Home Care Clinicians Research Articles

The Effect of Treatment Adherence on Health Status of Outpatients with Chronic Obstructive Pulmonary Disease

Adherence to COPD treatment plays a crucial role in patient health outcomes. Understanding the correlation between treatment adherence and health status is vital for clinicians to develop effective disease management strategies. This study aimed to examine treatment adherence and its impact on the health status of COPD patients, specifically focusing on the effects of adhering to inhaled medications and breathing exercises. A cross-sectional study involving 420 outpatients diagnosed with COPD was conducted. The study encompassed administering questionnaires, observing patient breathing exercises, and measuring ventilatory function. Results showed that only 36.9% of participants adhered to treatment, with 44.7% following inhaler protocols and 36.9% regularly engaging in breathing exercises. The patients who were non-adherent exhibited a 0.3-fold increase in disease severity compared to the adherent group (p = .002). These findings suggest that consistent adherence to treatment, including inhaled medications and breathing exercises, may positively affect health status by reducing disease severity and airway obstruction in COPD patients. To address this, we recommend that home care clinicians implement a post-discharge assessment and intervention program. This program should focus on educating patients about the importance of treatment adherence and promoting behaviors that reinforce adherence to prescribed therapies.

Home Care Clinicians' Perspectives on Advance Care Planning for Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates.

Advance care planning is important and timely for patients receiving home health services; however, opportunities to facilitate awareness and engagement in this setting are often missed. This qualitative descriptive study elicited perspectives of home health nurses and social workers regarding barriers and facilitators to creating advance care plans in home health settings, with particular attention to patients with few familial or social contacts who can serve as surrogate decision-makers. We interviewed 15 clinicians employed in a large New York City-based home care agency in 2021-2022. Participants reported a multitude of barriers to supporting patients with advance care planning at the provider level (eg, lack of time and professional education, deferment, discomfort), patient level (lack of knowledge, mistrust, inadequate support, deferment, language barriers), and system level (eg, discontinuity of care, variations in advance care planning documents, legal concerns, lack of institutional protocols and centralized information). Participants noted that greater socialization and connection to existing educational resources regarding the intended purpose, scope, and applicability of advance directives could benefit home care patients.

Improving the Accuracy of Code Status Documentation in Home Care.

Advance care planning discussions require specialized skills to elicit goals and preferences from patients contending with life-limiting illness. Documentation forms which include Health Care Proxies, Medical Orders for Life Sustaining Treatments, or Physician Orders for Life Sustaining Treatments are meant to accompany patients through every transition of care. However, they are often forgotten between the hospital and the home setting. Home care clinicians have the obligation to ensure all providers involved in the patient's care are made aware of their code status and goals of care. Consequently, home care clinicians need education about advance care planning to support patients in achieving their care goals as they transition from hospital to home. This quality improvement project implemented three consecutive interventions including reminding clinicians to review code status orders, applying short educational interventions at daily nursing huddles via email, and finally, administering primary palliative education classes for home care clinicians. The purpose was to guide home care nurses in reviewing and reaffirming code status orders and advance care documentation at the initiation of the home care episode and to improve the consistency and accuracy of code status documentation at the transition of care. After implementing the interventions to improve code status documentation, compliance improved from 8% to 100% in a 10-month period.

In-Home Management of Diabetes and Obesity.

The prevalence of type 2 diabetes and obesity is increasing. Research has demonstrated the use of GLP-1 RA and SGLT-2i medications to be safe and effective for the long-term management of T2DM and obesity. As continued research supports the use of GLP-1 RA and SGLT-2i medications for additional indications, home care clinicians will increasingly care for patients on these medications. It is imperative that home care clinicians are aware of patient indications, adverse effects, and potential safety considerations related to these drugs to ensure patient goals are met.

Operationalizing a holistic health definition as a framework to guide comprehensive assessment at the point of care: a modified eDelphi study

Background: Holistic assessment of client needs is an important component of person-centred care planning. However, the comprehensive nature of some standardized assessment tools from a documentation perspective, such as the internationally validated interRAI Home Care (interRAI HC) assessment tool, can make conducting and experiencing the assessment as a person-centred and conversational process challenging for both the assessor and the client1. Researchers in the Netherlands proposed the Pillars for Positive Health (PPH) as a broader definition of health to support more realistic and meaningful care planning for people living with chronic disease and other life-long health conditions2. To explore the use of PPH as a framework to guide person-centred care assessment and goal-setting conversations in home care, we sought to map PPH domains to assessment elements from the interRAI HC1.
 Methods: The study utilized a modified eDelphi approach to conduct a domain mapping exercise with a purposively sampled expert panel (n=25). The panel consisted of researchers, health care providers and older adults and caregivers. The eDelphi process was conducted in two stages, with each stage consisting of three survey rounds. In the first stage, the expert panel were asked to map 201 elements from the interRAI HC to the six PPH domains: 1) Bodily Functions; 2) Daily Functioning; 3) Mental Wellbeing; 4) Quality of Life; 5) Participation; and 6) Meaningfulness. The second stage focused on identifying opportunities to adapt or expand comprehensive assessment as it relates to the PPH domains.
 Results: In Stage 1, 189 of 201 elements reached consensus. These included: 80 assessment elements for Bodily Functions, 32 for Daily Functioning, 32 for Mental Wellbeing, 24 for Quality of Life, 10 for Participation, 1 for Meaningfulness. Ten elements were identified to have no pillar of best fit. The 12 elements that did not reach consensus in stage 1 formed the basis for Stage 2, where expert panel participants proposed four new assessment elements in the meaningfulness and participation pillars and 12 additional descriptors across the six PPH domains. Of these, two elements, each in both the meaningfulness and participation domains, and 10 of the 12 descriptors reached consensus.
 Learnings: The expert panel reached agreement on mapping 94% of the assessment elements drawn from the interRAI HC to the six domains of the PPH, confirming the potential use of this framework to operationalize comprehensive and person-centred assessment conversations around a broader definition of health, building on existing international best practices in standardized assessment of home care client needs. Findings indicated interRAI HC assessment elements are oriented toward the physical, functional, and mental health PPH domains. Complementary assessment elements and/or tools may be needed to support comprehensive assessment of ‘meaningfulness’ and ‘participation’ domains in home and community care. Additional descriptors may be needed to aid communication about PPH domains.
 Next Steps: Home care clinicians will be engaged in leveraging study findings to co-design tools and resources to guide person-centred comprehensive assessment conversations, leveraging PPH domains and additional descriptors to structure dialogue around interRAI-HC elements and other potential complementary assessment elements and/or tools.

Integrating health and social care in the community to support a new model of Long-term Life Care at home.

Background: Long-term care (LTC) reform was an international priority well before the COVID-19 pandemic. While strategies to promote de-institutionalization, rehabilitation, caregiver support and enhanced home and community care have varied by country in terms of implementation and success, the pandemic universally reinforced existing system-specific barriers and weaknesses. In Canada, heightened access issues and silo-ed delivery of community-based medical, functional and social care and support services contributed to increased caregiver burnout and growing residential care waitlists.
 Aims: This study aimed to develop an alternative model to residential LTC that would enable older adults to live, age and receive care at home long-term. The specific objectives were to: 1) describe variation in medical, functional and psychosocial ‘life care’ needs of community-dwelling older adults; 2) develop a model of needs-based care with packages to support variation in needs; and 3) to assess preliminary feasibility of the model using the Ontario, Canada (population 15 million) health care market. 
 Approach: An exploratory, sequential, mixed methods design was applied (5). Phase 1 involved historical analysis of 2017-18 Ontario interRAI home care assessments (n=283,601) and 2018-19 Ontario service utilization data (n=115,000) to develop unique patient vignettes. Phase 2 was a 6-week modified eDelphi process with interdisciplinary home care clinicians (n=42) to develop care packages for the model, including types and dose of care and services. Six focus groups (n=67) were then conducted with older adults, caregivers and health and social care providers across Ontario to validate and refine the model. Phase 3 explored feasibility of the emerging model through comparison of the home care patient vignettes with the needs of the residential LTC population using 2017-18 Ontario interRAI data (n=115,000). Preliminary costing of the model was based on existing system per diems and direct care costs in comparable transitional care models.
 Results: A model of ‘Long-term Life Care’ at home (LTLifeC model) includes care packages to meet the dominant life care needs of 6 unique patient groups representing known predictors of LTC home admission: social frailty, caregiver distress, chronic disease, cognition/ behaviours, medical complexity, and geriatric syndromes. Overlap in care needs of home care and LTC populations confirms potential to shift care to the community; yet current home care clients receive six times less daily care hours on average, compared to residential LTC standards. New LTLifeC packages of home-based interdisciplinary care ranged from 3.1-8.9 hours daily, including comprehensive assessment, integrated care planning, direct care provision and community referral(s). Initial cost comparisons suggest plausible short and long-term system benefits of model adoption.
 Learnings: Evidence-informed decision making for sustainable home and community care as part of an integrated system of LTC requires attention to both routinely collected health information, or ‘big data’, and expertise by lived-experience. Adoption of the LTLifeC model will require decision-making to prioritize societal values for living and aging at home and in community. 
 Next Steps: An evaluation framework will be developed to guide pilot implementation and testing of the LTLifeC model through the lens of the quadruple aim.

Development and validation of risk of CPS decline (RCD): a new prediction tool for worsening cognitive performance among home care clients in Canada

BackgroundTo develop and validate a prediction tool, or nomogram, for the risk of a decline in cognitive performance based on the interRAI Cognitive Performance Scale (CPS).MethodsRetrospective, population-based, cohort study using Canadian Resident Assessment Instrument for Home Care (RAI-HC) data, collected between 2010 and 2018. Eligible home care clients, aged 18+, with at least two assessments were selected randomly for model derivation (75%) and validation (25%). All clients had a CPS score of zero (intact) or one (borderline intact) on intake into the home care program, out of a possible score of six. All individuals had to remain as home care recipients for the six months observation window in order to be included in the analysis. The primary outcome was any degree of worsening (i.e., increase) on the CPS score within six months. Using the derivation cohort, we developed a multivariable logistic regression model to predict the risk of a deterioration in the CPS score. Model performance was assessed on the validation cohort using discrimination and calibration plots.ResultsWe identified 39,292 eligible home care clients, with a median age of 79.0 years, 62.3% were female, 38.8% were married and 38.6% lived alone. On average, 30.3% experienced a worsening on the CPS score within the six-month window (i.e., a change from 0 or 1 to 2, 3, 4, 5, or 6). The final model had good discrimination (c-statistic of 0.65), with excellent calibration.ConclusionsThe model accurately predicted the risk of deterioration on the CPS score over six months among home care clients. This type of predictive model may provide useful information to support decisions for home care clinicians who use interRAI data internationally.

Improving Clinician Communication through Action Research.

There are many challenges to interdisciplinary communication in home care. Management often takes a top-down approach, instructing home care clinicians on methods to improve communication. In this pretest-posttest intervention study, a bottom-up approach was taken using a focus group to allow home care clinicians to identify, develop, and implement strategies to share critical clinical and social information. The participants in the intervention group were compared with a control group who did not participate in the focus group. We found that empowering home care clinicians to develop strategies to improve interdisciplinary communication was beneficial in improving interdisciplinary collaboration. Actively involving home care clinicians in identifying issues and developing solutions may lead to improved collaboration.

Hearing Loss: Insights for Home Care Clinicians.

Hearing loss is a common problem caused by aging, noise exposure, ototoxic medications, and illness. Given their frequent contact with older adults, home care clinicians are uniquely positioned to recognize the adverse effects of hearing loss on physical, social, and cognitive health. This article explores the factors that contribute to hearing loss, highlighting their cumulative effects on overall hearing ability. The consequences of untreated hearing loss support the urgency of early identification, prompt intervention, and proper management of hearing disability. This article also provides an overview of available treatment options, including traditional prescription hearing aids and recently approved over-the-counter devices. By incorporating components of awareness, treatment, and effective communication strategies, healthcare clinicians can take an integrated approach to improve the overall well-being and quality of life of individuals struggling with hearing loss.

Weathering the Storm of Caregiving for Persons with Alzheimer's Disease.

Alzheimer's disease (AD) is a progressive incurable disease affecting an individual's cognitive, behavioral, and physical systems. As individuals become more impaired, assistance is required and care may be provided by spouses, family members, or other close companions who serve as informal caregivers. To examine the perceptions and meaning of caring for a person with AD an interpretive descriptive study was used. Semistructured interviews were conducted with 13 informal caregivers. Data analysis revealed two themes: Grappling with the Responsibilities of Invisible Care and Weathering the Storm of Visible Care. Both themes relate to the stress and struggle of the visible and invisible roles of caregivers. The results of the study strengthen the need for home care clinicians to support caregivers who provide both visible and invisible care for persons with AD.

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room.

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Clinical Features of Hypoxemia Due to Infection Under Home-Based Medication During the COVID-19 Pandemic Period.

Despite the growing demand for home-based medication during the COVID-19 pandemic period, there remains scarce evidence of hypoxemic infection in home-care settings. In this study, we investigated the clinical features of hypoxemic respiratory failure due to infection during the period under home-based medication (defined as 'home-care-acquired infection'). This retrospective observational study enrolled patients with home-care-acquired infection, other than COVID-19, in two home-care clinics in Sapporo, Japan, between April 2020 and May 2021 (the early phase of the COVID-19 pandemic). The participants were divided into two groups according to whether they required additional home oxygen therapy, and were compared to assess the predictors of hypoxemic respiratory failure. Furthermore, the clinical features were compared with those in patients aged >60 years with COVID-19 who were admitted to Toyama University Hospital during the same period. A total of 107 patients with home-care-acquired infections were included in the study (median age, 82 years). Twenty-two patients required home oxygen therapy, and 85 did not. Thirty-day mortality rates were 32% and 8%. Among the patients in the hypoxemia group, none had desired a care-setting transition, following the advanced care planning. Multivariable logistic regression analysis showed that initial antibiotic treatment failure and malignant disease were independently associated with hypoxemic respiratory failure (odds ratio, 7.28 and 7.10; p=0.023 and p<0.005, respectively). In comparison with hypoxemia in the COVID-19 cohort, the lower incidence of febrile co-habitants and earlier onset of hypoxemia were significant in those due to home-care-acquired infection. This study demonstrated that hypoxemia due to home-care-acquired infection was characterized by distinct features, possibly differentfrom those due to COVID-19 in the early pandemic period.

Dysphagia.

Dysphagia, or difficult swallowing, can result in malnutrition, dehydration, aspiration pneumonia, and airway obstruction. Some primary etiologies of dysphagia include neurological disorders, traumatic brain injury, Parkinson's disease, chronic obstructive pulmonary disease, head and neck cancer, cervical spine injury, and stroke. Home care clinicians are often the first healthcare professionals to encounter patients exhibiting signs of dysphagia and can play an important role in identifying, referring, and educating patients with dysphagia. This article will discuss the broad types of dysphagia, the signs and symptoms that suggest dysphagia, and the possible etiology and treatment.

Management system of home transfusion in Japan: A nationwide survey in 2019.

In Japan, there are various opinions on the pros and cons of home transfusion because of safety concerns. We hence aimed to elucidate the safety and availability of home transfusion in Japan, which has not been clarified to date. Clinics throughout Japan that provide home care and have experience in performing blood transfusions were surveyed. The analysis period was February to December 2019. Basic information about the clinics, their collaboration system with core hospitals, storage method of red blood cells (RBCs) and the system for the management of patient information regarding transfusion reactions were investigated. Detailed information was obtained regarding the implementation of home transfusions by 51 clinics. The proportion of home care clinics performing home transfusions was 17.6%, and they were more frequently performed in urban regions. Approximately half of the clinics collaborated with a core hospital for emergency responses to transfusion reactions. At 84% of the clinics, RBC units were stored in refrigerators that were not exclusively allocated to blood storage. Nurses and family members were involved as patient attendants in 83% and 77% of the home transfusions, respectively. No serious transfusion reactions were reported among the 150 patients in 2019, nor the 623 patients up to 2018. From data on its availability and safety, home transfusions are considered to be in the developing phase in Japan. Increased cooperation between hospitals and clinics is crucial towards improving the home transfusion system in Japan in the future.

Cross-Sectional Study on Risk of Flooding and Landslides and Their Associated Perceptions Among Home Health-Care Patients Living in Fukui Prefecture, Japan.

This study aimed to evaluate a risk of flooding and landslides among home-care patients, to reveal an extent to which patients require support for evacuation, and to determine whether risk was accurately perceived among the patients. This is a cross-sectional study targeting the patients who were actively treated at the home-care clinic in Fukui Prefecture, Japan. We collected data on the patients' sociodemographic and clinical characteristics. Additionally, we collected data on their risk of flooding and landslides through hazard maps and distributed a questionnaire to these patients regarding their risk awareness of flooding and landslides. Of the 199 eligible home-care patients, 84.9% (169 of 199) were at risk of flooding and/or landslides, and 58.6% (99 of 169) of them needs support during evacuation. Furthermore, of those who were at risk of flooding and/or landslides, 46.0% (45 of 99) had accurate risk assessments. Factors that resulted in inadequate risk awareness of flooding and landslides included: not placing importance on evacuation, not using medical equipment, and living on the first floor. There was limited risk awareness of flooding and/or landslides among the home-care patients. The information of the risk factors regarding inadequate risk awareness of flooding and landslides should be used to sophisticate flooding and landslides evacuation strategy.

Cardiovascular Assessment.

Cardiovascular (CV) disease affects 6.2 million people in the United States, placing many of these individuals at risk for heart failure. The number of patients with heart failure who utilize home healthcare services after hospital discharge is high. There is also a high rate of readmission following hospitalization for heart failure, contributing to morbidity and mortality, as well as creating a financial burden for healthcare systems. Home care clinicians can make a significant contribution to reducing CV morbidity and readmissions by becoming proficient at CV assessment and using this information to develop an action plan to prevent exacerbations and rehospitalizations. This article reviews the anatomy and physiology of the CV system and describes subjective and objective CV assessment.

Factors in Avoidable Emergency Visits for Ambulatory Care-sensitive Conditions among Older Patients Receiving Home Care in Japan: A Retrospective Study.

Objective Older adults have many health conditions that do not require hospitalization, such as cognitive decline and progression of frailty, so it is necessary to prevent avoidable emergency visits for ambulatory care-sensitive conditions (ACSCs) in this population. We therefore examine Freund's classification of reasons for hospitalization owing to ACSCs to identify factors involved in elderly patients visiting emergency departments in Japan. Methods This retrospective case-control study included patients who received emergency transport for medical treatment at Yushoukai Home Care Clinic Shinagawa in Japan between January 1, 2016, and April 30, 2019. We examined patients' medical records and categorized the reasons for emergency visit by ambulance in accordance with Freund's categories (physician related level, medical causes, patient level, and social level). In addition, we classified and compared patients who lived at home (Group A) with those living in a care facility for older adults (Group B). Results A total of 365 patients visited the emergency department (298 in Group A and 67 in Group B). Among these, we determined that emergency visits were potentially avoidable in 135 patients from Group A and 28 from Group B. The patient and social level categories accounted for 81% of potentially avoidable emergency visits. Confirmed advanced care planning (ACP) was significantly associated with avoidable emergency visit by ambulance in multivariate analyses. Conclusion To prevent emergency visits for ACSCs among older people, ACP should be encouraged.

Home management of intestinal stoma: An evidence based review

Shortened hospital stays for clients with an intestinal stoma have shifted the focus from institutional care in hospitals to self-care of ostomies to the home setting. Clients with intestinal ostomy experience numerous changes in physical functioning, psychosocial health, and in their sexual life after creation of stoma. This enhances the importance of a guide for home management of intestinal stoma to assist home care clinicians and stoma care nurses, who are determined to make ostomates self-reliant. This evidence-based review focused on published articles from the Medline, CINAHL, Social Sciences Citation Index, Psych INFO, a hand search through selected journals published since 2000, and from references lists, to prepare home management guide for intestinal stoma. This article provides information regarding measures to protect skin around stoma, daily care management for ostomates, and ways to prevent peristomal skin complications.

Evaluation of changes in prescription among Japanese elderly patients before and after transition to home care.

BackgroundMost patients receiving home care have multimorbidity and tend to be prescribed multiple drugs with the complicated regimen. Family physicians (FPs) are responsible for patients' prescriptions after transition to home care. This study aimed to assess changes in medication regimen complexity and potentially inappropriate medications (PIMs) made by FPs before and after transition to home care.MethodsA retrospective cohort study was conducted in six home care clinics in Ibaraki Prefecture, Japan. Data from patients aged 65 years and older taking any medication who initiated home care between April 2018 and March 2019 were collected using medical records. The medication regimen complexity index‐Japanese version (MRCI‐J) score and the presence of PIMs were assessed before and 3 months after transition to home care.ResultsThe mean age of 169 patients was 84.0 years. MRCI‐J score and percentage of PIMs remained unchanged between before and 3 months after home care initiation. However, MRCI‐J score significantly decreased among patients with polypharmacy, but significantly increased among patients with nonpolypharmacy. In multiple regression analysis, a greater number of medications before home care initiation was associated with a decreasing MRCI‐J score, but pharmacist home visit services were not associated with changes in MRCI‐J score.ConclusionsOur results suggest that FPs involved in home care are trying to adjust prescriptions by simplifying the medication regimen of patients with polypharmacy, and adding symptomatic drugs to those with nonpolypharmacy.

The survival time of end-of-life home care patients in Fukui prefecture, Japan: A retrospective observational study.

End-of-life advance care planning (ACP) has become increasingly important in home care setting. In facilitating ACP discussion in home care setting, accurate understanding of patients' survival would be beneficial because it would facilitate healthcare professionals to individualize ACP discussion. However, little is known about survival outcome of home care patients. This study aimed to clarify the outcome of patients and identify factors to better predict the survival outcome of home care patients with the focus on patients' primary diseases.We conducted a retrospective analysis using data from 277 patients managed at a home care clinic in Japan and first treated in 2017 or 2018. Data regarding sociodemographic and clinical characteristics, and clinical outcome on December 31, 2019 were extracted. Using Kaplan-Meier product-limit method, we estimated the overall 30 days, 90 days, 1 year, and 3 year survival probabilities among the entire patients and their differences according to their primary disease. We also evaluated whether outcomes differed based on the primary disease or other factors using the hazard ratio and Cox proportional hazards regression.The overall survival probability was 82.5% at 30 days, 67.8% at 90 days, 52.7% at 1 year, and 39.1% at 3 years. The survival rates at 30 days, 90 days, 1 year, and 3 years were 64.6%, 33.4%, 9.5%, and 4.1% among cancer patients; 91.9%, 86.4%, 78.1%, and 47.0% among dementia patients; and 91.9%, 86.4%, 78.1%, and 47.0% among patients with other nervous and cerebrovascular diseases, respectively. Cox proportional hazard regression clarified that cancer patients (hazard ratio 6.53 [95% CI 4.16-10.28]) and older adults (hazard ratio 1.01 [95% CI 1.00-1.02]) were significantly more likely to die than dementia patients and young patients, respectively.Primary disease had a significant influence on the prediction of survival time and could be a useful indicator to individualize ACP in home care setting.