Home Health Staff Research Articles

Home Health Staff Knowledge and Experience of Delirium and Delirium Superimposed on Dementia in Older Adults

Home Health Staff Knowledge and Experience of Delirium and Delirium Superimposed on Dementia in Older Adults

INNOVATING HOME HEALTH DELIVERY TO IMPROVE VETERANS’ ACCESS TO CARE AND CARE COORDINATION

Abstract Nearly 350,000 Veterans receive home health services through the Veterans Health Administration (VA) annually. Historically, VA has purchased most home health services from contract agencies in the community. VA leaders have expressed growing concerns about Veterans’ access to home health, especially in rural areas. Coordinating care between VA and contract agencies is an ongoing challenge. To address these challenges, the VA Midwest Health Care Network (VISN 23) developed the VA Home Health (VAHH) pilot program. The program launched at the Iowa City VA and is currently operating at 4 sites in Iowa and South Dakota. Through VAHH, local VA Medical Centers hire home health staff directly (nurses, aides, physical and occupational therapists), rather than purchase these services through contract agencies. In this presentation, we describe program development, challenges, and early evaluation findings. In fiscal year (FY) 2022, 200 Veterans received VAHH. So far in FY2023, over 700 Veterans have been served. Pre/post comparisons involving Veterans receiving VAHH show modest reductions in emergency room visits (727 vs. 664 visits) and inpatient admissions (227 vs. 192 admissions). Overall hospital lengths of stay have reduced more dramatically (2132 vs. 1390 total days). VAHH staff note close communication with Veterans’ primary care teams, and Veterans describe being highly satisfied with the program. Interest in VAHH is growing nationally, particularly as access to home health in many regions is limited. Early lessons from the VAHH pilot program could inform VA decisions about home health delivery and assist other sites in improving care for Veterans.

Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions

Background The hospital-to-home transition remains a high-risk care interval for older adults. Skilled home health (HH) agencies are uniquely positioned to address care-transitions-associated patient safety threats. We previously developed the Hospital-to-Home-Health Transition Quality (H3TQ) Index to identify safety issues after hospital discharge. Our objective is to evaluate a participatory ergonomics process engaging stakeholders to develop strategies to implement the H3TQ into HH agency workflow to improve transition-associated safety issues in real-time. Methods Stakeholders participated in three, two-hour Intervention Refinement Team (IRT) meetings with a focus on: (1) identifying facilitators and barriers to collect H3TQ data in real-time, (2) integration of H3TQ into workflows, and (3) sharing H3TQ safety threat information to improve care transition safety outcomes. We used the human factors engineering-informed Systems Ambiguity Framework to guide the structure of IRT meetings and qualitative data analysis to evaluate the IRT process itself. Results Stakeholders (N = 9) represented patients, family caregivers, and HH staff. Stakeholders identified three key strategies for H3TQ implementation: (1) mechanism and timing of H3TQ data collection using multiple platforms; (2) data sharing conditions for safety reporting across the health system; and (3) identification of targeted care transitions outcomes for improvement. Participants highly rated IRT meetings regarding meeting usefulness, comfort, and degree of input into the discussion. Conclusions The IRT participatory ergonomics process was successful. Stakeholders identified strategies to facilitate implementation of the H3TQ implementation to improve the hospital-to-HH. IRTs have potential application to other health system issues related to the care of people with complex needs.

Improving Laboratory Result Retrieval Times Within the Home Health Setting

This quality improvement project focuses on decreasing laboratory result retrieval times within a 6-month period at a rural home health setting. Prior to implementation, 73% of all laboratory results were not received within 24 hours (72 hours for cultures). Interventions included Lean Six Sigma methodologies (process mapping and process redesign) and Plan-Do-Study-Act to reduce laboratory result retrieval times. Data analysis included descriptive statistics including means, averages, and percentages for the primary outcome of laboratory result retrieval time. 119 participants included all patients who had laboratory specimens collected by home health staff during the project timeline. Laboratory result delays ≥24/72 hours decreased from 73% (29/40) to 14% (11/79). Furthermore, 25% (10/40) of labs were delayed ≥5 days pre-implementation and 0% post-implementation. Abnormal laboratory results with delayed treatment decreased from 28% (11/40) to 5% (4/79). Provider notification within 24 hours of an abnormal laboratory result increased from 0% (0/13) to 75% (6/8). Hospitalization rates within 30 days of an abnormal result was 15% (6/40) pre-implementation and decreased to 5% (4/79) post-implementation.

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 Staff Perspectives on Infection Prevention and Control: Implications for Coronavirus Disease 2019

ObjectivesThe role of home healthcare (HHC) services in providing care to vulnerable, often frail individuals with chronic conditions is critical. Effective infection prevention and control (IPC) in HHC is essential to keeping both healthcare workers and patients safe, especially in the event of an emerging infectious disease outbreak. Prior to the coronavirus disease 2019 pandemic, we explored successes and challenges with IPC from the perspectives of HHC staff. DesignQualitative descriptive study. Setting and ParticipantsFrom May to November 2018, we conducted in-depth telephone interviews with 41 staff from 13 agencies across the nation. MethodsTranscripts were coded by a multidisciplinary coding team, and several primary and subcategories were identified using directed content analysis. ResultsFour primary categories were generated including (1) uniqueness of HHC; (2) IPC as a priority; (3) importance of education; and (4) keys to success and innovation. Participants perceived that IPC plays a big part in patient safety and reducing rehospitalizations, and protection of patients and staff was a major motivator for compliance with IPC. The identified challenges included the unpredictability of the home environment, patient/family dynamics, the intermittent nature of HHC, and staffing issues. Education was seen as a tool to improve staff, patient, caregiver and families' compliance with IPC. Keys to success and innovation included a leadership focus on quality, using agency infection data to improve quality, and a coordinated approach to patient care. Conclusions and ImplicationsThis qualitative work identified barriers to effective IPC in HHC, as well as important facilitators that HHC agencies can use to implement policies and procedures to improve patient care and keep staff safe. Leadership prioritization of IPC is key to implementing appropriate IPC policies and may be especially important in midst of a crisis such as coronavirus disease 2019.

Caring for Miners During the Coronavirus Disease-2019 (COVID-19) Pandemic.

Caring for Miners During the Coronavirus Disease-2019 (COVID-19) Pandemic.

2447. Impact of Agency-Level Policies and Priorities upon Infection Prevention and Control in the Home Environment: Perspectives of Home Health Staff

BackgroundInfection prevention and control (IPC) is becoming a national priority in home healthcare (HHC) industry. However, little is known about the impact of agency-level policies and priorities upon IPC practices in the home environment. This qualitative study aimed to explore: 1) how home health agencies (HHA) are implementing IPC policies, and 2) perspectives of HHC staff on agency-level IPC policies and priorities and how they impact patient care.MethodsFrom March to November 2018, we recruited staff from HHAs across the United States to participate in in-depth, telephone interviews. HHAs were purposively sampled based on high or low Quality of Patient Care star rating and other agency characteristics from 2016 Provider of Services and Home Health Compare data. Interviews were conducted with 41 staff from 13 HHAs, including administrators, IPC and quality improvement personnel, registered nurses and home health aides. Interview guides were tailored toward the role of the interviewee. Interview transcripts were coded and themes were identified using content analysis.ResultsThemes included: 1) “Handwashing is our priority”; 2) Innovative approaches to care coordination and IPC; (3) Monitoring staff compliance; and, (4) Opportunities for improvement. Almost all HHC staff described that handwashing was a primary focus of IPC policies and staff education at their agencies. Some staff depicted creative ways that their agency was coordinating patient care among staff who were not always in the office, and also unique approaches to educating staff about IPC policies and practices. Administrators and managers explained the ways that they monitored staff compliance around IPC policies, while nurses and aides described how the monitoring reminded them about proper procedures. Finally, HHC staff mentioned various ways in which care coordination, staff education and compliance could be improved at their agencies; for example, more frequent supervisory visits were perceived as a way to improve compliance with agency policies and practices.ConclusionThis study increases our understanding of the impact that agency-level IPC policies and practices have upon HHC staff and patient care, in addition to specific approaches to care coordination, staff education and compliance monitoring.Disclosures All authors: No reported disclosures.

The Experience of Family Physicians and Home Health Staff Involved in an Intervention to Increase Patient-Related Collaboration.

RÉSUMÉLes médecins de famille (MF) et le personnel de soins de santé à domicile (PSD) canadiens rencontrent d’importants obstacles lorsqu’ils doivent collaborer pour la prestation de soins aux patients qu’ils ont en commun. Cette étude à méthodologie mixte visait à évaluer la qualité et la viabilité de l’utilisation de l’audioconférence sécurisée dans une optique d’amélioration de la planification des soins pour ces patients. Les données primaires incluaient les résultats d’un sondage réalisé avant et après l’intervention, ainsi que des entretiens semi-structurés et des groupes de discussion post-intervention. Des méthodes statistiques non paramétriques ont été utilisées pour analyser les résultats du sondage, et les données qualitatives ont fait l’objet d’une analyse thématique de contenu. Les résultats des analyses quantitatives et qualitatives ont ensuite été intégrés afin de faire ressortir les inférences reflétant les approches des MF et du PSD relatives aux obstacles et aux avantages de la planification interdisciplinaire des soins. Les MF et le PSD ont montré que des obstacles structurels limitent leur capacité à collaborer. Le PSD et les MF ont également convenu que les rencontres entre les intervenants des deux services étaient bénéfiques pour les patients et que l’utilisation de l’audioconférence constituait une méthode efficiente de planification collaborative des soins. Les limites comprenaient la petite taille de l’échantillon et la courte période d’intervention, compte tenu de l’ampleur des changements attendus.

The feasibility of employing a home healthcare model for education and treatment of opioid overdose using a naloxone auto-injector in a private practice pain medicine clinic

Objectives: The purpose of this study was to determine if employing a home healthcare model for education and treatment of opioid overdose using the Evzio (Naloxone) auto-injector in a private practice pain clinic.Methods: A prospective survey was used to determine the feasibility of integrating a naloxone auto-injector within the patient’s home with a home care training model. Twenty moderate or high-risk patients were enrolled from the chronic pain clinic. Patients who were moderate or high risk completed an evaluation survey. The naloxone auto-injector was dispensed to all patients meeting criteria. The treating provider after prescribing the naloxone auto-injector then consulted home health per standard clinical practice. All patients had home health consulted to perform overdose identification and rescue training. A Cochran’s Q test was conducted to examine differences in patient knowledge pre- and post-training. The post training test was done 2–4 weeks later.Results: Forty subjects enrolled after meeting inclusion/exclusion criteria. Twenty withdrew because their insurance declined coverage for the naloxone auto-injector. Those completing home health showed a statistically significant difference in their ability to correctly identify the steps needed to effectively respond to an overdose (p = .03).Discussion: Preliminary evidence would suggest training on overdose symptom recognition and proper use of prescription naloxone for treatment in the home setting by home health staff would prove more beneficial than the clinic setting, but feasibility was hindered by unaffordable costs related to insurance coverage limitations.

Improving Home Health Staff Knowledge of Heart Failure

Heart Failure (HF) affects millions of people in the United States and is the most frequent cause of 30 day rehospitalization. Use of home health (HH) services has been found to be a strong predictor for readmission risk, and many rehospitalizations of HF patients that utilize HH services are considered potentially avoidable. Educational programs which include topics such as HF risk factors, drug therapy, patient self management of HF, and recognition of acute HF can improve nurses knowledge.

Bridging Silos

Canadian family physicians (FPs) and home health staff (HHS) experience significant barriers to collaboration regarding patients whose needs are complex. This study used mixed methods to examine whether pre-scheduled, structured audio-conferencing could improve patient-related collaboration between physicians and HHS. The number of shared patients and contacts was collected across three phases: baseline, pre-intervention, and intervention. Interviews with FPs and focus groups with HHS were conducted post-intervention. Mixed effects Poisson regressions for count data, and content analysis for interview and focus group data, were used. No statistically significant “intervention” effect was observed in either the number of shared patients or the average patient contacts. Physicians participating in at least one audio-conference had a lower patient contact rate than the rest of the intervention group and controls. Qualitative data suggested that audio-conferences led to fewer contacts due to more efficient communication.

Predictors of Hospitalization Among Home Health Managed Care Patients

Objectives: To identify variables associated with hospitalization among managed care patients enrolled in home health services. Design: Retrospective analysis using Home Health Outcome and Assessment Information Set (OASIS) and home health visit data. Setting: Three managed care agencies. Participants: Sixty-five and above, Medicare patients admitted between March 1, 2007 and February 29, 2008. Measurements: Home health care episodes were defined as the time from admission to hospitalization or discharge. Cox regression analyses were conducted to determine predictors of hospitalization. Results: The analysis included 6,805 episodes. Predictors of hospitalization included being male or African American, living in a board and care facility, and having therapies at home, among others. Nurse visits were associated with increased hospitalization whereas social worker visits were associated with decreased hospitalization. Conclusion: This study provides implications for improving clinical practice. Knowing factors associated with hospital admission, home health staff can identify potential risks and develop targeted care plans that may reduce avoidable hospital admission rates.

Extending Work Environment Research Into Home Health Settings

Organizational attributes in work environments that support nursing practice are theoretically associated with superior nurse and patient outcomes, and lower frequencies of adverse events. This study explored associations between organizational support for nursing practice in home health care agencies and (a) the frequency of nurse-reported adverse events, (b) nurse-assessed quality of care, (c) nurse job satisfaction, and (d) nurses' intentions to leave their employing agency. Data were collected from a sample of 137 registered nurses employed as home health staff nurses in the United States and analyzed using descriptive techniques and bivariate correlation. As anticipated, organizational support for nursing was negatively associated with nurse-reported adverse patient events and intent to leave, and positively associated with nurse-assessed quality of care and job satisfaction. These findings may be helpful to nursing administrators who seek to create work environments in home health agencies that maximize patient outcomes and nurse satisfaction.

DIAGNOSIS: TUBERCULOSIS

Home care staff frequently become anxious when a patient with active infectious tuberculosis is referred for home care. Using a home care patient case study, this article reviews tuberculosis epidemiology, pathophysiology, treatment, and infection control. It also discusses home health staff's role in case finding because home care patients with chronic disease and immunosuppression conditions are at risk for active tuberculosis disease.

Caregivers' Use of Spirituality in Ethical Decision-Making

This qualitative study examined ethical dilemmas faced by female caregivers of frail elders as well as the dominant role of caregivers' spirituality in addressing these dilemmas. Dilemmas are difficult decisions that involve conflicting values, e.g., freedom versus safety. In-depth interviews were conducted with thirteen ethnically diverse caregivers recruited from a home health agency and its parent hospital. Purposive sampling was used to obtain variation among research participants. Focus group interviews of home health staff, key informant caregivers, and interviewees provided guidance for the research design, reflection on findings and development of implications. In order to deal with ethical dilemmas, all caregivers used spirituality as (1) a philosophy of life, e.g., “This is what you do when you're family,” (2) an aid to decision-making, e.g., through the use of prayer; and/or, (3) a way to transcend dilemmas, e.g., “no choice is hard.” Implications include the importance of care-giver-driven assessment, professional self-reflection, and sustained formal services for caregivers.

From the Woman's Viewpoint: Ethical Dilemmas Confronted by Women as Informal Caregivers of Frail Elders

Women as informal caregivers face complex ethical dilemmas in caring for a frail elder. Through in-depth interviews with 13 ethnically diverse caregivers, this qualitative study explored women's ethical decision-making. Focus group interviews of home health staff, key informant caregivers, and interviewees provided guidance for research design, reflection on findings and development of implications. Findings are integrated into an ethical decision-making model that includes types of ethical dilemmas (e.g., protection of life vs. autonomy); feelings that permeate decision making (e.g., fear); processes for addressing ethical dilemmas (e.g., family collaboration); and supportive services. Implications include (a) expansion of services to meet caregivers' ongoing needs, (b) research that acknowledges multiple decision-making components, and (c) the use of caregiving vignettes in the classroom.

A Nurse’s Fantasy

Richard Davis, BA, BS, RN, is a home health staff nurse in Vermont. Address for correspondence: Richard Davis, 679 Weatherhead Hollow Road, Guilford, VT 05301 ([email protected]).

Transition from Academia to Home Health Practice

When a professor leaves a long-time teaching position in baccalaureate nursing to work in a nursing staff position in home health care, this change engenders certain, perhaps conflicting, expectations from the professor and the agency. Tension may exist because of differences between the two roles in the level of independent functioning, the level of authority, communicating with physicians, professional competence, and time constraints. Supportive agency staff helps to minimize the conflicts through a tailored orientation. This article reviews role change theory as it pertains to this transition, discusses differences between academia and home health practice roles as they affect employment, makes recommendations for agencies and faculty to help with this role transition, and relates one nursing professor’s experiences during her orientation to a new home health staff position.

Get ready for your Medicare survey: Understanding the new interpretive guidelines

A Medicare survey can be a nail-biting experience for home health agency (HHA) management and staff, but understanding the government's new and changed requirements and the survey process can significantly decrease the stress. Although only 15 Conditions of Participation (COPs) are involved, the survey covers nearly 100 pages of interpretive guidelines, which were revised in transmittal 21 of the State Operations Manual in October 2000. Most agencies were too busy with the new prospective payment system (PPS) requirements to give much attention to these guidelines now being used by surveyors. A succinct review of the major changes and additions may help agencies focus on areas important for their particular situation.