Home Health Care Patients Research Articles

Comparison of Home Health Care Physical Therapy Outcomes Following Total Knee Replacement With and Without Subacute Rehabilitation

Few studies have examined the rehabilitation progression of patients managed through home health care physical therapy services following total knee replacement surgery. This study compares the episodes of care and functional outcomes of patients sent directly home to those discharged to a subacute rehabilitation setting prior to home health care. Prospective data were collected from 212 consecutive home health care patients referred for physical therapy following total knee replacement surgery. Data routinely recorded by the physical therapist at each home visit related to ambulatory progression and physical status was used in analysis. Patients admitted to the subacute facilities on hospital discharge were older and less likely to have a caregiver in or near the home. Equivalent physical therapy outcomes were seen regardless of hospital discharge disposition, although patients admitted to subacute rehabilitation settings required an additional 12.4 days. Younger patients admitted to subacute rehabilitation settings demonstrated less desirable outcomes at time of initial home visit, although these differences disappeared by time of discharge from home health care. Findings suggest that direct discharge home following total knee replacement surgery is a viable option for many patients. The application of evidence to physical therapy practice can promote more informed decision-making and foster the use of best practice in the home health care setting.

Development and Testing of an Analytic Model to Identify Home Healthcare Patients at Risk for a Hospitalization Within the First 60 Days of Care

SUMMARY Preventing hospitalization is one of the major objectives of home health care. Accomplishing this goal is being able to identify patients at risk for hospitalization and intervening appropriately. The current study explored which factors place patients at risk at the start of care and are predictive over the first 60 days of care. Outcomes Assessment Information Set (OASIS), plan of care, medications and medical record information from an urban home health agency were used to build and validate a predictive hospitalization model. The model was developed and tested using a large set of patients (n = 46,366). Patients were classified into seven risk groups from very low to very high. Results revealed that a combination of demographic, financial, clinical and health status factors could accurately predict patients' likelihood for hospitalization and the model agreed with clinical judgments. Examples of how the risk model could be used in practice are provided.

Digital pens and pain diaries in palliative home health care: Professional caregivers' experiences

Frequent pain assessment by the use of pain diaries for the follow-up of pain treatment can facilitate the caregivers' work with pain control in home health care. The aim was to explore and describe professional caregivers' experiences of palliative home health-care patients' use of pain diaries and digital pen technology for frequent pain assessment. A system for the follow-up of pain treatment was implemented in routine care and evaluated by means of a qualitative content analysis. Three nurses, two physicians and one secretary were interviewed. Additional analysis data were collected from patients' medical records, and the system log. The caregivers showed a shifting outlook towards the pain-assessment method, an initial cautious outlook due to low expectations of the patients' abilities to use the pain assessment method. Despite this, the caregivers experienced positive outcomes in terms of an increased awareness of pain, and positive patient influences including increased participation in their care, increased security, and improved changes in pain treatment as a response to reported pain assessments. Pain assessment by the use of pain diaries and digital pen technology has positive influences on palliative home-care patients and supports the caregivers' focus on the pain.

A data mining approach in home healthcare: outcomes and service use

BackgroundThe purpose of this research is to understand the performance of home healthcare practice in the US. The relationships between home healthcare patient factors and agency characteristics are not well understood. In particular, discharge destination and length of stay have not been studied using a data mining approach which may provide insights not obtained through traditional statistical analyses.MethodsThe data were obtained from the 2000 National Home and Hospice Care Survey data for three specific conditions (chronic obstructive pulmonary disease, heart failure and hip replacement), representing nearly 580 patients from across the US. The data mining approach used was CART (Classification and Regression Trees). Our aim was twofold: 1) determining the drivers of home healthcare service outcomes (discharge destination and length of stay) and 2) examining the applicability of induction through data mining to home healthcare data.ResultsPatient age (85 and older) was a driving force in discharge destination and length of stay for all three conditions. There were also impacts from the type of agency, type of payment, and ethnicity.ConclusionPatients over 85 years of age experience differential outcomes depending on the condition. There are also differential effects related to agency type by condition although length of stay was generally lower for hospital-based agencies. The CART procedure was sufficiently accurate in correctly classifying patients in all three conditions which suggests continuing utility in home health care.

Introduction

Future trends in the Medicare population and drug expenditures, the organizational structure of the Medicare program, and recent changes in Medicare rules and rates for pharmaceutical reimbursement are described. Large increases in the number of Medicare beneficiaries and drug spending are anticipated in the future. Medicare Part A provides insurance benefits for hospital inpatients, nursing home patients, home health care patients, and hospice care patients. Part B provides benefits for physician services, durable medical equipment, oral chemotherapy, and end-stage renal disease services. For hospitals, Part B rules are followed for ambulatory services, but these services are administered through the Part A Outpatient Prospective Payment System. The average sales price plus 6% is now used for pharmaceutical reimbursement, although physician-owned clinics may participate in a competitive acquisition program under Part B. Payments are the same for generic drugs and brand name products, although they differed in the past. Pharmaceutical reimbursement is available for uses listed in compendia approved by the Centers for Medicare & Medicaid Services and possibly some other authoritative sources. Medicare rules and rates for pharmaceutical reimbursement have undergone substantial changes in recent years and will continue to change in the future, with a potentially large impact on health systems and patients.

Strategies to Reduce Unplanned Hospitalizations of Home Healthcare Patients

Strategies to Reduce Unplanned Hospitalizations of Home Healthcare Patients

Comorbidity, Disability, and Geriatric Syndromes in Elderly Cancer Patients Receiving Home Health Care

To assess the prevalence of comorbidity, disability, and geriatric syndromes, or a combination thereof, in elders with cancer receiving home health care (HHC). Using the Ohio Cancer Incidence Surveillance System, we identified Ohio residents 65 years of age or older who were diagnosed with incident breast (n = 952), prostate (n = 324), or colorectal cancer (n = 1,276) during the 28-month study period, August 1999 through November 2001. We used the Outcome and Assessment Information Set, a database compiling comprehensive assessment forms completed for all HHC patients, to group individuals in independent and overlapping categories of comorbidity, disability, and geriatric syndromes on the basis of the patients' clinical condition 14 days before the date of the assessment. The proportion with no comorbidity, disability, or geriatric syndromes was 26.4% in breast cancer patients, 12.0% in prostate cancer patients, and 14.0% in colorectal cancer patients. The proportion of patients presenting all three entities at once was 11.7%, 24.7%, and 15.7%, respectively, in three cancer sites. As expected, the proportion of patients with no comorbidity, disability, or geriatric syndromes declined gradually with increasing age, and that of patients with all three entities was highest among patients 85 years or older. The proposed taxonomy will help us gain a more nuanced understanding of older cancer patients' clinical presentation and may lead to a more accurate identification of older patients who might benefit from standard cancer treatment, and those who might experience adverse outcomes.

Correlates of Suicide Among Home Health Care Utilizers Who Died by Suicide and Community Controls

Home health care patients often have several late-life risk factors for suicide and constitute a high risk group for suicidal behaviors. In this study, we examined the characteristics of 14 older adult home health care utilizers who died by suicide and four community controls who used similar services. Both groups of home health care utilizers had multiple health problems and, with one exception, all were functionally impaired. Descriptive comparison suggests that suicide decedents were more likely than their counterparts to suffer from depressed mood, suicidal ideation, prior suicide attempt(s), alcohol dependence, chronic pain, strained family relationships, lack of social support, and financial difficulties. Identifying suicide risk factors that place older adult home health care utilizers at particularly high risk for suicidal behaviors within this population will further help target suicide preventive interventions by home care providers.

Clinical Guidelines and Recent Research on Hypertension and Heart Failure

The summaries that follow capture important, research-based work that has been published recently and that we think may hold special interest for home healthcare nurses. The information provided is only a sample of the available findings. For additional information and insights, we suggest that readers go to the original articles. This month we focus on hypertension and heart failure, prevalent conditions in the home healthcare patient population.

Exploring the Utility of Automated Drug Alerts in Home Healthcare

Computerized drug utilization review (DUR) can potentially reduce adverse drug events. We examined automated DUR for home healthcare patients with diabetes or hypertension. Sixty-eight percent of diabetes patients and 50.7% of hypertension patients triggered severe, moderate, or duplicative alerts. Among diabetes patients, 74.3% of duplicative alerts were trivial or inappropriate, compared with 3.9% among hypertension patients. Experts judged that 40.5% of high-risk diabetes patients and 53.6% of hypertension patients had alerts requiring nurse follow-up. Adequate follow-up was significantly lower for the former. The relationship between inappropriate alerts and poorer follow-up reinforces the need for more specific alert systems to focus clinicians' attention on clinically important alerts.

Risk of adverse drug events by patient destination after hospital discharge

The prevalence of risk factors for adverse drug events (ADEs) in patients discharged from the hospital to various care settings was studied. Data on patient risk characteristics for ADEs were collected for hospital discharges for 2000. Differences in the prevalence of 10 risk characteristics among home health care (HHC), self-care (SC), and long-term-care (LTC) patients at the point of discharge were determined. Data for 4250 discharges were analyzed. The three groups differed significantly in the distribution of risk characteristics. HHC patients had the highest prevalence of heart failure, cardiovascular medication use, and polypharmacy, and LTC patients had the highest prevalence of hypoalbuminemia, cognitive impairment, and psychiatric drug use. The risk of ADEs in patients discharged to HHC appeared to be comparable to or higher than that in patients discharged to LTC.

Polypharmacy and Possible Drug-Drug Interactions Among Diabetic Patients Receiving Home Health Care Services

SUMMARY Objectives: In this study, we examined the drug regimens of diabetic patients receiving home health care services to measure the prevalence of polypharmacy and to assess the likelihood of drug-drug interactions, a consequence of polypharmacy. Design: The sample consisted of 139 diabetic patients who received home health care services from one home health agency in a large mid-Atlantic city. The data were collected from March 1, 1998 to September 30, 1999. Information regarding medications was collected by the home health nurse during the initial home visit and was recorded on the medication sheet in the patient's clinical record. Any changes in medications were noted on the medication sheets. Methods: We identified all systemic medications prescribed for 139 home health patients. To assess drug-drug interactions, we used Micromedex® formulary DRUG-REAX® System. Outcomes: We calculated (1) the number of systemic medications taken, and (2) the number of possible severe, moderate, and mild drug-drug interactions. Results: We found that the average number of medications taken was 8.9 (SD 3.4) prescribed medications per day. Our results show that 38.8% of the patients in the sample could potentially be subject to at least one severe drug-drug interaction. Nearly all of the patients (92.8%) were at risk for moderate drug-drug interactions, and 70.5% could have mild drug-drug interactions. Conclusion: We conclude that polypharmacy is a concern for home health care patients with diabetes and the potential for drug-drug interactions is substantial. Our results indicate that the drug regimens of diabetic patients should be monitored systematically to avoid adverse events such as hospitalization. Family practitioners and home health care takers are in a unique position to identify polypharmacy and to modify drug regimens.

Hospital Readmission From Home Health Care Before and After Prospective Payment

To describe and compare clients who were readmitted to the hospital during an episode of home health care, before and after the inception of the prospective payment system (PPS). A longitudinal mixed design was used to replicate a study conducted 9 years previously (pre-PPS) in the same home care agency in the central part of the United States. Seventy-six closed-case medical records from a not-for-profit hospital-affiliated home care agency were retrospectively reviewed and compared to pre-PPS data. The same data collection tool, the Hospital Readmission Inventory, was used for both pre- and post-PPS studies. Nurse administrators at the data collection agency were interviewed concerning comparative results. Currently readmitted clients were sicker than were those in the previous research report, they were readmitted sooner for a different diagnosis, and they had less continuity of services. The home health care industry has undergone a dramatic change in payment for services, from fee-for-service to PPS. Of particular concern is the adverse patient outcome of an unplanned hospital readmission. Prior studies have characterized such patients in home health care, but no comparative reports were found in a literature search since the inception of PPS. Findings from this study indicated that an increased emphasis on cost containment and higher-risk clients appear to have changed patterns of care delivery.

Payment Source and Length of Use Among Home Health Agency Discharges

Our study compared (1) length of use among home health care (HHC) discharges with Medicare, Medicaid, or private health insurance between 1991 and 2000 and (2) factors associated with length of HHC use among discharges with Medicare, Medicaid, or private health insurance. Data were obtained from the 1992, 1994, 1996, 1998, and 2000 National Home and Hospice Care Surveys (n = 18,416). Logistic regressions and stratified analyses by primary payment source were applied. After adjusting for covariates, Medicare HHC patients were from 0.52 to 0.75 times less likely to be discharged within 30 days in 1991-1996 than in 1997-1998. Medicaid patients were 0.37 times less likely to be discharged within 30 days in 1991-1992 than in 1997-1998. Patients with private insurance were 2.05 times more likely to be discharged within 30 days in 1993-1994 than in 1997-1998. No significant difference in length of use was found at the multivariate level between 1997-1998 and 1999-2000 among HHC patients with Medicare, Medicaid, or private health insurance. Results for being discharged within 60 days were similar to these described above. Our study shows that length of HHC use among Medicare discharges decreased after the implementation of the Medicare interim payment system. We did not find a spillover effect of the Medicare interim payment system on length of HHC use among discharges with Medicaid or private health insurance. Our results can help health professionals and policy makers better understand the dynamic associations between payment systems and length of use of HHC services.

A Needs Assessment: Infection Control Practices in Home Healthcare and Current Standards of Care

ISSUE: There is little research evidence on infection control practices in home healthcare agencies. Clinical guidelines set for acute- and long-term-care institutions have been used to “bridge the gap” to the home-care setting. Very little research evidence exists regarding the use of supplies for wound care and best practices in the home-care setting. PROJECT: A needs assessment was conducted to assess both the extent of the problem of wound care supplies in the home and the microbiological impact on patients with special emphasis placed on the presence of multidrug-resistant organisms. Items that the home-care nurses take from home to home as possible sources of fomites were examined, especially when multidrug-resistant organisms from institutions have been identified. RESULTS: Clearly, the needs assessment established that the extent of the problem of wound care supplies in the home, and guidelines for the treatment of wound infections in the home, require more research. The one research study done on bacterial contamination and wound care supplies found that bacteria were present in 75% of all wound care supplies left in homes for 7 days or more. Further research is necessary in this area to provide agencies with sound scientific data and to serve as guidelines for the development of evidence-based policies and procedures. LESSONS LEARNED: A tool for the quantification of the living conditions of the home-healthcare patients must be generated. Strong evidence can be provided for cause-and-effect relationships, with control of potential bias in the measurement of predictor variables.

Individualized education can improve foot care for patients with diabetes.

Providing individualized education to home care patients with diabetes can significantly improve their foot care practices. A nurse researcher from the Intercollegiate College of Nursing at Washington State University conducted a study of 40 home healthcare patients with Type 2 diabetes and found that an individualized educational intervention led to improved foot care knowledge, self-care practices, and confidence performing foot related self-care.

Patient-Level Home Health Care Outcomes Secondary to the Balanced Budget Act of 1997

The National Association for Home Care estimated 26% of all home health agencies (HHAs) have gone out of business since October 1997 when Medicare began to change the funding structure for home health care reimbursement. This study aims to answer two questions: Did HHAs that went out of business abandon patients? and Are HHAs that remained in business providing less-than-adequate services? Telephone interviews were conducted with 64 randomly selected elders receiving home care services during the funding transition from fee-for-service to an interim payment system. The findings indicate that HHAs that closed down primarily transferred their patients to other agencies and that 22% of patients experienced an increase in the number of hospital admissions following the funding structure transition. These preliminary results indicate that no substantial ill-effects have come to this sample of home health care patients as a result of the Balanced Budget Act of 1997.

Recognition of depression among elderly recipients of home care services.

Depression among older home care patients is prevalent but undertreated. The purpose of this study was to investigate the ability of home health nurses to correctly identify depression among older patients and to describe nurse and patient characteristics associated with more accurate assessment of depression. Forty-two nurses were surveyed about the presence of depressive symptoms among patients who had been evaluated independently for depressive disorders by research staff using the Structured Clinical Interview for Axis I DSM-IV Disorders. A sample of newly admitted home health care patients who were aged 65 years or older was randomly selected for this evaluation on a weekly basis from December 1997 to December 1999. Of 403 patients who were evaluated, 97 (24 percent) were found to have either major depression (64 patients) or minor depression (33 patients). The nurses correctly identified depression among 44 of the 97 patients who were depressed (sensitivity of 45.4) and 230 of the 306 patients who were not depressed (specificity of 75.2). The kappa coefficient measuring overall agreement between the nurses' assessment and the diagnosis of depression was.19. Nurses who had more geriatric nursing experience were more likely to correctly identify depression. Home health nurses have difficulty making accurate assessments of depression among older home care patients. Inaccuracy in assessment of depression by home health nurses is a significant barrier to treatment in this elderly homebound population.

A survey of the perceptions, knowledge, and use of A1C values by home care patients and nurses.

The purpose of this study was to provide baseline information on the perceptions, use, and knowledge of hemoglobin A1C (A1C) values among home healthcare nurses and patients. A convenience sample (44 patients, 26 nurses) from a Medicare-certified home care agency was surveyed using an investigator-developed demographic and knowledge questionnaire. Data collected from telephone interviews (patients), written questionnaires (nurses), and medical record reviews were analyzed using descriptive methods. Most of the home care nurses correctly identified the American Diabetes Association's recommendation for target A1C values; however, nurses rarely contact the physician to obtain A1C results. Nurses do not routinely teach patients about A1C values and inconsistently use A1C values to plan care for their patients with diabetes. Most patients said that they had never had an A1C test performed, and most did not recall the nurse providing any teaching about A1C. Education related to target A1C values is needed. Methods to increase the availability of A1C results in the home care setting should be explored. The importance and clinical utility of A1C values need to be more effectively conveyed to both nurses and patients in the home care setting.

A Profile of Asian/Pacific Islander Elderly in Home Health Care

This study explores the differences in patient characteristics, home health service use, and discharge outcomes between Asian/Pacific Islanders (API) (n = 408) and White elderly home health care patients (n = 2,480) with a primary diagnosis of diabetes, hypertension or cardiovascular disease. Outcomes Assessment Information Set and administrative data from a large urban home health agency located in the Northeast were used for analyses. Overall, API elders were more likely to be dually eligible for Medicare and Medicaid; entered with greater dependencies; and received more home health aide services than White elders. However, White elders reported greater anxiety and were more likely to live alone.