Toward a Comprehensive Care Intensity Instrument for Home Healthcare: Integrating Patient and Nursing Determinants

Improving the Quality of Home Health Care for Children With Medical Complexity

<i>A Question of Accessibility:</i> Understanding Lay Users Of Medical Devices

Home health care (HHC) provides skilled nursing (e.g., wound care, medication management), therapies (e.g., physical, occupational, speech), and aide services (e.g. bathing, grooming, dressing), which are key supports necessary to regain function, restore health, and maintain independence in the community. This panel presents five studies examining factors that challenge equitable access and high quality outcomes associated with skilled HHC among vulnerable older populations (i.e., Veterans, people living with dementia, patients needing post-acute care). The first panelist will discuss findings using national-level HHC quality data demonstrating that access to high-quality HHC varies widely across the country for people with dementia. The second panelist will share findings from a novel data linkage using Medicare Advantage (MA) and traditional Medicare claims to understand variation in use of HHC among people living with dementia. The third panelist’s presentation will focus on a particularly vulnerable population - hospitalized older Veterans - and how payer source shapes the use of post-acute HHC. The fourth panelist will discuss results from a qualitative study with MA plans about how they design and manage post-acute HHC benefits. The final presenter will share results from an analysis of national standardized HHC assessment data to identify failures in information transfer that impact care delivery and quality for HHC patients living with dementia. The discussant, a national industry leader with over two decades of experience working in the delivery of HHC, will contextualize findings and discuss how they can inform national policy discussions around improving access and quality of HHC.

Population aging is one of the significant global issues. Long-term care is emphasized as “aging in place,” and it is known that home and community-based service is a cost-effective way to achieve this. Over ten years have passed since the introduction of long-term care insurance in Korea, and it is necessary to improve home health care in long-term care. The aim of this study was to identify the measures that must be undertaken for enhancing home health care in Korea by comparing it to the home health care in Finland. The data were collected via a literature review, expert interview, and field survey in Kuopio, Eastern Finland, from March 16 to 23, 2018. Based on the comparison between Korean and Finnish home health care, some issues related to home health care in Korea that need to be resolved were identified: the complex process involved in availing home health care, low utilization rate, higher cost than home health aide services in long-term care, and undifferentiated roles in home health care between registered nurses and nurse assistants. Several strategies could be utilized to enhance home health care in Korea, such as a simplified procedure to use home health care, clarification of roles between registered nurses and nurse assistants in home care, supervision of the integration of home care services by registered nurses, and an expansion of home health care into comprehensive assessment and nursing activities for chronic illness care and health promotion.

In recent years, public reporting, targeted financial penalties, and incentives to develop alternative payment models that include the assumption of financial risk have compelled hospitals to focus on reducing readmission rates for high-cost conditions such as heart failure (HF). When older patients with multiple medical conditions including HF are discharged from the hospital, they are vulnerable to adverse events, which may result in recurrent hospitalization (the post-hospital syndrome).1 In theory, providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. Within the United States, home health care (HHC) referrals after acute care hospitalization increased by 65% to 3.7 million between 2001 and 2012.2,3 Patients discharged from US hospitals with a primary diagnosis of HF had the highest number of HHC referrals during this time, with ≈200 000 post-acute HHC referrals in 2012.2 In addition, HHC surpassed skilled nursing facilities as the most frequently used post-acute care among Medicare beneficiaries with HF in 2012 (unpublished HCUPnet data). Such an increase in HHC use for patients with HF is likely related to multiple factors, including decreasing length of stay for patients with HF4 and more recent pressures to improve readmission rates for HF after adoption of the Affordable Care Act in 2010, which included the Hospital Readmissions Reduction Program that was implemented in 2012.5,6 Despite substantial growth in post-acute HHC referrals for patients with HF,2 it is unclear whether HHC delivered in real-world settings consistently provides high-value care. Understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care. Because most patients referred for skilled HHC are Medicare beneficiaries, Medicare eligibility and payment policies have important implications for HHC. Patients who …

In 2007, there were 14,500 home health and hospice care agencies in the United States, an increase from 11,400 in 2000. Three-quarters of these agencies provided home health care only, 15% provided hospice care only, and 10% provided both home health and hospice care (mixed). The percentage of proprietary home health care only and hospice care only agencies increased during 1996-2007, whereas the percentage of proprietary mixed agencies remained relatively stable. The average number of home health care patients that home health care only and mixed agencies served decreased, while the average number of hospice care patients that hospice care only agencies served increased across years. Among mixed agencies, no significant changes were observed in the average number of hospice care patients being served. The percentage of home health care only agencies offering certain therapeutic and nonmedical services declined over the years. There was an increase in the proportion of hospice care only agencies' providing many core and noncore hospice care services during 1996-2007. Also during this time, the proportion of mixed agencies providing selected nonmedical services decreased.

Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States.

Urban-rural disparities in medical care, including in home healthcare, persist globally. With aging populations and medical advancements, demand for home health services rises, warranting investigation into home healthcare disparities. Our study aimed to (i) investigate the impact of rurality on home healthcare quality, and (ii) assess the temporal disparities and the changes in disparities in home healthcare quality between urban and rural home health agencies (HHAs), incorporating an analysis of geospatial distribution to visualize the underlying patterns. This study analyzed data from HHAs listed on the Centers for Medicare and Medicaid Services website, covering the period from 2010 to 2022. Data were classified into urban and rural categories for each HHA. We employed panel data analysis to examine the impact of rurality on home healthcare quality, specifically focusing on hospital admission and emergency room (ER) visit rates. Disparities between urban and rural HHAs were assessed using the Wilcoxon test, with results visualized through line and dot plots and heat maps to illustrate trends and differences comprehensively. Rurality is demonstrated as the most significant variable in hospital admission and ER visit rates in the panel data analysis. Urban HHAs consistently exhibit significantly lower hospital admission rates and ER visit rates compared to rural HHAs from 2010 to 2022. Longitudinally, the gap in hospital admission rates between urban and rural HHAs is shrinking, while there is an increasing gap in ER visit rates. In 2022, HHAs in Mountain areas, which are characterized by a higher proportion of rural regions, exhibited higher hospital admission and ER visit rates than other areas. This study underscores the persistent urban-rural disparities in home healthcare quality. The analysis emphasizes the ongoing need for targeted interventions to address disparities in home healthcare delivery and ensure equitable access to quality care across urban and rural regions. Our findings have the potential to inform policy and practice, promoting equity and efficiency in the long-term care system, for better health outcomes throughout the USA.

Patient-clinician relationships are fundamental attributes of high-quality home health care (HHC); yet little is known about patient-clinician relationships in HHC (where 5 million Medicare beneficiaries receive care annually). The objective of the study was to describe perspectives of HHC patients and HHC clinicians about patient-clinician relationships in HHC. We conducted a secondary qualitative analysis of semi-structured interviews (n=34) from a completed qualitative study investigating perspectives of older adult HHC patients (or caregivers as proxy) and their HHC clinicians (17 pairs) on discharge preparedness in a large HHC organization in North-Carolina. A conceptual model of patient-clinician relationships guided content analysis of the interview data. HHC patients identified as White (65%) and black (35%). Most HHC patients reported female sex (53%) and average age was 83 years (range= 69-93). Clinicians were registered nurses and physical therapists. Across the patient-clinician pairs, HHC patients valued relationships with clinicians with shared commonalities and those who provided reciprocal informational exchange and respected their autonomy. HHC clinicians valued relationships in which they felt helpful and respected as a healthcare professional. Relational conflicts arose when there was discordance in expectations of care (e.g., type of HHC services provided). Conflicts also arose when organizational constraints, such as disruptive scheduling, limited HHC visit time, and when limited continuity of care prevented the formation of patient-clinician relationships. Relational conflicts and organizational constraints influence patient-clinician relationships in HHC. Multi-level interventions (targeting modifiable factors at the patient, clinician, and organizational levels) are needed to improve the patient-clinician relationships and the quality of HHC.

The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admission: a systematic review protocol

Home health care services are provided to more than 2,900 patients in the Madinah region in Saudi Arabia, and vary according to the patient’s needs and level of care required. The home health care center in Medina alone provides services to more than 700 patients. Nursing care is considered one of the main pillars of home health care, and all home health care centers depend on nurses to provide service. This makes the quality of nursing services in home health care one of the most important means of identifying the level of service quality in general in-home health care. In this article, the researcher aimed to determine the quality of nursing services based on patient and family caregiver satisfaction with the services provided; identify the most important factors that affect patients’ and family caregivers’ level of satisfaction; and determine whether there is a relationship between service quality, patient satisfaction, and improvement of the patient’s health in general. A cross-sectional method was used in this article; the Home Nursing Quality Scale (HNQS) questionnaire was translated into Arabic and distributed to participants via Google Forms. There were 267 participants in this article; the majority were female (54.7%), whereas only 45.3% were male. The patients’ and family caregivers’ level of education was one of the strongest factors affecting the extent of patient satisfaction, where satisfaction decreased with an increase in education level, i.e., patients and family caregivers with postgraduate degrees had mean scores of 3.83 (standard deviation [SD] = 1.17) and patients and family caregivers with primary degree had mean scores of 4.68 (SD = 0.76). Likewise, the age factor also affected the level of satisfaction: older patients and family caregivers were more satisfied, where patients and family caregivers aged &gt;65 years had mean scores of 4.84 (SD = 0.37). There was a strong and positive relationship between nursing care quality and level of satisfaction among patients and family caregivers with home health care, which reflected the health status of the patients. Moreover, nursing managers and home health care managers must implement interventions to empower patients and caregivers to be more aware and capable of understanding the level of quality in the care provided by home health care nurses. Keywords: Patient Satisfaction, Nursing Care, Quality DOI: 10.7176/JHMN/100-08 Publication date: May 31 st 2022

A clinician's biased behavior toward patients can affect the quality of care. Recent literature reviews report on widespread implicit biases among clinicians. Although emerging studies in hospital settings show racial biases in the language used in clinical documentation within electronic health records, no studies have yet investigated the extent of judgment language in home health care. We aimed to examine racial differences in judgment language use and the relationship between judgment language use and the amount of time clinicians spent on home visits as a reflection of care quality in home health care. This study is a retrospective observational cohort study. Study data were extracted from a large urban home health care organization in the Northeastern United States. Study data set included patients (N=45,384) who received home health care services between January 1 and December 31, 2019. The study applied a natural language processing algorithm to automatically detect the language of judgment in clinical notes. The use of judgment language was observed in 38% (n=17,141) of the patients. The highest use of judgment language was found in Hispanic (7,167/66,282, 10.8% of all clinical notes), followed by Black (7,010/65,628, 10.7%), White (10,206/107,626, 9.5%), and Asian (1,756/22,548, 7.8%) patients. Black and Hispanic patients were 14% more likely to have notes with judgment language than White patients. The length of a home health care visit was reduced by 21 minutes when judgment language was used. Racial differences were identified in judgment language use. When judgment language is used, clinicians spend less time at patients' homes. Because the language clinicians use in documentation is associated with the time spent providing care, further research is needed to study the impact of using judgment language on quality of home health care. Policy, education, and clinical practice improvements are needed to address the biases behind judgment language.

One-Year Medical Utilization and Mortality in Home Health and Nursing Home Care Recipients from Northern Taiwan.

BackgroundResearch that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research.MethodsData come from the Outcomes and Assessment Information Set (OASIS) from a large urban home health care agency and other agency data. Prognostic data yields 49,437 episodes, while follow-up data yields 47,684 episodes. We tested three indices defined as substantial decline in three or more (gt3_ADLs), two or more (gt2_ADLs), and one or more (gt1_ADLs) ADLs. Multivariate logistic regression determines the performance of the models for each index as measured by the c-statistic and Hosmer-Lemeshow chi square (χ2).ResultsFrequencies for gt3_ADLs, gt2_ADLs, and gt1_ADLs are 212 (0.43%), 783 (1.58%), and 4,271 (8.64%) respectively. Follow-up results are comparable with frequencies of 218 (0.46%), 763 (1.60%), and 3,949 (8.28%) for each index. Gt3_ADLs does not produce valid models. The model for gt2_ADLs consistently yields a higher c-statistic compared to gt1_ADLs (0.754 vs. 0.679, respectively). Both indices' models yield non-significant Hosmer-Lemeshow chi square indicating reasonable model fit. Findings for gt2_ADLs and gt1_ADLs are consistent over time as indicated by follow-up data results.ConclusionGt2_ADLs yields the best models as indicated by a high c-statistic and a non-significant Hosmer-Lemeshow χ2, both of which exhibit exceptional consistency. We conclude that gt2_ADLs may be preferable in defining ADL adverse events in the context of home health care.

A systematic review of case-mix models for home health care payment: Making sense of variation