving (odds ratio, 0.31; P = 0.01) and a reduction in mean caregiver strain score (-0.73; P = 0.04). There was no statistically significantly association between the odds of high caregiver strain (score ≥5) and receipt of paid care (odds ratio, 0.65; P = 0.33). IMPLICATIONS The provision of paid care for individuals with dementia in the community may benefit family caregivers. Future work should acknowledge the important ways that paid caregivers contribute to outcomes for all members of the collaborative dementia care team.
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Kathrin Boerner
- Department of Gerontology, McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, MA
| | - Emily Franzosa
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai and Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, New York, NY
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY
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23
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Reckrey JM, Yang M, Kinosian B, Bollens-Lund E, Leff B, Ritchie C, Ornstein K. Receipt Of Home-Based Medical Care Among Older Beneficiaries Enrolled In Fee-For-Service Medicare. Health Aff (Millwood) 2021; 39:1289-1296. [PMID: 32744949 DOI: 10.1377/hlthaff.2019.01537] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Millions of older Americans are homebound and may benefit from home-based medical care. We characterized the receipt of this care among community-dwelling, fee-for-service Medicare beneficiaries ages sixty-five and older surveyed in the National Health and Aging Trends Study between 2011 and 2017. Five percent of those surveyed received any home-based medical care between 2011 and 2017 (mean follow-up time per person was 3.4 years), and 75 percent of home-based medical care recipients were homebound. Only 11 percent of the total homebound population (approximately 4.4 million fee-for-service Medicare beneficiaries in 2017) received any home-based medical care between 2011 and 2017. Receipt of home-based medical care was more common among homebound beneficiaries living in metropolitan areas and assisted living facilities, which suggests that geographic factors create operational efficiencies for home-based medical care practices that may improve their financial sustainability within the fee-for-service reimbursement setting. The significant unmet needs of this high-need, high-cost population and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care.
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Affiliation(s)
- Jennifer M Reckrey
- Jennifer M. Reckrey is an associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, in New York, New York
| | - Mia Yang
- Mia Yang is an assistant professor of internal medicine and geriatrics and gerontology at the Wake Forest University School of Medicine, in Winston-Salem, North Carolina
| | - Bruce Kinosian
- Bruce Kinosian is an associate professor of geriatrics at the University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Evan Bollens-Lund
- Evan Bollens-Lund is a data analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Bruce Leff
- Bruce Leff is a professor of medicine in the Division of Geriatric Medicine at Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Christine Ritchie
- Christine Ritchie is a professor of palliative care and geriatric medicine at Massachusetts General Hospital, in Boston, Massachusetts
| | - Katherine Ornstein
- Katherine Ornstein is an associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai
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24
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Reckrey JM, Gazarian P, Reuben DB, Latham NK, McMahon SK, Siu AL, Ko FC. Barriers to implementation of STRIDE, a national study to prevent fall-related injuries. J Am Geriatr Soc 2021; 69:1334-1342. [PMID: 33580718 PMCID: PMC8177692 DOI: 10.1111/jgs.17056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/08/2021] [Accepted: 01/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Evaluations of complex models of care for older adults may benefit from simultaneous assessment of intervention implementation. The STRIDE (Strategies To Reduce Injuries and Develop confidence in Elders) pragmatic trial evaluated the effectiveness of a multifactorial intervention to reduce serious fall injuries in older adults. We conducted multi-level stakeholder interviews to identify barriers to STRIDE intervention implementation and understand efforts taken to mitigate these barriers. DESIGN Qualitative interviews with key informants. SETTING Ten clinical trial sites affiliated with practices that provided primary care for persons at increased risk for fall injuries. PARTICIPANTS Specially trained registered nurses working as Falls Care Managers (FCMs) who delivered the intervention (n = 13 individual interviews), Research Staff who supervised trial implementation locally (n = 10 group interviews, 23 included individuals), and members of Central Project Management and the National Patient Stakeholder Council who oversaw national implementation (n = 2 group interviews, six included individuals). MEASUREMENTS A semi-structured interview guide derived from the consolidated framework for implementation research (CFIR). RESULTS We identified eight key barriers to STRIDE intervention implementation. FCMs navigated complex relationships with patients and families while working with Research Staff to implement the intervention in primary care practices with limited clinical space, variable provider buy-in, and significant primary care practice staff and provider turnover. The costs of the intervention to individual patients and medical practices amplified these barriers. Efforts to mitigate these barriers varied depending on the needs and opportunities of each primary care setting. CONCLUSION The many barriers to implementation and the variability in how stakeholders addressed these locally may have affected the overall STRIDE intervention's effectiveness. Future pragmatic trials should incorporate simultaneous implementation aims to better understand how research interventions translate into clinical care that improves the lives of older adults.
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Affiliation(s)
| | | | - David B Reuben
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nancy K Latham
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Siobhan K McMahon
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA
| | - Albert L Siu
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
| | - Fred C Ko
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
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25
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Tsui EK, Franzosa E, Reckrey JM, LaMonica M, Cimarolli VR, Boerner K. Interventions to Reduce the Impact of Client Death on Home Care Aides: Employers' Perspectives. J Appl Gerontol 2021; 41:332-340. [PMID: 33522367 DOI: 10.1177/0733464821989859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
For home care agencies and aides, the death of clients has important, yet often unrecognized, workforce implications. While research demonstrates that client death can cause grief and job insecurity for aides, we currently lack home care agencies' perspectives on this issue and approaches to addressing it. This study uses key informant interviews with leaders from a diverse sample of eight New York City home care agencies to explore facilitators and barriers to agency action. We found that agencies engaged primarily in a range of informal, reactive practices related to client death, and relatively few targeted and proactive efforts to support aides around client death. While leaders generally acknowledged a need for greater aide support, they pointed to a lack of sustainable home care financing and policy resources to fund this. We recommend increased funding to support wages, paid time off, and supportive services, and discuss implications for future research.
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Affiliation(s)
- Emma K Tsui
- The City University of New York Graduate School of Public Health & Health Policy, New York City, USA
| | - Emily Franzosa
- James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, NY, USA.,Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | | | - Marita LaMonica
- The City University of New York Graduate School of Public Health & Health Policy, New York City, USA
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26
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Abstract
This cohort study compares family caregiver hours provided to those with vs without dementia during the last 10 years of life.
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Affiliation(s)
| | | | | | | | - Amy S Kelley
- Icahn School of Medicine at Mount Sinai, New York, New York
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27
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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28
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Reckrey JM, Tsui EK, Morrison RS, Geduldig ET, Stone RI, Ornstein KA, Federman AD. Beyond Functional Support: The Range Of Health-Related Tasks Performed In The Home By Paid Caregivers In New York. Health Aff (Millwood) 2020; 38:927-933. [PMID: 31158023 DOI: 10.1377/hlthaff.2019.00004] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paid caregivers (for example, home health aides and personal care attendants) are formally tasked with helping older adults with functional impairment meet their basic needs at home. This study used thirty semistructured interviews with dyads of patients or their proxies and their paid caregivers in New York City to understand the range of health-related tasks that paid caregivers perform in the home and determine whether these tasks are taught in the New York State Department of Health's curriculum. We found that patients, proxies, and paid caregivers all reported that paid caregivers performed a wide range of health-related tasks that were often not part of their formal training. Creating clear competencies for paid caregivers that reflect the full breadth of health-related tasks they may perform in the home could help maximize the positive impact of the paid caregiver workforce on the lives of patients living at home with functional impairment.
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Affiliation(s)
- Jennifer M Reckrey
- Jennifer M. Reckrey ( ) is an associate professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City
| | - Emma K Tsui
- Emma K. Tsui is an assistant professor of community health and social sciences at the City University of New York School of Public Health, in New York City
| | - R Sean Morrison
- R. Sean Morrison is a professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Emma T Geduldig
- Emma T. Geduldig is a student in the Department of Medical Education, Icahn School of Medicine at Mount Sinai
| | - Robyn I Stone
- Robyn I. Stone is senior vice president for research at LeadingAge, in Washington, D.C
| | - Katherine A Ornstein
- Katherine A. Ornstein is an assistant professor in the Department of Geriatrics and Palliative Medicine and the Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai
| | - Alex D Federman
- Alex D. Federman is a professor in the Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai
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29
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Abstract
Despite high-intensity caregiving support, those with dementia may experience adverse consequences because the care they receive does not match their care needs. This study evaluates the relationship between content of care (i.e., specific assistance with toileting) and adverse consequences (i.e., toileting accidents because no one was there to help) in a population of community-dwelling Medicare beneficiaries with dementia and impairment in toileting enrolled in the National Health and Aging Trends Study (NHATS). Only two thirds of individuals received specific assistance with toileting, which was associated with a reduced risk of adverse consequences related to toileting in a multivariable model adjusted for key variables including high-intensity caregiving (odds ratio [OR] = 0.36, 95% confidence interval [CI] = [0.23, 0.58]). To ensure care meets the needs of those with dementia living in the community, it is important to consider not only the quantity but also the content of care received.
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30
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Reckrey JM. COVID-19 Confirms It: Paid Caregivers Are Essential Members of the Healthcare Team. J Am Geriatr Soc 2020; 68:1679-1680. [PMID: 32424889 PMCID: PMC7276871 DOI: 10.1111/jgs.16566] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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31
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Aldridge MD, Ornstein KA, McKendrick K, Moreno J, Reckrey JM, Li L. Trends In Residential Setting And Hospice Use At The End Of Life For Medicare Decedents. Health Aff (Millwood) 2020; 39:1060-1064. [PMID: 32479223 PMCID: PMC8045974 DOI: 10.1377/hlthaff.2019.01549] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
As more people live and die in the community despite complex health needs and functional impairment, the need for hospice increases. We found high and increasing penetration of hospice in community-based residential settings, compared with hospice use in private residences and nursing homes.
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Affiliation(s)
- Melissa D Aldridge
- Melissa D. Aldridge is a professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City, and the James J. Peters Bronx Veterans Affairs Medical Center, in the Bronx, New York
| | - Katherine A Ornstein
- Katherine A. Ornstein is an associate professor in the Department of Geriatrics and Palliative Medicine and the Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai
| | - Karen McKendrick
- Karen McKendrick is a senior data analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Jaison Moreno
- Jaison Moreno is a data analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Jennifer M Reckrey
- Jennifer M. Reckrey is an associate professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Lihua Li
- Lihua Li is an assistant professor in the Department of Population Health, Icahn School of Medicine at Mount Sinai
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32
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Reckrey JM, Geduldig ET, Lindquist LA, Morrison RS, Boerner K, Federman AD, Brody AA. Paid Caregiver Communication With Homebound Older Adults, Their Families, and the Health Care Team. Gerontologist 2020; 60:745-753. [PMID: 31112604 DOI: 10.1093/geront/gnz067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although paid caregivers (e.g., home health aides and home care workers) provide essential care for homebound older adults with serious illness in their homes, little is known about how and to whom paid caregivers communicate about the health needs they encounter. This study explored how paid caregivers (i) communicate when older adults experience symptoms or clinical changes and (ii) interact with the health care team. RESEARCH DESIGN AND METHODS We conducted separate one-on-one, semi-structured interviews (n = 30) lasting 40-60 min with homebound older adults (or their proxies if they had cognitive impairment) and their paid caregivers (provided they had worked with the older adult for ≥8 hr per week for ≥6 months). Interviews were audio-recorded, transcribed, and coded. RESULTS Thematic analysis identified four themes: (i) older adults or their families were the gatekeepers to paid caregiver communication with the health care team; (ii) communication between older adults, their families, and paid caregivers was enhanced when close relationships were present; (iii) paid caregivers responded to health care team inquiries but rarely communicated proactively; and (4) most older adults, families, and paid caregivers were satisfied with existing paid caregiver communication with the health care team. DISCUSSION AND IMPLICATIONS Rather than discuss concerns with the health care team, paid caregivers communicated directly with older adults or their families about the health needs they encounter. Understanding how communication occurs in the home is the first step to maximizing the potentially positive impact of paid caregivers on the health of older adults living at home.
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emma T Geduldig
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lee A Lindquist
- Department of Medicine, Division of General Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts Boston, New York
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Abraham A Brody
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York.,New York University Rory Meyers College of Nursing
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33
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Linda V DeCherrie
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth T McCormick
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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34
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Reckrey JM, Morrison RS, Boerner K, Szanton SL, Bollens-Lund E, Leff B, Ornstein KA. Living in the Community With Dementia: Who Receives Paid Care? J Am Geriatr Soc 2020; 68:186-191. [PMID: 31696511 PMCID: PMC6957088 DOI: 10.1111/jgs.16215] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Paid caregivers (eg, home health aides and personal care attendants) provide hands-on care that helps individuals with dementia live in the community. This study (a) characterizes paid caregiving among community-dwelling individuals with dementia and (b) identifies factors associated with receipt of paid care. DESIGN Cross-sectional analysis. SETTING The 2015 National Health and Aging Trends Study (NHATS), a nationally representative study of Medicare recipients aged 65 years and older. PARTICIPANTS Community-dwelling individuals with dementia (n = 899). MEASUREMENTS Paid and family caregiving support was determined by participant or proxy report of help received with functional tasks. Multivariable logistic regression was used to examine factors associated with receipt of paid care. NHATS population sampling weights were used to produce national paid caregiving prevalence estimates. RESULTS Only 25.5% of community-dwelling individuals with dementia received paid care, and 10.8% received 20 hours or more of paid care per week. For those who received it, paid care accounted for approximately half of the 83 total caregiving hours (paid and family) that they received each week. Among the subgroup of individuals with advanced dementia (those with impairment in dressing, bathing, toileting, and managing medications and finances), nearly half (48.3%) received paid care. Multivariable analysis, adjusting for sociodemographic, family caregiving support, functional, and clinical characteristics, found that the odds of receiving paid care were higher among men (odds ratio [OR] = 1.91; 95% confidence interval [CI] = 1.24-2.95), the unmarried (OR = 2.20; 95% CI = 1.31-3.70), those with Medicaid (OR = 2.16; 95% CI = 1.27-3.66), and those requiring more help with activities of daily living (ADLs) (OR = 1.32; 95% CI = 1.18-1.48) and instrumental ADLs (OR = 1.29; 95% CI = 1.14-1.46). CONCLUSIONS New ways of making paid caregiving more accessible throughout the income spectrum are required to support family caregivers and respect the preferences of individuals with dementia to remain living in the community. J Am Geriatr Soc 68:186-191, 2019.
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Affiliation(s)
- Jennifer M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - R. Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
- James J. Peters VA Medical Center, McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston
| | - Kathrin Boerner
- Department of Gerontology, McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston
| | - Sarah L. Szanton
- Johns Hopkins School of Nursing, Center for Transformative Geriatric Research, Johns Hopkins School of Medicine
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Bruce Leff
- Department of Medicine, Division of Geriatrics, Center for Transformative Geriatric Research, Johns Hopkins School of Medicine
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
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35
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Tsui EK, Wang WQ, Franzosa E, Gonzalez T, Reckrey JM, Sterling MR, Baron S. Training to Reduce Home Care Aides' Work Stress Associated with Patient Death: A Scoping Review. J Palliat Med 2019; 23:1243-1249. [PMID: 31855094 DOI: 10.1089/jpm.2019.0441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Home care workers (HCWs)-including home health aides, personal care aides, and other direct care workers-provide functional and other essential support that allows older, disabled, and seriously ill people to live at home. As a growing number of patients are aging and dying at home, HCWs are increasingly providing care at the end of life (EOL). Although prior qualitative studies have shown that patient death is an impactful and challenging experience for HCWs, the majority of HCWs receive almost no training on EOL issues. Objective: The goal of this scoping review is to identify intervention studies describing training of HCWs in EOL issues to map types of training and to assess the degree to which existing efforts address HCW health and well-being. Design: Our scoping review covered three databases and focused on articles published in English since 2000. Results: Of the 393 articles screened, 26 underwent full-text review and 6 met inclusion criteria. Only one article discussed training designed for and implemented with HCWs exclusively. Other trainings simultaneously targeted multiple kinds of workers. Supporting HCWs in reducing their stress and improving their coping skills was substantially addressed in only one article, although HCWs' emotional needs were addressed less centrally in several others. Conclusion: Our findings suggest that there is a paucity of EOL training interventions tailored specifically to the experiences and positioning of HCWs. We recommend that future intervention studies address the multiple facets of HCWs' stress related to patient death to improve EOL care in the home.
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Affiliation(s)
- Emma K Tsui
- Department of Community Health and Social Sciences, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Wei-Qian Wang
- Department of Counseling and Clinical Psychology, Columbia University, New York, New York, USA
| | - Emily Franzosa
- Department of Community Health and Social Sciences, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Tailisha Gonzalez
- Department of Community Health and Social Sciences, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Jennifer M Reckrey
- Departments of Medicine and Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madeline R Sterling
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sherry Baron
- Barry Commoner Center for Health and the Environment, Queens College, City University of New York, Flushing, New York, USA
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Reckrey JM, Hua P, Ornstein K. ADVERSE CONSEQUENCES OF UNMET NEEDS AMONG INDIVIDUALS WITH DEMENTIA: THE ROLE OF PAID CAREGIVING. Innov Aging 2019. [PMCID: PMC6844726 DOI: 10.1093/geroni/igz038.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Individuals with dementia may enlist help from paid caregivers (i.e. home health aides, personal care attendants) to address increasingly complex care needs. Yet it is unclear what specific tasks paid caregivers help with and how this is related to the individual’s experience of unmet care needs. We used data from the 2015 National Health and Aging Trends Study (NHATS) to examine the association between type and intensity of individual paid caregiver tasks and adverse consequences of unmet needs among community-dwelling adults with dementia. Nearly one half (46%) of those with any functional impairment reported an adverse consequence of an unmet need (e.g., inability to go outside because of lack of help). Individuals who experienced adverse consequences were more likely to receive paid caregiving (37.9% vs. 21.4%, p<0.01). Those who received paid care with an individual task (e.g. toileting) were more likely to report an adverse consequence related to that task (e.g. remaining in wet or soiled clothes 50.2% vs. 41.0%, p=0.21). Paid caregivers provided a median of 15 hours of care per week. For those persons with dementia receiving less hours of care weekly, paid caregivers rarely helped with unscheduled or frequently recurring functional tasks like toileting or eating (<10% of the time). The help received by individuals with dementia was inadequate to meet their care needs. Paid caregiving will only be able to prevent adverse consequences of unmet care needs when the level of paid care provided is better matched to the care needs of the individual with dementia.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Peiying Hua
- Icahn School of Medicine at Mount Sinai, New York, United States
| | - Katherine Ornstein
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Reckrey JM, Tsui E, Morrison RS, Geduldig E, Stone R, Ornstein K, Federman A. THE HEALTH-RELATED TASKS PAID CAREGIVERS IN NEW YORK STATE PERFORM IN THE HOME. Innov Aging 2019. [PMCID: PMC6846062 DOI: 10.1093/geroni/igz038.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Paid caregivers (e.g. home health aides, personal care attendants) are formally tasked with helping older adults with functional impairment meet their basic needs at home. This study used semi-structured interviews (n=30) with dyads of patients or their proxies and their paid caregivers in New York City to 1) understand the range of health-related tasks paid caregivers perform in the home and 2) determine if these tasks are taught in the New York State government’s Department of Health curricula. We found that patients, proxies, and paid caregivers all described that paid caregivers performed a wide range of health-related tasks that were often not a part of their formal training. Creating clear competencies for paid caregivers that reflect the full breadth of health-related tasks they may perform at home will help maximize the potentially positive impact of the paid caregiver workforce on the lives of patients living at home with functional impairment.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Emma Tsui
- CUNY Graduate School of Public Health and Health Policy, New York, New York, United States
| | - R S Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Emma Geduldig
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Robyn Stone
- Leading Age, Washington, District of Columbia, United States
| | - Katherine Ornstein
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Alex Federman
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Reckrey JM, Bowers B. BEYOND FUNCTIONAL SUPPORT: PAID CAREGIVERS AND THE HEALTH OF OLDER ADULTS. Innov Aging 2019. [PMCID: PMC6846061 DOI: 10.1093/geroni/igz038.789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
This symposium will explore role that paid caregivers (e.g. home health aides, personal care attendants, and other direct care workers) play in the health and team-based healthcare of older adults living in the community. The large and growing workforce of paid caregivers witness the changes in health status, chronic health needs, and psychosocial stressors of the older adults they care for. Yet existing research on paid caregivers has largely been limited to workforce issues such as recruitment, retention, and job satisfaction. The unique potential of paid caregivers to impact the health of their clients remains largely unstudied. The first presenter will describe results from qualitative interviews with seriously ill older adults and their long-time paid caregivers that found that paid caregivers perform a wide variety of health-related tasks in the course of their routine care. The second presenter will describe results from focus groups with paid caregivers that found that though not a part of the official care plan, paid caregivers provided deliberate cognitive, emotional, and social care that sought to improve their clients’ “total” health. The third presenter will outline the rationale for and development of an educational intervention aiming to improve paid caregiver’s ability to provide care to patients with heart failure. Finally, the fourth presenter will discuss the limited role paid caregivers currently play in the healthcare team. She will then highlight key policy, educational, and clinical recommendations to promote further paid caregiver integration in the healthcare team.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Barbara Bowers
- University of Wisconsin-Madison, School of Nursing, Madison, Wisconsin, United States
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Abstract
The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.
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Affiliation(s)
- Jennifer M Reckrey
- Associate Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA.,Associate Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Alex D Federman
- Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Evan Bollens-Lund
- Data Analytics Manager, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - R Sean Morrison
- Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Katherine A Ornstein
- Associate Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
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Reckrey JM, DeCherrie LV, Dugue M, Rosen A, Soriano TA, Ornstein K. Meeting the Mental Health Needs of the Homebound: A Psychiatric Consult Service Within a Home-Based Primary Care Program. ACTA ACUST UNITED AC 2018; 16:122-8. [PMID: 26414814 DOI: 10.1891/1521-0987.16.3.122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.
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Abstract
Despite the growing homebound population and the development of innovative models of care that work to bring care to people in their homes, home visits are not a routine part of education for many healthcare providers. This manuscript describes the experience of Mount Sinai Visiting Doctors teaching home-based primary care to learners of various disciplines and reports the results of a survey performed to assess trainee experience. Mount Sinai Visiting Doctors is the largest academic home-based primary care program in the country and trainees of various disciplines have nearly 1,700 contact days annually of directly supervised clinical teaching. In order to improve trainee education and meet our practice needs, trainees: 1) independently conduct urgent visits, 2) carry longitudinal panels of homebound patients, and 3) perform subspecialist consultations. Mount Sinai Visiting Doctors has exposed thousands of trainees to home-based primary care in the past 20 years and trainees report positive reviews of their experiences. As the need to train future providers in home-based primary care grows, we will be challenged to provide trainees with adequate exposure to multidisciplinary teams and to teach about the importance of continuity of care.
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Affiliation(s)
- Jennifer M Reckrey
- Jennifer M. Reckrey, MD, is an Assistant Professor, Department of Geriatrics and Palliative Medicine, and Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. Katherine A. Ornstein, PhD, is an Assistant Professor, Department of Geriatrics and Palliative Medicine, and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York. Ania Wajnberg, MD, is an Associate Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. M. Victoria Kopke, MD, is an Assistant Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. Linda V. DeCherrie, MD, is an Associate Professor, Department of Geriatrics and Palliative Medicine, and Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Reckrey JM, Brody AA, McCormick ET, DeCherrie LV, Zhu CW, Ritchie CS, Siu AL, Egorova NN, Federman AD. Rationale and design of a randomized controlled trial of home-based primary care versus usual care for high-risk homebound older adults. Contemp Clin Trials 2018; 68:90-94. [PMID: 29588167 DOI: 10.1016/j.cct.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, NY, United States; Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, United States
| | - Elizabeth T McCormick
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Linda V DeCherrie
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Carolyn W Zhu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, United States
| | - Christine S Ritchie
- Department of Medicine, University of California San Francisco, School of Medicine, San Francisco, CA, United States
| | - Albert L Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, United States
| | - Natalia N Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Yang N, Ornstein KA, Reckrey JM. Association Between Symptom Burden and Time to Hospitalization, Nursing Home Placement, and Death Among the Chronically Ill Urban Homebound. J Pain Symptom Manage 2016; 52:73-80. [PMID: 27033155 PMCID: PMC5369236 DOI: 10.1016/j.jpainsymman.2016.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/10/2016] [Accepted: 02/13/2016] [Indexed: 10/22/2022]
Abstract
CONTEXT Homebound adults experience significant symptom burden. OBJECTIVES To examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death. METHODS Three hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death. RESULTS Of the study sample, 45% had severe symptom burden (i.e., Edmonton Symptom Assessment Scale score >6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P < 0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P < 0.01), higher prevalence of depression (43.4% vs. 12.0%, P < 0.01), lower prevalence of dementia (34.3% vs. 60.6%, P < 0.01), and used fewer hours of home health services (73.6 vs. 94.4 hours/wk, P < 0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio = 1.51, 95% CI 1.06-2.15) in adjusted models but had no association with time to nursing home placement or death. CONCLUSION The homebound with severe symptom burden represents a unique cohort of patients who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population.
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Affiliation(s)
- Nancy Yang
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Katherine A Ornstein
- 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
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Reckrey JM, Soriano TA, Hernandez CR, DeCherrie LV, Chavez S, Zhang M, Ornstein K. The team approach to home-based primary care: restructuring care to meet individual, program, and system needs. J Am Geriatr Soc 2015; 63:358-64. [PMID: 25645568 DOI: 10.1111/jgs.13196] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.
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Affiliation(s)
- Jennifer M Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai School of Medicine, New York City, New York; Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai School of Medicine, New York City, New York
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Abstract
The growing homebound population has many complex biomedical and psychosocial needs and requires a team-based approach to care (Smith, Ornstein, Soriano, Muller, & Boal, 2006). The Mount Sinai Visiting Doctors Program (MSVD), a large interdisciplinary home-based primary care program in New York City, has a vibrant social work program that is integrated into the routine care of homebound patients. We describe the assessment process used by MSVD social workers, highlight examples of successful social work care, and discuss why social workers' individualized care plans are essential for keeping patients with chronic illness living safely in the community. Despite barriers to widespread implementation, such social work involvement within similar home-based clinical programs is essential in the interdisciplinary care of our most needy patients.
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Abstract
OBJECTIVE To describe informal caregiver and patient characteristics associated with high caregiver burden in homebound elders and to examine associations between high caregiver burden and patient health care utilization at the practice level. METHOD We used a cross-sectional and prospective cohort design to study 214 caregiver-patient dyads in a home-based primary care program. RESULTS Informal caregivers with the highest burden were more likely to help with more activities of daily living and instrumental activities of daily living and spend >40 hr/week in caregiving. Patients whose caregivers experienced the highest burden were more likely to be non-White males without 24-hr paid homecare. There were no significant independent associations between high burden and high calls, high visits, or social work involvement. DISCUSSION In this medically complex and highly dependent population, further study of how families and other caregivers impact health care utilization is needed.
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Reckrey JM, Diane McKee M, Sanders JJ, Lipman HI. Resident Physician Interactions with Surrogate Decision-Makers: The Resident Experience. J Am Geriatr Soc 2011; 59:2341-6. [DOI: 10.1111/j.1532-5415.2011.03728.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine; Mount Sinai School of Medicine; New York; New York
| | - M. Diane McKee
- Department of Family and Social Medicine; Albert Einstein College of Medicine; Bronx; New York
| | - Justin J. Sanders
- Department of Family and Social Medicine; Montefiore Medical Center; Bronx; New York
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