Home-based Primary Care Providers Research Articles

Home-based primary care providers' perspectives on the unique challenges of working with late life posttraumatic stress disorder within their population of Veterans.

Posttraumatic stress disorder (PTSD) is more prevalent in medically ill older Veterans in Home-Based Primary Care (HBPC) settings than in the general population, raising unique considerations. The aim of this qualitative project was to explore HBPC mental health providers' perceptions of the presentation and treatment of PTSD and trauma-related symptoms in this population of older Veterans, many of whom face additional barriers to treatment due to living in rural settings. Five focus groups and one one-on-one interview were conducted with 23 HBPC mental health providers serving rural or rural/urban mixed communities across the United States. We applied qualitative content analysis to the data. Three themes were found: (1) Presentation of Trauma-Related Symptoms and PTSD in HBPC Population; (2) Treatment Challenges in HBPC; and (3) PTSD Treatment Strategies. Each theme had multiple subthemes which illustrate unique issues in this population. Results of this project contribute to key insights surrounding the unique presentation of PTSD and trauma-related processes and treatment considerations in a medically, cognitively, and psychosocially complex group of veterans. Efforts to improve access to care should consider the specific needs of veterans who are homebound, live in rural settings and identify with rural cultural norms, and have difficulty engaging in specialized PTSD treatment due to the convergence of these factors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Psychological Impact of COVID-19 on Home Based Primary Care Providers in New York: A Qualitative Study

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in the New York including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

Who Provides Care in a Crisis? Family Caregivers’ Experiences of Home Care During the COVID-19 Pandemic

Many homebound individuals with dementia rely on both paid caregivers (e.g., home health aides, home attendants, other homecare workers) and family caregivers to live safely at home. We conducted semi-structured interviews with 15 family caregivers of individuals with severe dementia receiving home-based primary care in NYC to explore how caregiving changed during the COVID pandemic. Most individuals with long-standing paid caregivers experienced infrequent home care disruptions. In fact, paid caregivers were often the primary and sometimes only individuals to provide direct care; family caregivers themselves often stayed away and managed care from a distance. While most family caregivers described heightened attention to infection control, guidance about COVID prevention and safety rarely came from home-based primary care providers or home care agencies and instead was considered “common sense.” These findings confirm the essential role paid caregivers play in home-based dementia care teams.

Provider Perceptions of Video Telehealth in Home-Based Primary Care During COVID-19

Home health care is the most commonly used home- and community-based service to older adults “Aging in Place”. Patient experience of healthcare services is a critical aspect of patient-centered care. Indeed, policymakers have linked patient-rated quality of care to payment to healthcare providers. This study aimed to examine the association between patient-rated care performance of home health agencies and risk for hospitalization among Medicare beneficiaries. This study used several national datasets from 2016 and included 491,718 individuals from 8,459 home health agencies. Home health agencies’ performance was measured using patient experience star rating from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS). Propensity score matching was used to balance the differences in patient characteristics at baseline between those receiving care from high-performing home health agencies and those in lower-performing agencies. On average, patients were 80.5 years old, 65% female, 81% White, 10% Black, and 6% Hispanic, with 90% taking 5 or more medications. Patients had a mean score of 1.73 (SD=1.69) on the Charlson Index. Respectively, 10% and 16% of patients were hospitalized within 30 and 60 days of home health care initiation. Estimates of logistic regression after propensity score matching found that patients receiving care from lower-performing agencies were at similar risk for both 30-day (OR=0.99, p=0.817) and 60-day (OR=1.02, p=0.616) hospitalization following the start of home health care, compared to those in high-performing agencies. Our findings suggest discrepancies (or no relationship) between patient experience and objective outcomes of home health care.

“I felt useless”: a qualitative examination of COVID-19’s impact on home-based primary care providers in New York

ABSTRACT Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

"Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care.

Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors. Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery. Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits. We employed an exploratory, content-driven approach to qualitative data analysis. Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides. HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.

"At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19.

COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide. Cross-sectional qualitative design using semi-structured interviews. HBPC practices in the NYC metro area during spring 2020. HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices. Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients. NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.

PSYCHOTROPIC MEDICATION USE PATTERNS IN HOME-BASED PRIMARY CARE: A SYSTEMATIC REVIEW

Introduction Up to a third of patients seen by home-based primary care providers suffer from mental health problems, predominantly major depressive disorder. These conditions tend to be under-recognized and under-treated for patients receiving home-based care. This may be due to providers feeling inadequately trained on how to screen for various mental health disorders, and/or how to provide comprehensive mental health treatment. Given the high prevalence of patients suffering from mental health problems in this setting, the goal of this systematic review was to evaluate current psychotropic use patterns for patients receiving home-based primary care (HBPC). Methods Using controlled vocabulary terms (e.g. MeSH, Emtree) and keywords, a medical librarian conducted systematic literature searches in the following seven databases: Ovid/MEDLINE, Wiley/Cochrane Library, Elsevier/Embase, Elsevier/Scopus, Clarivate/Web of Science, EBSCO/CINAHL, and EBSCO/PsycInfo, limiting articles to those published between January 1, 2007 and January 5, 2018. Two independent reviewers screened all titles and abstracts and resolved differences by consensus. Two independent reviewers screened the full text of all publications selected in the screening phase. Differences were resolved by consensus with a third reviewer. Studies were selected if a) they were conducted in home-based primary care settings and b) identified psychotropic use/prescription patterns. We specifically did not include studies that were limited to patients in hospice care or nursing or rehabilitation facilities. Studies were excluded if they were: not in English; drug trials; limited to pediatric patients; or opinion pieces, case studies, case series, meeting abstracts, reviews, systematic reviews, or meta-analyses. Results Of the 2,675 publications identified through the seven database searches, 1,388 remained after duplicates were removed (Figure 1). Of these, 1,329 were eliminated because of irrelevance to the topic and 59 were selected for full text screening. Of these, four met full selection criteria and were included in the data extraction and analysis. Citation checking of these four, as well as of relevant review articles, resulted in the selection of an additional 15 articles for full text screening. None of these additional articles met the full selection criteria. Conclusions Pending ongoing investigation. This research was funded by This research did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.

Stressors Facing Home-Based Primary Care Providers.

The numbers of homebound patients in the United States are increasing. Home-based primary care (HBPC) is an effective model of interdisciplinary care that has been shown to have high patient satisfaction rates and excellent clinical outcomes. However, there are few clinicians that practice HBPC and clinicians that do face additional stressors. This study sought to better understand the stressors that HBPC providers face in caring for homebound patients. This was a cross-sectional qualitative survey and analysis of HBPC providers. Responses were categorized into four themes: The patient in the home setting, caregiver support, logistics, and administrative concerns. This research is the first to analyze the stressors that providers of HBPC face in serving the needs of complex homebound patients. Awareness and attention to these issues will be important for the future sustainability of home-based primary care.

Disaster Preparedness in Home-based Primary Care: Policy and Training.

Veterans served by Veterans Health Administration (VHA) home-based primary care (HBPC) are an especially vulnerable population due to high rates of physical, functional, and psychological limitations. Home-bound patients tend to be an older population dealing with normal changes that accompany old age, but may not adequately be prepared for the increased risk that often occurs during disasters. Home health programs are in an advantageous position to address patient preparedness as they may be one of the few outside resources that reach community-dwelling adults. Problem This study further explores issues previously identified from an exploratory study of a single VHA HBPC program regarding disaster preparedness for HBPC patients, including ways in which policy and procedures support the routine assessment of disaster preparedness for patients, including patient education activities. This project involved semi-structured interviews with 31 practitioners and leadership at five VHA HBPC programs; three urban and two rural. Transcripts of the interviews were analyzed using content analysis techniques. Practitioners reported a need for further training regarding how to assess properly patient disaster preparedness and patient willingness to prepare. Four themes emerged, validating themes identified in a prior exploratory project and identifying additional issues regarding patient disaster preparedness: (1) individual HBPC programs generally are tasked with developing their disaster preparedness policies; (2) practitioners receive limited training about HBPC program preparedness; (3) practitioners receive limited training about how to prepare their patients for a disaster; and (4) the role of HBPC programs is focused on fostering patient self-sufficiency rather than presenting practitioners as first responders. There was significant variability across the five sites in terms of which staff have responsibility for preparedness policies and training. Variability across and within sites regarding how patient needs are addressed by preparedness policies, and in terms of preparedness training for HBPC providers, could place patients at heightened risk of morbidity or mortality following a disaster. Despite the diversity and uniqueness of HBPC programs and the communities they serve, there are basic aspects of preparedness that should be addressed by these programs. The incorporation of resources in assessment and preparedness activities, accompanied by increased communication among directors of HBPC programs across the country, may improve HBPC programs' abilities to assist their patients and their caregivers in preparing for a disaster.

The Role of the Home-Based Provider in Disaster Preparedness of a Vulnerable Population

Background: Veterans receiving home-based primary care (HBPC) are an especially vulnerable population served by the Veterans Health Administration (VHA) due to high rates of physical, functional, and psychological limitations. These vulnerabilities may prevent these persons from being adequately prepared for disasters. HBPC providers connect the community-dwelling population with their regional health care system and thus are appropriate partners for assessing preparedness. The limited literature on this topic suggests that there are issues with the development and implementation of emergency management plans, dissemination to staff, and inconsistencies with preparedness strategies across agencies. Objective: To further explore identified issues regarding emergency management planning for patients receiving medical care in their home, including ways in which policy and procedures support the routine assessment of disaster preparedness for patients. Methods: This exploratory pilot project, carried out in a single VHA HBPC program located in an urban area, involved seven 15- to 25-min semistructured interviews with practitioners and leadership. Transcripts of the interviews were analyzed using content analysis techniques to develop themes to describe information obtained through the interviews. Results: Six themes emerged from the data: (1) a national policy regarding the inclusion of disaster preparedness assessment in routine HBPC assessment exists in only a skeletal manner and individual HBPC programs are tasked with developing their own policies; (2) the tools used at the initial assessment were rudimentary and, in some cases, individually developed by providers; (3) the comprehension of criteria for assigning risk categories (i.e. acuity levels) varied among providers; (4) the primary challenges identified by respondents to patient engagement in emergency preparedness activities included cognitive impairments, patients' willingness to invest in preparedness activities, and limited resources; (5) providers received limited formal training on how to prepare their patients for a disaster, and (6) provider recommendations included training to focus on better strategies to get patients to participate, more consistent time spent on patient education, formalization of the initial assessment, and having emergency preparedness be formally addressed on a more consistent basis. Conclusion: Formal standardized strategies regarding disaster preparedness assessment for HBPC patients, which leave room for flexibility in consideration of local factors, could assist in creating more comprehensive emergency management planning agendas and community collaboration.

To the Hospital and Back Home Again: A Nurse Practitioner-Based Transitional Care Program for Hospitalized Homebound People

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.