Home Health Agencies Research Articles

Exploring Family-Centered Care from the Perspectives of Home-Health Physical Therapists

Background and Purpose: Older adults often need caregivers to help them age in place successfully while maximizing their quality of life. These caregivers have the highest rates of burnout, injury, and turnover. Family-centered care (FCC) involves collaboration between the healthcare practitioner and the patient, family members, and caregivers. There is a paucity of evidence on how FCC is applied to older adults and their caregivers. The purpose of this general qualitative study was to explore how a group of home health physical therapists (HHPTS) deliver FCC to care-dependent older adults. Methods: This general qualitative study used individual, semi-structured interviews with a purposeful sample of 14 HHPTs working for a variety of home health agencies in San Diego County. The interview responses were hand transcribed, hand coded, thematically analyzed, and conceptualized in the International Classification of Functioning, Disability, and Health model (ICF model). The coding table and interview guide were modified based on reviews by experts in home health physical therapy. A proprietary coding software program called NVivo was used to triangulate the results. Results and Discussion: The 3 main themes that emerged were: (a) "FCC is Complex"; (b) "FCC Impacts Older Adults' Health Factors"; and (c) FCC is Impacted by Contextual Factors". Eleven subthemes also emerged. The themese and subthemes were conceptualized within the ICF Model. The first theme demonstrated that the HHPTs had a variety of understandings of, training on, and applications with FCC. The HHTP was conceptualized as an environmental factor that could impact the patient's health based on their knowledge and skills with FCC. The second theme demonstrated that FCC was utilized to address every ICF health factor by the HHPTs. This theme was conceptualized around the entire ICF Model. Neurological conditions and motivated families were seen as large factors in performing FCC. The third theme demonstrated that a wide variety of contextual factors impacted the HHPTs ability, time, and resources to perform FCC. This was conceptualized in ICF Model as personal and environmental factors that could facilitate or inhibit ("+/-") FCC approaches by the HHPTs. Conclusions: This study closed some of the gaps in the literature on how FCC is delivered to older adult clients, their caregivers, and their family members. This knowledge may help to foster changes in FCC approaches and research. Changes like these could lead to improved health outcomes for older adults through reduced hospital readmissions and improved caregiver satisfaction with care as seen in pediatrics. Key Words: Family-centered care, home health physical therapist, caregiver satisfaction, burnout, and International Classification of Functioning, Disability, and Health model.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access.

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors. We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design. After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use. Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

“I Quit”: Schedule Volatility as a Driver of Voluntary Employee Turnover

Problem definition: Employers across many sectors of the economy have been fast to adopt variable work scheduling policies. The cost of this flexibility for employers is usually borne by employees, for whom unstable work schedules create several disruptions. In the context of home healthcare, we examine how employer-driven volatility in nurses’ schedules impacts their decision to voluntarily leave their job. Methodology/results: Using an instrumental variables approach, we causally identify the effect of schedule volatility on nurses’ voluntary turnover. We begin by constructing an operational measure of schedule volatility using time-stamped work log data from one of the largest home health agencies in the United States. Because this measure may be endogenous to the worker’s decision to quit, we instrument for schedule volatility using paid days off taken by other nurses in the same branch. We find that higher levels of schedule volatility substantially increase a worker’s likelihood of quitting. Specifically, a one-standard-deviation increase in schedule volatility increases the average worker’s propensity to quit on a given day by more than threefold. Translated into yearly terms, 30 days of high schedule volatility over the course of the year increases the average worker’s probability of quitting that year by 20%. Our policy simulations of counterfactual scheduling policies suggest that excess schedule volatility can explain a significant portion of voluntary turnover, and some interventions have the potential to substantially reduce workers’ daily propensity to quit. Managerial implications: This work contributes to the understanding of the extent to which employees value control over their own work schedules and are averse to volatile work schedules that are dictated by employers. Especially in the current environment where there is a growing emphasis on work-life balance and employee-driven flexibility, finding a way to support stable schedules could be important for employers to attract and retain workers. Funding: This work was supported by the National Research Service Award Postdoctoral Fellowship, the Wharton Dean's Research Fund, the Agency for Healthcare Research and Quality [T32 Grant 5T32HS26116], and the Claude Marion Endowed Faculty Scholar Award. Supplemental Material: The e-companion is available at https://doi.org/10.1287/msom.2023.1205 .

Development and Evaluation of Rehabilitation Service Areas for the United States

BackgroundGeographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries.MethodsA patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward’s clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries.ResultsThe method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care.ConclusionsRehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.

Too Many Walls and Not Enough Bridges: Care Transitions Models to Support Older Adults with Mental Illness and Cognitive Impairment

Challenges in transitions of care can lead to increased morbidity, mortality, and increased health care costs. In particular, older adults with mental illness (MI) or cognitive impairment (CI) are particularly vulnerable when transitioning from different health care settings and back to the community. For instance, almost half of older adults with cognitive impairment who are discharged home from the emergency department return within 30 days. Similarly, older adults with MI and CI admitted to a skilled nursing facility are less likely to be discharged and, if discharged, spend less time in the community. Importantly, these outcomes mediated by the presence of depression, agitation, and functional impairment, highlighting the need for interventions that provide symptom management and address frailty.Some interventions have been shown to improve transitions from acute care to post-acute care. The Institute for Health Improvement Age Friendly Health System Initiative incorporates the 4 M model of what matters most, mobility, medications, and mentation framework in order to bring to together evidenced based initiatives that improve safety and outcomes for older adults. These interventions embed comprehensive geriatric care throughout the care continuum: hospitals, transitions out of hospitals, and post-acute and long-term care facilities. Other interventions have utilized home visits upon discharge to minimize readmission and increase time at home. Less is known about initiatives which address the role of subspeciality care and community-based organizations (CBOs) in maintaining older adults with MI and CI in the community.Montefiore Einstein is a fully integrated academic health system including 11 hospitals including a rehabilitation hospital, 65 primary care sites, 18 mental health/ substance abuse treatments clinics, a care management organization, and a home health program. Montefiore's Center of Excellence for Alzheimer's Disease (CEAD) has successfully expanded the delivery of comprehensive, high-quality, cost-effective care for people with CI. The CEAD is staffed with board-certified neurologists, geriatricians, psychiatrists, neuropsychologists and social workers. Our focus on the early diagnosis of Alzheimer's disease and related dementias helps patients and their caregivers prepare for the future and better manage the cost of care, potentially avoiding costly, unnecessary emergency room visits and hospitalizations. It was also recently designated an IHI-designated Age Friendly system. Montefiore Home Care (MHC), established in 1947, is the nation's first hospital- based certified home health agency. 40% of homebound older adults have MI and CI but have limited access to appropriate evaluation and treatment. Accordingly in 2004, MHC developed a consultative geriatric program in collaboration with the Division of Geriatric Psychiatry to provide comprehensive social work and geriatric psychiatry assessments in the home after discharge from hospital. In addition to the collaboration with MHC, Montefiore Division of Geriatric Psychiatry has leveraged foundational funding to collaborate with CBOs to bring evidence-based mental health services to seniors over the past two decades.During this session, presenters will describe several ongoing and new Montefiore initiatives to address care transitions for older adults with MI and CI. Dr. Zwerling will describe how the CEAD is spearheading the transition for Montefiore Einstein to an Age Friendly system. Ms. Korenblatt will highlight how the MHC Geriatric Psychiatry Program social work team serves as a bridge between acute care and CBOs to minimize hospital readmissions. Finally, Dr. Ceïde will highlight a specific example of an evolving partnership with one specific CBO in order to maintain older adults with MI and CI in the community.

Association of Long-term Exposure to Air Pollution With Late-Life Depression in Older Adults in the US

Emerging evidence has suggested harmful associations of air pollutants with neurodegenerative diseases among older adults. However, little is known about outcomes regarding late-life mental disorders, such as geriatric depression. To investigate if long-term exposure to air pollution is associated with increased risk of late-life depression diagnosis among older adults in the US. This population-based longitudinal cohort study consisted of US Medicare enrollees older than 64 years. Data were obtained from the US Centers for Medicare and Medicaid Services Chronic Conditions Warehouse. The participants were continuously enrolled in the Fee-for-Service program and both Medicare Part A and Part B. After the 5-year washout period at entry, a total of 8 907 422 unique individuals were covered over the study period of 2005 to 2016, who contributed to 1 526 690 late-onset depression diagnoses. Data analyses were performed between March 2022 and November 2022. The exposures consisted of residential long-term exposure to fine particulate matter (PM2.5), measured in micrograms per cubic meter; nitrogen dioxide (NO2), measured in parts per billion; and ozone (O3), measured in parts per billion. Late-life depression diagnoses were identified via information from all available Medicare claims (ie, hospital inpatient, skilled nursing facility, home health agency, hospital outpatient, and physician visits). Date of the first occurrence was obtained. Hazard ratios and percentage change in risk were estimated via stratified Cox proportional hazards models accounting for climate coexposures, neighborhood greenness, socioeconomic conditions, health care access, and urbanicity level. A total of 8 907 422 Medicare enrollees were included in this study with 56.8% being female individuals and 90.2% being White individuals. The mean (SD) age at entry (after washout period) was 73.7 (4.8) years. Each 5-unit increase in long-term mean exposure to PM2.5, NO2, and O3 was associated with an adjusted percentage increase in depression risk of 0.91% (95% CI, 0.02%-1.81%), 0.61% (95% CI, 0.31%- 0.92%), and 2.13% (95% CI, 1.63%-2.64%), respectively, based on a tripollutant model. Effect size heterogeneity was found among subpopulations by comorbidity condition and neighborhood contextual backgrounds. In this cohort study among US Medicare enrollees, harmful associations were observed between long-term exposure to air pollution and increased risk of late-life depression diagnosis.

The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood. Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic. Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020. Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses. Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset. During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (-3.9%, CI [-5.2%, -2.7%]) or to home (-2.8% CI [-4.4%, -1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics. Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.

Hospital Discharge Planners Need More Information When Referring Patients to Home Health Care: Insights From the Coronavirus Disease 2019 Pandemic.

Hospital discharge planners play an important role in helping patients choose appropriate home health care. However, during the COVID-19 pandemic, they may not have had enough information to make the best decisions for their patients. A study of 58 discharge planners from Michigan hospitals found that 90% of them wanted information about the quality of home health agencies and whether they were prepared for COVID-19. However, only about 20% had this information readily available. The study also found that discharge planners varied in how they incorporated quality information. Some did not incorporate any quality information at all, while others provided it to patients without explaining its significance. Only about 25% of discharge planners helped patients interpret different sources of information. These findings suggest that hospital discharge planners had an unmet need for quality information, and they also provided limited assistance to patients. This may have led to some patients receiving suboptimal care. Thus, we proposed that hospital discharge planners need more information about the quality of home health agencies. Discharge planners should be more transparent about the quality of information they have, and they should help patients interpret it.

CHARACTERISTICS OF HOSPITALS AND PROVIDER MARKETS ASSOCIATED WITH INCREASES IN HOME HEALTH CARE USE

Abstract Many older adults require post-acute care from a nursing home or home health agency following hospitalization. Recent trends show providers are increasingly relying on home health agencies rather than institutionalized settings, with home health volume surpassing skilled nursing facility (SNF) volume since 2017. Using MedPAR patient encounter data from 2016–2019 and provider data from CMS, we analyze changes in the profile of patients receiving home health over time, showing that individuals discharged to home health are increasing in complexity based on hospital length of stay, comorbidities, and use of critical care services. Mixed effects models additionally suggest that grouping patients at the hospital and market level helps to account for unexplained variation in whether a patient is likely to receive home health versus SNF services. Examining the characteristics of hospitals and provider markets with increasing rates of home health referrals over time, we found that hospitals with increasing rates of discharge to home health were more likely to be for-profit facilities in urban areas with higher operating margins. However, this increase was not consistently tied to a corresponding decrease in rates of discharge to SNF, suggesting that hospitals are experiencing a combination of both patient-shifting across post-acute settings as well as an overall increase in baseline complexity of hospitalized patients over this time period. These results have implications for understanding the how policies currently being considered to improve value in the post-acute sector filter through heterogeneous market structures and complex organizational environments to impact patient care decisions.

PAY RATES AND EMOTIONAL LABOR: CONTENT ANALYSIS OF JOB ADVERTISEMENTS FOR HOME HEALTH AIDES

Abstract In the United States, over 3.5 million home health aides provide care and assistance to older adults and people with disabilities living in the community (Almeida, Cohen, Stone, & Weller, 2021). These providers are often tasked with emotionally and physically demanding work and are poorly compensated for their labor. In this poster I discuss the connection between the emotional demands of home health care jobs and their compensation through a quantitative content analysis of online job advertisements for home health aide positions (n=312). This research addresses two primary research questions: 1) what are the prevailing pay rates for home health aides and how do they compare to living wages? 2) what is the relationship between emotion work requirements and pay rates in home health aide job advertisements? In about 57% of the job advertisements hourly wages were not sufficient to meet the living wage level according to the MIT Living Wage Calculator. Using linear probability models, I found that there is no statistically significant difference between pay rates listed by home health agencies requiring emotional labor and home health agencies not requiring emotional labor while holding education, experience, and licensure requirements constant. Stratifying the data by home health agency/company size (1,000 employees or less and 5,000 employees or more) yielded no statistically significant results. These findings support and expand upon existing literature that home health aides are undercompensated for their work regardless of agency size, and provide evidence for the need for fair compensation and support.

RACIAL DISPARITY IN THE START OF HOME HEALTHCARE IN HIGH-RISK ADRD PATIENTS BY THE QUALITY OF HOME HEALTH

Abstract Improving the quality and timely access of home health care is a new quality measure and particularly crucial in high-risk ADRD adults following hospitalization. However, a significant portion of older patients waits longer than 2 days to receive home healthcare. In this study, we examine how the quality of home health agency and race are associated with the delay in care among ADRD patients receiving home healthcare and how this delay mitigates the risk of rehospitalization. We find that Black patients in low rated home health agencies have 28% higher odds of delay in care compared to White patients in high rated home health agencies (Odds ratio (95% CI) =1.28 (1.21 - 1.36)). Timely initiation of home health care also reduces the risk of rehospitalization in minority older adults with ADRD.

A DATA-BASED PROPOSITION FOR THE CREATION OF NEW ICD-10 DIAGNOSIS CODES FOR POST-ACUTE SEPSIS SURVIVORS

Abstract Sepsis survivors have the second highest readmission rate among Medicare beneficiaries, next to heart failure. I-TRANSFER is an implementation science study to improve transitions and reduce readmissions among sepsis survivors transitioning from acute to home health care (HHC). A total of 63 semi-structured interviews were conducted with stakeholders among 12 hospitals and 5 affiliated home health agencies (HHAs). The purpose of this secondary analysis was to: 1) examine how the sepsis diagnosis is reflected in HHC documentation, 2) identify barriers in sepsis information transfer to HHC, 3) recommend a documentation strategy to enhance information transfer and HHC documentation. We analyzed the diagnosis coding within a national OASIS dataset and eight I-TRANSFER interviews with hospitalists, documentation specialists, and HHC coders. Findings include: a) sepsis diagnoses were nearly invisible in HHC records being documented for only 10% of 165,000 sepsis survivors transitioned to HHC, b) sepsis information in referral documentation can be unclear to HHC coders, c) the lack of sepsis diagnosis documentation might make HHC clinicians unaware of the patient’s risk for readmission, d) HHC coders recommended improved language in the acute care discharge summary to link the need for HHC to sepsis, thereby supporting the use of ICD-10 sepsis ‘A’ codes in HHC. The use of terms, such as “History of Sepsis” or “Sepsis Resolved,” leads to HHC using non-specific codes, thus is not recommended. We highlight the need for new ICD-10 codes for “Sepsis Aftercare” and “Post-Sepsis Syndrome” to clearly communicate and document the needs of sepsis survivors.

DEVELOPING AN INTERPROFESSIONAL GRADUATE CERTIFICATE IN LONG-TERM SERVICES AND SUPPORTS

Abstract The demand for long-term services and supports (LTSS) is increasing and the capacity and competencies of the interprofessional LTSS workforce need to be expanded to provide value-based, person-centered care. The purpose of this presentation is to describe the process of developing an interprofessional LTSS graduate certificate in Gerontology. We broadened an existing nursing graduate certificate to encompass content related to skilled nursing facilities, assisted living and home health and hospice agencies. We will discuss: 1) how we engaged faculty from seven graduate programs: Pharmacy, Physical Therapy, Occupational Therapy, Dentistry, Social Work, Nursing and Physician Assistant to co-create the certificate; 2) challenges and benefits to developing a certificate; and 3) the 15-credit hour certificate components. Our faculty partners were committed to offering a LTSS focused graduate certificate which includes didactic courses and clinical hours. Four students have enrolled in the LTSS graduate certificate in Gerontology since implementation in Spring 2021.

HOME HEALTHCARE WORKFORCE AND NEIGHBORHOOD CHARACTERISTICS

Abstract Despite the rapid increase in the needs for home- and community-based services (HCBS), including home health care which is the most commonly used HCBS, workforce shortage has become a critical challenge to home health agencies in providing quality care to meet the needs of millions of homebound Americans. This study aimed to examine the availability of home health care workforce and its variations by neighborhood characteristics. We linked several national datasets from 2019 and included information from 11,005 HHC agencies in 1,849 counties. The unit for analysis is county. We found that on average county had fulltime equivalent (FTE) 83 (SD=351) home health care nurses, 120 (SD=411) FTE skilled home health providers (e.g., nurses, physical/occupational therapists) and 37 (SD=411) FTE aides. For every 1,000 persons, on average counties had 0.7 (SD=4.6) FTE nurses, 0.9 (SD=4.7) FTE skilled providers, and 0.2 (SD=0.8)) FTE aides. For every 1,000 older adults (>=65), on average counties had 3.6 (SD=23.9)) FTE nurses, 4.8 (SD=24.6) FTE skilled providers and 1.2 (SD=4.4) FTE aides. We also found that counties with moderate (2nd tertile) proportion of Black and Hispanic Americans; counties with highest (3rd title) proportion of Black and Hispanic Americans had the lowest number of FTE home health care aides per every 1,000 persons. Our findings highlight the staff shortage facing home health care and suggest the existence of disparities in availability of home health care workforce.

THE IMPACT OF PUBLIC REPORTING ON INEQUITIES IN HIGH-QUALITY HOME HEALTH UTILIZATION

Abstract Literature suggests that public reporting of quality may exacerbate disparities in access to high-quality post-acute and long-term care for older adults. The objective of this study was to evaluate the impact of the home health (HH) 5-star ratings on changes in high-quality HH agency (HHA) use, by race, ethnicity, income level, and place-based factors. Using a difference-in-differences framework, we found that after introduction of 5-star ratings adjusted rates of high-quality HHA use increased for all HH users, except for Latinx, Asian American/Pacific Islander, and low-income HH users, and disparities in access to high-quality HHAs were exacerbated for each of these groups. Last, we found that users within predominantly Latinx and lower income neighborhoods had a significantly greater decrease in their use of high-quality HHAs. Policymakers should be aware of the potential unintended consequences of public reporting and should consider adding measures of equity to the publicly reported information.

469. Healthcare Resource Utilization (HRU) among Hospitalized Patients (Pts) with Candidemia (C) and Invasive Candidiasis without Candidemia (IC) Who Received Definitive Treatment with an Echinocandin (EC) Across United States (US) Hospitals

Abstract Background Guidelines recommend ECs as preferred agents for C/IC. Although studies demonstrate that the ECs are safe and effective for the treatment of pts with C/IC, there are scant HRU data among hospitalized adult pts who received an EC for C/IC. This study sought to describe current EC use patterns and outcomes for C/IC across US hospitals. Methods A retrospective, multi-centered observational study was performed using the Premier Healthcare Database (1/2016-4/2019). Inclusion criteria: hospitalized; age ≥ 18 years, presence of Candida sp. on clinical culture consistent with C/IC; and received ≥3 days of an EC between -2 days of index culture to discharge. Pts were stratified by presence of C/IC. Baseline characteristics and treatment patterns (EC received, receipt of EC in relation to index culture, and EC duration) were assessed. Outcomes: discharge status (in-hospital death vs discharge location), hospital length of stay (LOS) post index culture, and hospital costs (overall and component costs) post index culture. Results 1,865 pts met study criteria. The mean (SD) age was 58.9 (19), 48% were female, mean (SD) Charlson Comorbidity Index was 3.4 (2.7) and 55% resided in the ICU at index culture. The most common Candida sp. were C. albicans (37%), C. glabrata (28%), C. parapsilosis (11%), and C. tropicalis (10%). Most pts had C (66%). Baseline characteristic and treatment patterns were largely similar between C/IC pts except for Candida sp., EC received, and EC duration (Table). Mean HRU was greater in pts with IC vs C (Table and Figure). No differences in HRU were observed in pts who died vs survived. In-hospital mortality was higher in pts with C vs IC. Most pts with C/IC received additional medical care post-discharge and pts with IC vs C were more likely to be discharged to a home health agency. Conclusion Hospital costs associated with C/IC are substantial, with most attributable to room and board costs. In-hospital mortality was considerable for pts with C/IC and many pts with C/IC required additional medical care in a long-term care facility or with a home health agency post-discharge. New treatment options are needed to mitigate the costs and outcomes associated with daily receipt of EC for pts with C/IC. Disclosures Thomas Lodise, Jr., Pharm.D., PhD, BioFire Diagnostics: Grant/Research Support|cidara: Advisor/Consultant|cidara: Honoraria|Entasis: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Paratek: Advisor/Consultant|Shionogi: Advisor/Consultant|Spero: Advisor/Consultant|Venatrox: Advisor/Consultant Kevin W. Garey, PharmD, MS, Acurx: Grant/Research Support|cidara: Advisor/Consultant|cidara: Grant/Research Support|Paratek: Grant/Research Support|Seres Health: Grant/Research Support|Summit: Grant/Research Support Brian H. Nathanson, Ph.D., cidara: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support.

Improving Care Coordination Between Veterans Health Administration Primary Care Teams and Community Home Health Aide Providers: A Qualitative Study.

Effective coordination between medical and long-term services is essential to high-quality primary care for older adults, but can be challenging. Our study assessed coordination and communication through semi-structured interviews with Veterans Health Administration (VHA) primary care clinicians (n = 9); VHA-contracted home health agencies (n = 6); and home health aides (n = 8) caring for veterans at an urban VHA medical center. Participants reported (1) establishing home health services is complex, requiring collaboration between many individuals and systems; (2) communication between medical teams and agencies is often reactive; (3) formal communication channels between medical teams and agencies are lacking; (4) aides are an important source of patient information; and (5) aides report important information, but rarely receive it. Removing structural communication barriers; incentivizing reporting channels and information sharing between aides, agencies, and primary care teams; and integrating aides into interdisciplinary teams may improve coordination of medical and long-term care.

Association of Social Determinants of Health Measures and Successful Community Discharge Across Rehabilitation Service Areas

<h3>Research Objectives</h3> Evaluate: 1) variation in successful community discharge across Rehabilitation Service Areas (RSAs) nationally, and 2) the relationship between social determinants of health (SDH) variables/indices and successful community discharge across RSAs. <h3>Design</h3> Retrospective cross-sectional analysis of Centers for Medicare & Medicaid Services (CMS) and AHRQ SDH dataset. We performed maximum likelihood factor analysis with varimax rotation and principled mean analysis to identify how many factors to extract from the AHRQ-SDH dataset and calculated a rehabilitation-specific SDH measure (SDH-R) based on these factors and variables. Next, we calculated the Social Deprivation Index (SDI) and the SDH-R for a random sample of 800 RSAs and examined the association between SDI and SDH-R and successful community discharge. <h3>Setting</h3> We examined discharges following post-acute care from long-term care hospitals, home health agencies, and skilled nursing and inpatient rehabilitation facilities. <h3>Participants</h3> The population included 2013–2015 Medicare records from fee-for-service beneficiaries >65 years. The cohort included 2,287,210 records across all diagnostic groups. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Successful community discharge across the 1711 RSAs nationally using CMS quality measure specifications. <h3>Results</h3> The national average for successful community discharge across RSAs was 55.1%. The pattern of successful community discharge indicates the majority of RSAs(1239, 72.4%) perform at the national average for successful community discharge with 253 RSAs (14.8%) significantly below and 219(12.8%) significantly above the national average. Factor analysis with AHRQ-SDH variables identified five factors with eigenvalues >1.0. The resultant model explained 23.1% of the variation in successful community discharge. The SDH-R model performed significantly better than the SDI (RMSE:SDH-R=0.88 vs SDI=0.99). <h3>Conclusions</h3> Successful community discharge varied across RSAs nationally. We identified SDH variables related to successful community discharge following rehabilitation. More research is needed to understand how SDH impacts community discharge across high- and low-performing RSAs and explore disparities and equity issues related to successful community discharge following post-acute care rehabilitation. <h3>Author(s) Disclosures</h3> This work was supported by the Agency for Healthcare Research and Quality (AHRQ) R01-HS024711 (TR,JP,AH,YK,KE), T32-HS026133 (YK,JD). All authors declare no conflicts.

Home health staff knowledge and experience of delirium and delirium superimposed on dementia in older adults

AbstractBackgroundPrevious studies have shown delirium is common in the home setting and can indicate a medical emergency. Many older adults come into the hospital or ER with delirium. However, little is known about the recognition of delirium by home health workers and community nurses. The purpose of this study is to explore the experience of home health staff caring for an older adult with delirium and delirium superimposed on dementia (DSD), with a focus on capturing rich details of these experiences and their knowledge of recognition and management of delirium.MethodStory circle methodology was employed. Data were collected from 20 staff members (age x̄ = 50, SD = 12.33) of a home health agency that serves 18 counties across rural Pennsylvania via Zoom video conference. Qualitative content analysis was utilized (Sandelowski, 2010). The reporting of this study followed the criteria for reporting qualitative studies in the (COREQ) 32‐item checklist.ResultNine themes emerged: (i) Negative emotions; (ii) A sudden change; (iii) Knowing the person with dementia; (iv) Potential causes of delirium; (v) Fear of delirium and staff fear; (vi) Lack of protocol; (vii) Distancing and redirecting for management; (viii) Role of family and care partners; and (ix) Barriers to identification.ConclusionThis is one of only a few studies that have explored delirium and DSD in the home health setting. This study had several innovations, including the use of story methodology and exploring the views of interdisciplinary team members. Importantly, delirium was a common occurrence in the stories they shared. Delirium often resulted in an ER visit or hospitalization. One of the most important findings was that home health staff had training for dementia and depression, but no training, agency protocol, or standardized assessment tool for delirium. A second important finding was the contribution of family and care partners in the assessment and management of delirium in persons with dementia. Implications for practice, research, and policy will be discussed.

Home Health Unplanned Readmission Across Metro and Rural Areas following Stroke and Joint Replacement.

<h3>Research Objectives</h3> Explore national geographic differences in unplanned readmission after accounting for patient-level admission factors and area-level post-acute care availability for individuals receiving home health services following stroke or lower-extremity joint replacement (JR). <h3>Design</h3> Retrospective cross-sectional analysis of Centers for Medicare & Medicaid Services (CMS) home health claims records and the Outcome and Assessment Information Set (OASIS). Using Rural-Urban Continuum Codes (RUCC) we classified all US counties into metro, metro-adjacent rural, and non-metro-adjacent rural areas and examined the availability of other post-acute care (PAC) provider types (long-term care hospitals, skilled nursing (SNF), and inpatient rehabilitation facilities) in each. We conducted multilevel logistic regressions to show the association between county classification and the odds of an unplanned readmission. <h3>Setting</h3> We examined acute care discharges to home health agencies. <h3>Participants</h3> The population included 100% Medicare records from 2013–2015 fee-for-service beneficiaries >65 years. The cohort included 21,395 stroke records and 160,287 JR records. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Odds of an unplanned readmission for individuals who received home health services following stroke or JR. <h3>Results</h3> Overall, 11.0% of stroke and 3.4% of JR had an unplanned readmission. For those >65 with JR, unplanned readmissions increased as age (range 2.6–5.4%) and length of stay (2.9–13%) increased. PAC availability other than home health varied across county groups. For metro counties, >50% were SNF-only; only 20% had all PAC provider types, whereas 80% of metro-adjacent rural counties were SNF-only with < 2% with all PAC provider types. Compared to metro areas, residing in a rural area was protective of readmission for those with stroke (metro-adjacent rural OR=0.887 (95CI 0.751–1.047), metro non-adjacent rural OR=0.789 (0.634–0.982). There was no significant effect of rural area on JR unplanned readmission. <h3>Conclusions</h3> Residing in rural counties is protective against unplanned readmission following home health services for stroke care. Further research should characterize social and contextual factors in rural areas that contribute to community-dwelling individuals' health. <h3>Author(s) Disclosures</h3> This work was supported by the Agency for Healthcare Research and Quality (AHRQ) R01-HS024711. Authors declare no conflicts.