Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19.

BACKGROUND: Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge. METHODS: Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization. RESULTS: Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization. CONCLUSIONS: HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Development and Validation of the Hospital-to-Home-Health Transition Quality (H3TQ) Index: A Novel Measure to Engage Patients and Home Health Providers in Evaluating Hospital-to-Home Care Transition Quality.

BACKGROUND: Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions. OBJECTIVE: To describe the development, initial psychometric validation, and feasibility of the Hospital-to-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks. METHODS: Development: A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing: Prospective H3TQ implementation on older adults' hospital-to-HH transitions. Populations Studied: Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists). RESULTS: The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients' lack of general understanding of care plans (27%). CONCLUSIONS: The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition.

Skilled home healthcare clinicians' experiences in communicating with physicians: A national survey.

BACKGROUND: Effective communication between skilled home healthcare (SHHC) clinicians and physicians is critical to care coordination. No studies have examined this from the point of view of SHHC clinicians at the national level. The objective is to determine in national sample issues related to how SHHC agency clinicians communicate with physicians. DESIGN: Mailed survey. METHODS: Mailed survey to a national representative random sample of SHHC agencies. The survey measured the experiences of SHHC clinicians in communicating with physicians. Multilevel logistic regression models examining odds of adverse patient outcomes associated with communication failures. RESULTS: A total of 265 surveys from 168 SHHC agencies were returned for a response rate of 13.3% at the individual respondent level and 16.8% at the SHHC agency level. Agency-level characteristics were similar between responding and nonresponding agencies. The most common method of contacting physicians during routine SHHC visits was telephone; communication via the electronic health record was uncommon. Nearly 40% of SHHC clinicians report never or rarely being able to reach a physician. SHHC clinicians rate the Center for Medicare and Medicaid Services Home Health Certification and Plan of Care (CMS-485) as a useful means of communication 6.3 (SD, 2.5) scale of 1 (least useful) to 10 (most useful); only 14% could have SHHC orders signed electronically. In multilevel logistic models, compared to SHHC clinicians who could reach a physician nearly every time or always, the odds of an SHHC clinician sending someone to the emergency department were 3.66 (95% confidence interval 1.16-11.5) for SHHC clinicians who were sometimes or often able to reach a physician and 5.43 (95% CI 1.56-18.9) for those who never or rarely reached a physician. CONCLUSIONS: In this exploratory study, SHHC clinicians experience significant communication barriers with physicians who order SHHC services. Strategies to enhance meaningful communication between SHHC clinicians and physicians must be developed.

Skilled Home Healthcare Clinician and Staff Perspectives on Communication With Physicians: A Multisite Qualitative Study.

Communication between physicians who order, and clinicians who provide skilled home healthcare (SHHC), is critical to well-coordinated care. The views of SHHC staff on communication with physicians have not been well studied. The objective of this study was to explore how SHHC staff view the communication processes with physicians who order SHHC services. Using purposive and snowball sampling, we conducted semistructured interviews with 22 SHHC staff across multiple regions of the United States. Qualitative thematic content analysis was used to analyze the data. SHHC staff experienced significant barriers to effective communication with physicians, including not being able to communicate in a timely manner when necessary for patient care, and challenges identifying the correct physician to coordinate care and sign SHHC orders. Key strategies to enhance communication focused on creating standardized processes to streamline communication, setting expectations for response times in communication, and improving the Centers for Medicare & Medicaid Services Home Health Certification and Plan of Care form (commonly referred to as the "CMS-485"/Plan of Care). SHHC staff experience significant communication challenges with physicians who order SHHC services that can compromise care coordination and delivery. Modifications to workflows are urgently needed to improve efficiency and quality of communication, care coordination, and quality of care.

Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.

BACKGROUND: Middle-aged and older adults requiring skilled home healthcare ('home health') services following hospital discharge are at high risk of experiencing suboptimal outcomes. Information management (IM) needed to organise and communicate care plans is critical to ensure safety. Little is known about IM during this transition. OBJECTIVES: (1) Describe the current IM process (activity goals, subactivities, information required, information sources/targets and modes of communication) from home health providers' perspectives and (2) Identify IM-related process failures. METHODS: Multisite qualitative study. We performed semistructured interviews and direct observations with 33 home health administrative staff, 46 home health providers, 60 middle-aged and older adults, and 40 informal caregivers during the preadmission process and initial home visit. Data were analysed to generate themes and information flow diagrams. RESULTS: We identified four IM goals during the preadmission process: prepare referral document and inform agency; verify insurance; contact adult and review case to schedule visit. We identified four IM goals during the initial home visit: assess appropriateness and obtain consent; manage expectations; ensure safety and develop contingency plans. We identified IM-related process failures associated with each goal: home health providers and adults with too much information (information overload); home health providers without complete information (information underload); home health coordinators needing information from many places (information scatter); adults' and informal caregivers' mismatched expectations regarding home health services (information conflict) and home health providers encountering inaccurate information (erroneous information). CONCLUSIONS: IM for hospital-to-home health transitions is complex, yet key for patient safety. Organisational infrastructure is needed to support IM. Future clinical workflows and health information technology should be designed to mitigate IM-related process failures to facilitate safer hospital-to-home health transitions.

Helping Older Adults Improve Their Medication Experience (HOME) by Addressing Medication Regimen Complexity in Home Healthcare.

In skilled home healthcare (SHHC), communication between nurses and physicians is often inadequate for medication reconciliation and needed changes to the medication regimens are rarely made. Fragmentation of electronic health record (EHR) systems, transitions of care, lack of physician-nurse in-person contact, and poor understanding of medications by patients and their families put patients at risk for serious adverse outcomes. The aim of this study was to develop and test the HOME tool, an informatics tool to improve communication about medication regimens, share the insights of home care nurses with physicians, and highlight to physicians and nurses the complexity of medication schedules. We used human computer interaction design and evaluation principles, automated extraction from standardized forms, and modification of existing EHR fields to highlight key medication-related insights that had arisen during the SHHC visit. Separate versions of the tool were developed for physicians/nurses and patients/caregivers. A pilot of the tool was conducted using 20 SHHC encounters. Home care nurses and physicians found the tool useful for communication. Home care nurses were able to implement the HOME tool into their clinical workflow and reported improved communication with physicians about medications. This simple and largely automated tool improves understanding and communication around medications in SHHC.

Identifying Challenges Associated With the Care Transition Workflow From Hospital to Skilled Home Health Care: Perspectives of Home Health Care Agency Providers.

Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.