Nursing Home Care Research Articles

Smart Nursing: The Use of Technology to Support Homecare Nurses with Their Care of the Elderly.

The demand for homecare services is on the rise, while simultaneously there is a shortage of homecare nurses who are burdened with increasingly heavier workloads. The introduction of assistive technologies has the potential to assist elderly individuals as well as (informal) caregivers. This study aims to facilitate nursing care with technology, within the framework of a proper daily structure for elderly people. Initially, a needs assessment was performed with homecare nurses to identify the most relevant daily structure patterns. Subsequently, a prototype comprising of a test setup and a mobile application was developed, followed by a case study involving participation from homecare nurses, informal caregivers, and patients. Both subjective experiences and standardized outcome measures (System Usability Scale, Usefulness Satisfaction and Ease of Use Scale and User Experience Questionnaire) revealed highly positive attitudes towards the test setup and application. Future research endeavours should focus on scaling up the technology and expanding its availability to other caregivers.

The Mediating Effects of Social Networks and Wisdom on the Relationship between Lifestyle Habits and Healthy Aging in Older Adults with Chronic Diseases.

The purpose of this study was to analyze the mediating effects of social networks and wisdom on the relationship between lifestyle habits and healthy aging in older adults with chronic diseases. Participants were 120 community-dwelling older adults aged 65 and older with at least one chronic disease. Data were collected from elderly people by visiting nursing care worker training centers, senior centers, social gatherings, and home welfare centers in D, G, and S cities, with a questionnaire of lifestyle habits, social networks, wisdom and healthy aging, and general characteristics. There were differences in the degree of healthy aging according to age (F = 3.76, p = 0.026), spousal relationship (t = 3.11, p = 0.002), education (F = 9.08, p < 0.001), number of diseases (F = 8.65, p < 0.001), and economic level (t = -2.45, p = 0.016). The most common diseases among the subjects were hypertension, hyperlipidemia, joint diseases and diabetes mellitus. Social networks (β = 0.46, p < 0.001) and wisdom (β = 0.55, p < 0.001) had partial mediating effects (z = 4.15, p < 0.001; z = 5.11, p < 0.001) on the relationship between subjects' lifestyle habits and healthy aging. To increase the degree of healthy aging of subjects, it is necessary to establish a mediating intervention program that manages to have good lifestyle habits in daily life, increase social networks, and become wise.

The Care Gap in Later Life Across European Countries.

Do adults without kin experience a care gap where they need help with activities of daily living but get no help from any source? We examine the prevalence of the care gap across Europe, and test whether those without partners or children substitute for their lack of close kin with help from broader networks, or whether they disproportionately experience care gaps. Using data from the Survey on Health, Ageing and Retirement in Europe, we estimate the care gap in 28 European countries and Israel, how it varies, and who provides help for respondents with different family structures. The care gap is substantial, with 6.1% of all respondents ages 50 and above reporting a gap. It is highest in Western and Eastern Europe and lowest in Southern Europe and Israel. Respondents without partners or children are significantly more likely to have care gaps than those with close kin. However, respondents without close kin draw more often on more diverse networks of friends and relatives and use nursing home care. Our study introduces the concept of the care gap and shows that although it is most common among unpartnered adults without children it is also quite common for those with immediate family. A broader network partially but not completely substitutes for care gaps among those without immediate family. Our results offer new insights into the demand for public care services in countries with diverse welfare states.

Nurses' professional discretion in the purchaser-provider split in home care in Norway.

To explore how nurses' professional discretion is operationalized in home care services that follow a purchaser-provider organization in Norway. A qualitative descriptive study. Semi-structured interviews with open-ended questions were used, and data were collected from in-depth interviews with 15 registered nurses working in home care in four Norwegian local authority areas between April and November 2020. Braun and Clark's six-step analysis was used to analyse the empirical data. The analysis yielded two main themes, namely 'The purchaser's instructions: facilitating and constraining care' and 'Professional discretion meets the purchaser-provider organisation of healthcare,' with five associated codes. Nurses are dependent on an organizational framework due to the complexity of health care services and the number of tasks involved. At the same time, they perform considerable compensatory work and need the ability to be flexible to enable this work and to perform actions related to the unforeseen needs of individual patients or those involving professional discretion. The purchaser-provider model both facilitates and constrains nursing practice and professional responsibility in home nursing. Home nursing services need to be well organized because of their complexity and the wide variety of tasks they involve. In this context, the element of constraint is associated with the need for flexibility and professional discretion. Despite a strict framework, the nurses perform additional and compensatory tasks. Reforms inspired by 'New Public Management,' such as the purchaser-provider split, limit the workload for nurses; however, there is still a need to exercise discretion. The findings of this study may help home care managers and health policy-makers understand the interaction between management logic and health care logic, leading to a more appropriate organization of health care services where the nurses, as actors, gain more trust. This study highlights home care nurses' opportunities to exercise discretion in an organizational framework that strives towards standardization. The nurses' ability to exercise discretion is important for individual and holistic patient care. At the same time, an organizational framework is needed because nurses cannot attend to all the needs the patients may have, as this will overload both home health services and the nurses.

How we treat octogenarians with brain metastases.

Biologically younger, fully independent octogenarians are able to tolerate most oncological treatments. Increasing frailty results in decreasing eligibility for certain treatments, e.g., chemotherapy and surgery. Most brain metastases are not an isolated problem, but part of widespread cancer dissemination, often in combination with compromised performance status. Multidisciplinary assessment is key in this vulnerable patient population where age, frailty, comorbidity and even moderate additional deficits from brain metastases or their treatment may result in immobilization, hospitalization, need for nursing home care, termination of systemic anticancer treatment etc. Here, we provide examples of successful treatment (surgery, radiosurgery, systemic therapy) and best supportive care, and comment on the limitations of prognostic scores, which often were developed in all-comers rather than octogenarians. Despite selection bias in retrospective studies, survival after radiosurgery was more encouraging than after whole-brain radiotherapy. Prospective research with focus on octogenarians is warranted to optimize outcomes.

Digital ethical reflection in long-term care: Leaders' expectations.

Healthcare leader support and facilitation for ethics work are of great importance for healthcare professionals' handling of ethical issues, moral distress, and quality care provision. A digital tool for ethical reflection in long-term care was developed in response to the demand for appropriate tools. This study aimed to explore healthcare leaders' expectations of using a digital tool for ethical reflection among their home nursing care staff. A qualitative research design with vignettes and focus group interviews was used. The data were analyzed using reflexive thematic analysis. The sample comprised ten healthcare leaders from municipal long-term care in Norway. Participation was voluntary and based on informed consent. The Norwegian Agency for Shared Services in Education and Research approved this study. The analysis resulted in the development of three themes representing leaders' expectations of the tool: (i) giving staff a voice, (ii) revealing ethics in practice, and (iii) keeping the pot boiling. Leaders must be informed about the ethical issues experienced to engage in supportive measures for their staff. Digital channels can increase the democratization, safety, and efficiency of communication between employees and leaders and increase awareness of ethical aspects in daily care work. The leaders had positive expectations of employees' activities and benefits from using the tool for ethical reflection. However, they admitted that realizing the tool's potential to ensure continuity in ethics work requires considerable organizational and leader involvement. This study shows that healthcare leaders are open to digital solutions for managing ethics work in home nursing care. Both opportunities and important prerequisites for successfully implementing the digital tool were identified.

How Digital Systems Are Used in Swedish Home Care Nursing Practice: A Qualitative Interview Study to Identify Challenges and Opportunities.

This study investigates how digital technology is used (or not used) in home care nursing, to identify challenges and opportunities that can move the digitalization of home care nursing forward. The use of digital technology in daily practices of home care nursing was analyzed based on semistructured interviews in four Swedish home care organizations. The results correspond to the two initial stages of a design thinking process: (1) knowledge about users and the use context, presented as an up-to-date description of how digital technology has affected home care nursing practice, and (2) definition of areas for improvement, presented as challenges and opportunities. We identified the following areas to proceed with in the subsequent stages of designing home care nursing digitalization: (1) nurses' ability to access information and conduct documentation in the field, particularly how new digital systems are integrated with existing routines and systems; (2) the multitude of communication processes that nurses must manage, including communication channels that are used and the level of synchronicity; (3) an increasingly complex digital working environment, where evaluating existing systems and routines is one way to learn where improvements can be most efficient.

Introduction of augmented reality to the remote wound care nursing consultation system.

We implemented augmented reality (AR) in remote consultations for enhanced pressure injury (PI) care in homecare nursing and improved the efficiency of on-site technical education for homecare nurses. The study aimed to depict expert techniques using AR technology to improve PI healing time in a male patient. We developed and implemented a new system that combines a transparent hand with an image and gives an output as a video image in the existing remote consultation software. The system was used to support remote care of PIs by nurses. We succeeded in superimposing the expert nurse's nonverbal hand gestures onto the patient's wound in real time. The visiting nurse's understanding of the system had improved and there was an improvement in the patient's PI healing. These results suggest that remote consultation using AR is effective to observe precise wound care demonstrations of the steps of the PI treatment and provide effective treatment.

New Dimensions of Staffing Patterns in Nursing Homes and Nursing Home Quality: Comparing Staffing Instability to Staffing Turnover.

This study examines how measures of staffing-turnover and instability-are associated with one another and how they independently contribute to quality of care in nursing homes. Cross-sectional analysis of 2021-2022 administrative data. Data included the Payroll Based Journal for daily staffing information, merged with Nursing Home Care Compare (NHCC) data for nursing home characteristics, total staffing turnover, and nursing home quality. A total of 11,840 nursing homes nationally reporting data on daily staffing and staffing turnover. We explored correlations between measures of staffing and estimated facility-level regression models with robust standard errors. The dependent variables were indicators of nursing home quality included in the NHCC 5-star ratings. The independent variables of interest were average total staffing hours per resident-day, total staffing turnover, and total staffing instability. For the 11,840 nursing homes in the study, there was a weak positive correlation between turnover and instability, with some overlap between nursing homes with high instability and high turnover. Regression analysis revealed that staffing instability and turnover contributed independently to nursing home quality, with instability having a stronger association with some measures of quality and turnover with others. Staffing instability was positively and more strongly associated with long-stay residents' decline in activities of daily living levels and receipt of antipsychotic drugs and short-stay residents' functioning at discharge. Turnover was positively and more strongly associated with long-stay residents' prevalence of pressure ulcers and worsening mobility, and short-stay residents' hospitalizations. Instability and turnover in total nursing home staffing independently contribute to nursing home quality. This suggests that adding measures of staffing instability to the existing measures of average staffing and staff turnover in NHCC may enhance the report card's value for providers engaged in quality improvement and consumers searching for high-quality nursing homes.

When health trumps money: Economic incentives and health equity in the public provision of nursing homes in Norway

The allocation of public care services should be determined by individual needs, but can be influenced by economic factors. This paper examines the impact of economic incentives on the allocation of public nursing home care in the Norwegian long-term care system. In Norway, municipalities and city districts have economic incentives for choosing nursing home care for high-income individuals in need of care and home-based care in sheltered housing for low-income individuals. The study uses a theoretical model and empirical data from the municipality of Oslo to determine if nursing home spots are allocated based on income, which would be financially advantageous for the city districts. We do not find evidence that the economic incentives of the care provider play a role in the allocation of nursing homes. Thus, in this setting, needs seem to be the dominant factor for allocation of nursing home care, while economic incentives seem to play no significant role. The clear legal mandate to provide services based on needs only is likely an important factor in this.

The organisation of paediatric hospital-at-home care: a multi-country comparative study

PurposeMany countries have developed hospital-at-home (HAH) models to bring hospital services closer to home. Although some countries already have a long tradition of HAH for adults, paediatric HAH has been developed more recently. Specificities of paediatric care make it difficult to directly extend an adult HAH model to the paediatric population. The objective of this study is to compare the organisation of paediatric HAH in four countries: France, Australia (states of Victoria and New South Wales), the Netherlands and Belgium. Ultimately, lessons can be drawn for further development in the countries analysed and/or for implementation in other countries.Design/methodology/approachLegal documents and other grey literature were analysed to describe the legal context for the provision of paediatric HAH in the selected countries. In addition, semi-structured in-depth interviews were conducted with key informants from paediatric HAH organisations in these countries, addressing the following topics: historical background, legal framework, functioning of HAH models, workforce, number of services, profile of children, type of care activities, funding, coordination with other providers and quality of care. Results were reviewed by a content expert from the respective country.FindingsOrganisational differences were highlighted in terms of coordinating actor (hospital or home nursing care services), decision-making process, range of clinical conditions treated, territorial organisation, qualifications and expertise of the team members, medical expertise, financing, responsibilities, etc.Originality/valueThere is no single preferred model for the provision of HAH care for children. There is a large variety in almost all aspects of organisation. There are, however, also some common characteristics across the different models. Notably, paediatric expertise of nurses within the HAH team was considered indispensable in all programmes.

Difficulties for Homecare Nurses in Providing Nutritional Support to Terminally Ill Clients with Cancer at Home

Difficulties for Homecare Nurses in Providing Nutritional Support to Terminally Ill Clients with Cancer at Home

How patient-centered is education and counseling of patients treated with oral anticancer drugs? A multicenter cross-sectional study

ObjectiveIn this multicenter cross-sectional study, the quality of patient-centered education and counseling for patients treated with oral anticancer drugs was examined. MethodsThe CONTACT-Patient-Centered Care Questionnaire was administered to 266 patients, recruited in 11 Flemish hospitals. The questionnaire consists of 80 items, each evaluating the degree of performance of a key element in patient-centered education and counseling. ResultsIn total, 15 key elements were seriously underperformed (degree of performance < 50%). Elements regarding adherence monitoring, specific topics in patient education, and involvement of the community pharmacist and home care nurse received a very low score. Only six key elements were systematically performed (degree of performance ≥ 90%), among which the elements on communication style and involvement of the general practitioner. ConclusionThis study uncovered three major gaps in patient-centered education and counseling of patients on oral anticancer drugs: unmet patient information needs due to shortcomings in patient education, inadequate adherence monitoring, and lacking collaboration with community pharmacists and home care nurses. Practice implicationsThis study highlights the need for interdisciplinary and patient-centered education and counseling of patients using OACD, including all key stakeholders: physicians, nurses, hospital pharmacists, general practitioners, community pharmacist and home care nurses.

Understanding the Experiences of Family Caregivers of Nursing Home Residents With Dementia: A Grounded Theory Study.

Alzheimer's disease and related dementias progress over time and result in cognitive decline, loss of independence, and behavioral and psychiatric symptoms of dementia that can lead to nursing home placement. Research has focused on examining the effects of nursing home placement on the family caregiver; however, their experiences are less understood. We sought to investigate the experiences and perceptions of family caregivers of nursing home residents with dementia. The objective was to create a conceptual model that explains the complex nature of the family caregiver experience. This study is part of a larger randomized controlled trial. Following a grounded theory approach, we completed 30 in-depth, one-on-one interviews with family caregivers of nursing home residents with dementia. Data analysis followed an iterative process that employed open, axial, and selective coding. Our conceptual model depicts the interrelationship between contributing factors that interrelate and impact family caregiver satisfaction with nursing home care. Six factors contribute to family caregiver satisfaction: family caregiver interactions with nursing home staff; staff management of resident behavioral symptoms; nursing home context; family caregiver knowledge of dementia; family caregiver strain; and the resident experience. Our findings revealed family caregiver experiences that are unique to the institutional nursing home setting and not reflected in prior work focusing on experiences within community-based settings. Understanding family caregiver experiences and the contributors to how satisfaction in care is perceived, may foster collaboration and teamwork among families and staff.

Informal caregivers involvement in heart failure self-care: perceived acceptability and contribution to heart failure self-care from a feasibility quasi-experimental study

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): HES-SO University of Applied Sciences and Arts Western Switzerland, Service d’Aide et de Soins à Domicile de la Sarine, Fribourg Background Heart failure (HF) self-care is recommended to reduce HF hospitalisation and mortality. Informal caregivers play a key role in HF self-care support and contribute to outcomes. Uncertainties remain about the acceptability to include informal caregivers to support self-care in people with HF, as well as informal caregivers’ responsiveness of being exposed to an intervention supporting symptom perception in HF, a specific HF self-care process. Purpose We aimed to test an intervention supporting symptom perception in people with HF including among informal caregivers. Methods We used a quasi-experimental feasibility study with a pre-test post-test design. Informal caregivers and people with HF were exposed to an evidence-informed self-care support intervention targeting symptom perception, delivered by trained homecare nurses during one month at people with HF home. We assessed acceptability of informal caregivers involved in HF self-care support using the Treatment Acceptability and Preferences (TAP) Measure adapted for this study (responses from 1=completely disagree to 5=completely agree). We assessed outcome responsiveness regarding contribution to HF self-care using the Caregiver Contribution to Self-care of HF Index version 2 (CC-SCHFI 2), and caregivers’ burden with the Zarit Burden Interview. We used descriptive statistics and calculated effect sizes using Cohen’s d based on mean absolute change between pre and post intervention. Results Seven informal caregivers (mean age 64.7 years, 6/7 women) were exposed to the intervention. All were spouse or child of the people with HF. Mean acceptability score was 4.28. Informal caregivers’ contribution to HF self-care positively responded after intervention exposure. There was a 10-point increase on the CC-SCHFI 2 symptom monitoring and perception post intervention (mean score 69.1) compared to baseline (mean score 58.9) with a large effect size (Cohen’s d=1.37). Contribution to HF self-care maintenance and management also responded positively to the intervention, respectively from 60 to 63.5 for self-care maintenance (Cohen’s d=0.28) and from 49.3 to 52.5 for self-care management (Cohen’s d=0.17). Caregiver burden slightly increased 2-points post intervention from 18.5 to 20.5 with a low effect size (Cohen’s d=0.14). Mean caregiver burden scored high at baseline before intervention exposure, and informal caregivers reported low burden to participate in the intervention (TAP mean item score 4.4). Conclusion Informal caregivers reported the intervention as highly acceptable. Informal caregiver contribution to symptom monitoring and perception was responsive to the intervention, as well as overall contribution to HF self-care. Caregiver burden should be carefully monitored when involved in HF self-care support interventions. Evaluating the effectiveness of including informal caregivers in HF self-care support and in specific symptom perception is needed.Caregivers outcomes responsiveness

Temporalities of Aged Care: Time Scarcity, Care Time and Well-Being in Danish Nursing Homes

ABSTRACT Aged care staff in Danish nursing homes feel the pressures of time scarcity acutely. But what does this mean for the well-being of residents? Using the concept “care time” we consider subjective experiences of time to make sense of the multiplicity of temporal experiences in nursing home care. We will show how the temporal structures of a neoliberal institutional care logic is at odds with what residents expect from care time. Finally, drawing on a phenomenological understanding of well-being, we explore how residents’ temporal orientation to the present and the past can be drawn on to enhance well-being.

Dental care utilization among home care recipients, nursing home residents, and older adults not in need of long-term care: An observational study based on German insurance claims data

ObjectivesTo describe and compare dental care utilization (DCU) among home care recipients, nursing home residents, and older adults not in need of long-term care (LTC). MethodsUsing nationwide claims data of 8 German statutory health and LTC insurance funds, proportions of home care recipients (n = 68,137), nursing home residents (n = 21,167), and non-LTC dependents (n = 632,205) aged 65+ years with DCU in 2017 were determined and compared. Associations between DCU and individual characteristics and setting were investigated via multivariable logistic regression. The proportions of individuals with DCU one year before and after transition to (a) home care (n = 23,590) and (b) nursing home care (n = 6,583) were compared. ResultsProportions of home care recipients and nursing home residents with DCU were lower compared to non-LTC dependents (51.9, 53.1, and 73.2%, respectively). Adjusted odds ratios for DCU for home care recipients vs. non-LTC dependents ranged from 0.55 (LTC grades 1/2; 95% confidence interval 0.54–0.56) to 0.38 (LTC grades 4/5; 0.36–0.40). For nursing home residents vs. non-LTC dependents they ranged from 0.69 (3; 0.65–0.72) to 0.67 (4/5; 0.63–0.71). Women, older individuals, those with 0–1 diseases of the Elixhauser comorbidity index, dementia, and those from West Germany were also less likely to utilize dental care than their counterparts. Utilization decreased after transition to home care (60.0 vs. 55.6%) and increased after transition to nursing homes (46.1 vs. 53.5%). ConclusionsNursing home residents and especially home care recipients utilized dental care less frequently than older non-LTC dependents. Organizational barriers for dental care utilization and ways to remove them should be investigated. Clinical significanceDental care utilization among LTC dependents is low and should be improved in both the home care and nursing home setting.

Nursing Home Resident Preferences for Daily Care and Activities: A Latent Class Analysis of National Data.

Uncovering subgroups of nursing home residents sharing similar preference patterns is useful for developing systematic approaches to person-centered care. This study aimed to (i) identify preference patterns among long-stay residents, and (ii) examine the associations of preference patterns with resident and facility characteristics. This study was a national cross-sectional analysis of Minimum Data Set assessments in 2016. Using resident-rated importance for 16 preference items in the Preference Assessment Tool as indicators, we conducted latent class analysis to identify preference patterns and examined their associations with resident and facility characteristics. We identified 4 preference patterns. The high salience group (43.5% of the sample) was the most likely to rate all preferences as important, whereas the low salience group (8.7%) was the least likely. The socially engaged (27.2%) and the socially independent groups (20.6%) featured high importance ratings on social/recreational activities and maintaining privacy/autonomy, respectively. The high salience group reported more favorable physical and sensory function than the other 3 groups and lived in facilities with higher staffing of activity staff. The low salience and socially independent groups reported a higher prevalence of depressive symptoms, whereas the low salience or socially engaged groups reported a higher prevalence of cognitive impairment. Preference patterns also varied by race/ethnicity and gender. Our study advanced the understanding of within-individual variations in preferences, and the role of individual and environmental factors in shaping preferences. The findings provided implications for providing person-centered care in NHs.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia

New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care. To evaluate changes in nursing home use among older adults with dementia following MLTC implementation. This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019. Mandatory MLTC enrollment. Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators. This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year). The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

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

Home health care (HHC) and nursing home care (NHC) are mainstays of long-term service in the aged population. Therefore, we aimed to investigate the factors associated with 1-year medical utilization and mortality in HHC and NHC recipients in Northern Taiwan. This study employed a prospective cohort design. We enrolled 815 HHC and NHC participants who started receiving medical care services from the National Taiwan University Hospital, Beihu Branch between January 2015 and December2017. Multivariate Poisson regression modeling was used to quantify the relationship between care model (HHC vs NHC) and medical utilization. Cox proportional-hazards modeling was used to estimate hazard ratios and factors associated with mortality. Compared with NHC recipients, HHC recipients had higher 1-year utilization of emergency department services [incidence rate ratio (IRR) 2.04, 95% CI 1.16-3.59] and hospital admissions (IRR 1.49, 95% CI 1.14-1.93), as well as longer total hospital length of stay (LOS) (IRR 1.61, 95% CI 1.52-1.71) and LOS per hospital admission (IRR 1.31, 95% CI 1.22-1.41). Living at home or in a nursing home did not affect the 1-year mortality. Compared with NHC recipients, HHC recipients had a higher number of emergency department services and hospital admissions, as well as longer hospital LOS. Policies should be developed to reduce emergency department and hospitalization utilization in HHC recipients.