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BACKGROUND: We developed the Hospital-to-Home-Health Transition Quality (H3TQ) Index for skilled home healthcare (HH) agencies to identify threats to safe, high-quality care transitions in real time. OBJECTIVE: Assess the validity of H3TQ in a large sample across diverse communities. RESEARCH DESIGN: A survey of recently hospitalized older adults referred for skilled HH services and their HH provider at two large HH agencies in Baltimore, MD, and New York, NY. SUBJECTS: There were five hundred eighty-seven participants (309 older adults, 141 informal caregivers, and 137 HH providers). Older adults, caregivers, and HH providers rated 747 unique transitions. Of these, 403 were rated by both the older adult/caregiver and their HH provider, whereas the remaining transitions were rated by either party. MEASURES: Construct, concurrent, and predictive validity were assessed via the overall H3TQ rating, correlation with the care transition measure (CTM), and the Medicare Outcome and Assessment Information Set (OASIS). RESULTS: Proportion of transitions with quality issues as identified by HH providers and older adults/caregivers, respectively; Baltimore 55%, 35%; NYC 43%, 32%. Older adults/caregivers across sites rated their transitions as higher quality than did providers (P<0.05). H3TQ summed scores showed construct validity with the CTM-3 and concurrent validity with OASIS measures. Summed H3TQ scores were not significantly correlated with 30-day ED visits or rehospitalization. CONCLUSIONS: The H3TQ identifies care transition quality issues in real-time and demonstrated construct and concurrent validity, but not predictive validity. Findings demonstrate value in collecting multiple perspectives to evaluate care transition quality. Implementing the H3TQ could help identify transition-quality intervention opportunities for HH patients.
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Servicios de Atención de Salud a Domicilio , Humanos , Masculino , Femenino , Anciano , Anciano de 80 o más Años , Servicios de Atención de Salud a Domicilio/normas , Reproducibilidad de los Resultados , Cuidadores , Baltimore , Calidad de la Atención de Salud/normas , Persona de Mediana Edad , Indicadores de Calidad de la Atención de Salud , Continuidad de la Atención al Paciente/normasRESUMEN
The objective of this scoping review is to examine current evidence regarding unpaid/family caregivers' experiences during older adults' hospital-to-home transitions to identify gaps and opportunities to involve caregivers in transitional care improvement efforts. Eligible articles focused on caregiver experience, outcomes, or interventions during older adults' hospital-to-home transitions. Our review identified several descriptive studies focused on exploring the caregiver experience of older adult hospital-to-home transitions and caregiver outcomes (such as preparedness, strain, burden, health, and well-being). Qualitative studies revealed challenges at multiple levels, including individual, interpersonal, and systemic. Few interventions have targeted or included caregivers to improve discharge education and address support needs during the transition. Future work should target underrepresented and marginalized groups of caregivers, and caregivers' collaboration with community-based services, social networks, or professional services. Work remains in developing and implementing interventions to support both older adult and caregiver needs.
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Cuidadores , Cuidado de Transición , Humanos , Anciano , Alta del Paciente , Investigación Cualitativa , HospitalesRESUMEN
The Alzheimer's Association hosted the second Latinos & Alzheimer's Symposium in May 2021. Due to the COVID-19 pandemic, the meeting was held online over 2 days, with virtual presentations, discussions, mentoring sessions, and posters. The Latino population in the United States is projected to have the steepest increase in Alzheimer's disease (AD) in the next 40 years, compared to other ethnic groups. Latinos have increased risk for AD and other dementias, limited access to quality care, and are severely underrepresented in AD and dementia research and clinical trials. The symposium highlighted developments in AD research with Latino populations, including advances in AD biomarkers, and novel cognitive assessments for Spanish-speaking populations, as well as the need to effectively recruit and retain Latinos in clinical research, and how best to deliver health-care services and to aid caregivers of Latinos living with AD.
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Enfermedad de Alzheimer , COVID-19 , Enfermedad de Alzheimer/diagnóstico , Enfermedad de Alzheimer/epidemiología , Enfermedad de Alzheimer/terapia , Biomarcadores , Hispánicos o Latinos , Humanos , Pandemias , Estados UnidosRESUMEN
BACKGROUND: Medicare home health providers are now required to deliver family caregiver training, but potential consequences for service intensity are unknown. OBJECTIVE: The objective of this study was to assess how family caregiver training needs affect the number and type of home health visits received. DESIGN: Observational study using linked National Health and Aging Trends Study (NHATS), Outcomes and Assessment Information Set (OASIS), and Medicare claims data. Propensity score adjusted, multivariable logistic, and negative binomial regressions model the relationship between caregivers' training needs and number/type of home health visits. SUBJECTS: A total of 1217 (weighted n=5,870,905) National Health and Aging Trends Study participants receiving Medicare-funded home health between 2011 and 2016. MEASURES: Number and type of home health visits, from Medicare claims. Family caregivers' training needs, from home health clinician reports. RESULTS: Receipt of nursing visits was more likely when family caregivers had medication management [adjusted odds ratio (aOR): 3.03; 95% confidence interval (CI): 1.06, 8.68] or household chore training needs (aOR: 3.38; 95% CI: 1.33, 8.59). Receipt of therapy visits was more likely when caregivers had self-care training needs (aOR: 1.70; 95% CI: 1.01, 2.86). Receipt of aide visits was more likely when caregivers had household chore (aOR: 3.54; 95% CI: 1.82, 6.92) or self-care training needs (aOR: 2.12; 95% CI: 1.11, 4.05). Medication management training needs were associated with receiving an additional 1.06 (95% CI: 0.11, 2.01) nursing visits, and household chores training needs were associated with an additional 3.24 total (95% CI: 0.21, 6.28) and 1.32 aide visits (95% CI: 0.36, 2.27). CONCLUSION: Family caregivers' activity-specific training needs may affect home health visit utilization.
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Cuidadores/educación , Familia , Servicios de Atención de Salud a Domicilio/organización & administración , Medicare/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Administración del Tratamiento Farmacológico/organización & administración , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
BACKGROUND: Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital. FACTORS CONTRIBUTING TO SUBOPTIMAL CARE TRANSITIONS: Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation. Fundamental elements for effective care transitions put forth by The Joint Commission for effective care transitions include interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge. REVIEW OF FOUR EXISTING MODELS OF CARE TRANSITIONS: Consideration of four existing care transitions models representing different health care settings-Care Transitions Intervention® Guided Care, Interventions to Reduce Acute Care Transfers (INTERACT®), Home Health Model of Care Transitions-revealed that they are important but limited in their impact on transitions across health care settings. PROPOSAL OF THE INTEGRATED CARE TRANSITIONS APPROACH: An innovative approach, Integrated Care Transitions Approach (ICTA), is proposed that incorporates the best practices of the four models discussed in this article and factors identified as essential for an effective care transition while addressing limitations of existing transitional care models. ICTA's four key characteristics and seven key elements are unique and stem from factors that help achieve effective care transitions.
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Continuidad de la Atención al Paciente/organización & administración , Modelos Organizacionales , Transferencia de Pacientes/organización & administración , Calidad de la Atención de Salud/organización & administración , Integración de Sistemas , Anciano , Anciano de 80 o más Años , Comunicación , Continuidad de la Atención al Paciente/normas , Conducta Cooperativa , Registros Electrónicos de Salud/organización & administración , Femenino , Humanos , Masculino , Conciliación de Medicamentos/normas , Planificación de Atención al Paciente/normas , Alta del Paciente/normas , Prioridad del Paciente/psicología , Transferencia de Pacientes/normas , Calidad de la Atención de Salud/normas , Atención Subaguda/organización & administraciónRESUMEN
We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.
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Consenso , Continuidad de la Atención al Paciente/normas , Calidad de la Atención de Salud/normas , Instituciones de Cuidados Especializados de Enfermería/organización & administración , Cuidado de Transición/organización & administración , Benchmarking , Centers for Medicare and Medicaid Services, U.S. , Hospitalización , Humanos , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/economía , Atención Primaria de Salud/organización & administración , Instituciones de Cuidados Especializados de Enfermería/economía , Cuidado de Transición/economía , Estados UnidosRESUMEN
BACKGROUND: There is a little understanding of the association between hospital organizational characteristics and hospital readmissions. We previously developed a Senior Care Services Scale (SCSS) that describes hospital availability of services relevant to the care of older adults. OBJECTIVE: Determine whether hospitals' SCSS scores were associated with risk of readmission among Medicare beneficiaries. DESIGN: Retrospective cohort analysis. SETTING AND PARTICIPANTS: Medicare beneficiaries ≥65 years of age (n = 3 553 367), admitted to 5568 US acute-care hospitals in 2006, discharged alive. Medicare data were linked to the American Hospital Association database of hospital characteristics. MEASUREMENTS: All-cause non-elective hospital readmission, or death without readmission, within 30 days of hospital discharge. RESULTS: We examined the association between high and low scores of each of two hospital SCSS service groups: inpatient specialty care (IP) and post-acute (PA) community care. There was no association between high IP scores and readmission (RR 1.00, 95% CI 0.98-1.02). Older adults admitted to hospitals with high PA scores had lower risk of experiencing hospital readmission when compared to older adults admitted to hospitals with low PA scores (RR 0.97, 95% CI 0.95-0.98). High PA scores were associated with increased mortality (RR 1.09, 95% CI 1.06-1.13). In sensitivity analyses exploring relationships at 90 days, both the IP and PA subcomponents were associated with older adults' reduced risk of hospital readmission (IP: RR 0.97, 95% CI 0.95-0.99; PA: RR 0.97, 95% CI 0.95-0.99). CONCLUSION: Senior services at the hospital-level represents a modifiable risk factor with important impact. Employing organization-level characteristics in readmission risk prediction tools should be expanded.
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Servicios de Salud para Ancianos/estadística & datos numéricos , Administración Hospitalaria/normas , Readmisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Humanos , Medicare , Mortalidad , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: The availability of hospital services for older adults nationwide is not well understood. OBJECTIVE: To present the development of the Senior Care Services Scale (SCSS) through: (1) identification of hospital services relevant to the care of older adults; (2) development of a taxonomy classifying these services; and (3) description of prevalence, geographic variation, and trends in service provision in US hospitals over time. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of US hospitals in 1999 and 2006 rounds of American Hospital Association Annual Survey of Hospitals (n=4998 and 4831 hospitals, respectively). Exploratory factor analysis was used to create the SCSS, and confirmatory factor analysis was used to examine services over time. The paper reports prevalence of services nationwide. RESULTS: The SCSS consisted of 2 service groups: (1) Inpatient Specialty Care (IP): geriatrics, palliative care, psychiatric geriatrics, pain management, social work, case management, rehabilitation, and hospice; and (2) Postacute Community Care (PA): skilled nursing, intermediate care, other long-term care, assisted living, retirement housing, adult day care, and home health services. Over time, hospitals offered more IP services and fewer PA services. The distribution of services did not mirror the distribution of where older adults reside in the United States. CONCLUSIONS: The development of the SCSS provides important information about senior care services before the passage of the Affordable Care Act. The apparent mismatch of hospital services and demographic trends suggests that many US hospitals may not provide a seamless continuum of care for an increasing population of older adults.
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Continuidad de la Atención al Paciente/organización & administración , Servicios de Salud para Ancianos/organización & administración , Administración Hospitalaria , Anciano , Anciano de 80 o más Años , American Hospital Association , Continuidad de la Atención al Paciente/clasificación , Continuidad de la Atención al Paciente/tendencias , Análisis Factorial , Femenino , Servicios de Salud para Ancianos/clasificación , Servicios de Salud para Ancianos/tendencias , Administración Hospitalaria/clasificación , Administración Hospitalaria/tendencias , Hospitales , Humanos , Masculino , Prevalencia , Estudios Retrospectivos , Estados UnidosRESUMEN
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.
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Agencias de Atención a Domicilio/normas , Percepción , Cuidado de Transición/normas , Flujo de Trabajo , Anciano , Anciano de 80 o más Años , Continuidad de la Atención al Paciente , Conducta Cooperativa , Femenino , Agencias de Atención a Domicilio/tendencias , Auxiliares de Salud a Domicilio/psicología , Hospitales/normas , Humanos , Masculino , Enfermeros de Salud Comunitaria/psicología , Alta del Paciente/normas , Transferencia de Pacientes/métodos , Transferencia de Pacientes/normas , Investigación CualitativaRESUMEN
With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.
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Cuidados Posteriores , Continuidad de la Atención al Paciente/organización & administración , Servicios de Salud para Ancianos/organización & administración , Alta del Paciente/normas , Servicios Preventivos de Salud , Cuidados Posteriores/métodos , Cuidados Posteriores/organización & administración , Anciano , Cuidadores/educación , Enfermedad Crónica/terapia , Participación de la Comunidad , Comorbilidad , Femenino , Política de Salud , Humanos , Vida Independiente/educación , Masculino , Evaluación de Resultado en la Atención de Salud , Planificación de Atención al Paciente , Atención Dirigida al Paciente/organización & administración , Servicios Preventivos de Salud/métodos , Servicios Preventivos de Salud/organización & administración , Mejoramiento de la Calidad , Estados UnidosRESUMEN
UNLABELLED: Article-at-a-Glance Background: Care transitions across health care settings are common and can result in adverse outcomes for older adults. Few studies have examined health care professionals' perspectives on important process measures or pay-for-performance (P4P) strategies related to transitional care. A study was conducted to characterize health care professionals' perspectives on (1) successful transitional care of older adults (age 65 years and older), (2) suggestions for improvement, and (3) P4P strategies related to transitional care. METHODS: In a qualitative study, one-hour semistructured in-depth interviews were conducted in an acute care hospital, a skilled nursing facility, two community-based primary care practices, and one home health care agency with 20 health care professionals (18 physicians and 2 home health care administrators) with direct experience in care transitions of older adults and who were likely to be affected by P4P strategies. RESULTS: Findings were organized into three thematic domains: (1) components and markers of effective transitional care, (2) difficulties in design and implementation of P4P strategies, and (3) health care professionals' concerns and unmet needs related to delivering optimal care during transitions. A conceptual framework was developed on the basis of the findings to guide design and implementation of P4P strategies for improving transitional care. CONCLUSION: In characterizing health care professionals' perspectives, specific care processes to target, challenges to address in the design of P4P strategies, and unmet needs to consider regarding education and feedback for health care professionals were described. Future investigations could evaluate whether performance targets, educational interventions, and implementation strategies based on this conceptual framework improve quality of transitional care.
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Importance: Financial incentives in Medicare Advantage (MA), the managed care alternative to traditional Medicare (TM), were designed to reduce overutilization. For patients near the end of life (EOL), MA incentives may reduce potentially burdensome care and encourage hospice but could also restrict access to costly but necessary services. Objective: To compare receipt of potentially burdensome treatments and transfers and potentially necessary postacute services in the last 6 months of life in individuals with MA vs TM. Design, Setting, and Participants: A retrospective analysis of Medicare claims data among older Medicare beneficiaries who died between 2016 and 2018. The study included Medicare decedents aged 66 years or older covered by TM (n = 659â¯135) or MA (n = 360â¯430). All decedents and the subset of decedents with 1 or more emergent hospitalizations with a life-limiting condition (cancer, dementia, end-stage organ failure) that would likely qualify for hospice care were included. Exposure: MA enrollment. Main Outcomes: Receipt of potentially burdensome hospitalizations and treatments; receipt of postdischarge home and facility care. Results: The study included 659â¯135 TM enrollees (mean [SD] age at death, 83.3 [9.0] years, 54% female, 15.1% non-White, 55% with 1 or more life-limiting condition) and 360â¯430 MA enrollees (mean [SD] age at death 82.5 [8.7] years, 53% female, 19.3% non-White, 49% with 1 or more life-limiting condition). After regression adjustment, MA enrollees were less likely to receive potentially burdensome treatments (-1.6 percentage points (pp); 95% CI, -2.1 to -1.1) and less likely to die in a hospital (-3.3 pp; 95% CI, -4.0 to -2.7) compared with TM. However, when hospitalized, MA enrollees were more likely to die in the hospital (adjusted difference, 1.3 pp; 95% CI, 1.1-1.5) and less likely to be transferred to rehabilitative or skilled nursing facilities (-5.2 pp; 95% CI, -5.7 to -4.6). Higher rates of home health and home hospice among those discharged home offset half of the decline in facility use. Results were unchanged in the life-limiting conditions sample. Conclusions: MA enrollment was associated with lower rates of potentially burdensome and facility-based care near the EOL. Greater use of home-based care may improve quality of care but may also leave patients without adequate assistance after hospitalization.
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Medicare Part C , Medicare , Cuidado Terminal , Humanos , Estados Unidos , Femenino , Masculino , Medicare Part C/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios Retrospectivos , Cuidado Terminal/estadística & datos numéricos , Cuidado Terminal/economía , Medicare/estadística & datos numéricos , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Hospitalización/estadística & datos numéricosRESUMEN
OBJECTIVES: Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and Drug Administration, often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood. METHODS: We conducted semistructured interviews with community-dwelling older adults 65 years and older who took 5 or more prescription medications to explore medication safety strategies they use. We also compared 2 organizations' medication safety guidelines for areas of concordance and discordance. RESULTS: A total of 28 older adults were interviewed. Four overarching themes of medication management strategies emerged: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. Study findings revealed that older adults followed some of the published guidelines by the 2 government organizations, although there were some areas of discord. Some of the strategies used were unintentionally against the recommended guidelines. For example, older adults tried weaning themselves off their medications without notifying their providers. CONCLUSIONS: Older adults and their caregivers in our study used strategies different from those recommended by government organizations in managing medications to enhance drug safety. Patient-provider collaboration and positive patient outcomes can be improved by understanding and respecting strategies older adults use at home. Future studies must effectively incorporate older adults' perspectives when developing medication safety guidelines.
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Vida Independiente , Administración del Tratamiento Farmacológico , Humanos , Anciano , Preparaciones Farmacéuticas , Personal de Salud , CuidadoresRESUMEN
OBJECTIVES: This study examines the perspectives of key stakeholders in home health toward Medicare's Home Health Value Based Purchasing (HHVBP) program, piloted among home health agencies (HHAs) in 9 states from 2016 to 2021, and based on initial performance, was expanded to the remaining 41 (nonpilot) states in January 2023. DESIGN: We conducted semistructured interviews wherein we inquired participants' views toward and experiences with HHVBP. We used convenience and purposive sampling to obtain diversity in HHA size, geography, and quality. SETTING AND PARTICIPANTS: We conducted interviews from July 2022 to May 2023 with HHA leaders, staff, and clinicians, advocacy and trade organization leaders, and policy experts from pilot and nonpilot states. METHODS: We used thematic analysis to develop a codebook that included framework-derived, a priori, and inductive codes. We identified key themes and subthemes accordingly. RESULTS: Forty-seven stakeholders representing 25 unique organizations participated: 22 (47%) from pilot states and 25 (53%) from nonpilot states; of these, 24 (51%) were HHA leaders, 13 (28%) were organizational leaders, and 10 (21%) were clinicians; 26 (55%) were centered in the Northeast, 9 (19%) in the West, 7 (15%) had a national presence, and 5 (11%) were centered across the South. Four key themes emerged. There were (1) wide variations in awareness, understanding, and attitudes toward HHVBP regardless of pilot status or stakeholder type; (2) concerns about aspects of HHVBP, including consequences for HHAs and patients; (3) a range of strategies used by HHAs to address HHVBP; (4) other concurrent issues that HHAs were navigating alongside HHVBP. CONCLUSIONS AND IMPLICATIONS: Despite HHVBP's national implementation, awareness of and attitudes toward HHVBP varied across stakeholders from pilot and nonpilot states, as did efforts to address it. Although some viewed the policy favorably, others were concerned it could negatively impact HHAs and patients. Understanding the experiences of stakeholders is vital for illuminating the intended and unintended consequences of HHVBP policy.
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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.
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COVID-19 , Transferencia de Pacientes , Humanos , Anciano , Estudios Retrospectivos , Transición del Hospital al Hogar , Pandemias , COVID-19/epidemiología , Alta del Paciente , Hospitales , Instituciones de Cuidados Especializados de Enfermería , Servicio de Urgencia en HospitalRESUMEN
BACKGROUND: Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources. OBJECTIVE: This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety. METHODS: The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits. RESULTS: The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024. CONCLUSIONS: This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits. TRIAL REGISTRATION: ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57878.
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Vida Independiente , Participación del Paciente , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Transversales , Participación del Paciente/métodos , Seguridad del Paciente , Atención Primaria de Salud , Ensayos Clínicos Controlados no Aleatorios como AsuntoRESUMEN
Background: The Senior Care Services Scale (SCSS) describes hospital provision of older adult services before the passage of the Affordable Care Act. Objectives: Since act passage, (1) update SCSS service groups; and (2) investigate hospital SCSS scores' relationship to readmission or mortality among Medicare beneficiaries. Methods: Retrospective cohort analysis of older adults ≥65 years (n = 1,416,669), admitted to 2570 US acute-care hospitals from 2014 to 2015. Outcomes: Hospital readmission, or death, within 30 and 90 days of discharge. Results: The updated SCSS had three service groups: Inpatient Specialty Care, Post-Acute Community Care, and Home Care and Hospice. Older adults admitted to high Inpatient-Specialty-Care-scoring hospitals had lower risk of death within 30 days (RR .94, 95% CI .91-.98), and 90 days (RR .94, 95% CI .91-.97). There was no significant association between Home-Care-and-Hospice and Post-Acute-Community-Care scores and study outcomes. Conclusion: Greater provision of hospital-level senior services may be associated with mortality reduction among Medicare beneficiaries.
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Patient Protection and Affordable Care Act , Readmisión del Paciente , Humanos , Estados Unidos , Anciano , Estudios Retrospectivos , Medicare , Alta del Paciente , HospitalesRESUMEN
BACKGROUND: Research and policy demonstrate the value and need for the systematic inclusion of care partners in hospital care delivery of people living with Alzheimer disease and related dementias (ADRD). Support provided to care partners through information and training regarding caregiving responsibilities is important to facilitating their active inclusion and ultimately improving hospital outcomes of people living with ADRD. To promote care partners' active inclusion, a toolkit that guides health systems in the identification, assessment, and training of care partners is needed. User-centered approaches can address this gap in practice by creating toolkits that are practical and responsive to the needs of care partners and their hospitalized family members and friends living with ADRD. OBJECTIVE: This paper describes the study protocol for the development and refinement of the ADRD Systematic Hospital Inclusion Family Toolkit (A-SHIFT). A-SHIFT will provide health care systems with guidance on how to effectively identify, assess, and train care partners of hospitalized persons living with ADRD. METHODS: The A-SHIFT study protocol will use a 3-aimed, convergent mixed method approach to iteratively develop and refine the toolkit. In Aim 1, we will use a systems-engineering approach to characterize patterns of care partner inclusion in hospital care for people living with ADRD. In Aim 2, we will partner with stakeholders to identify and prioritize health care system facilitators and barriers to the inclusion for care partners of hospitalized people living with ADRD. In Aim 3, we will work with stakeholders to co-design an adaptable toolkit to be used by health systems to facilitate the identification, assessment, and training of care partners of hospitalized people living with ADRD. Our convergent mixed method approach will facilitate triangulation across all 3 aims to increase the credibility and transferability of results. We anticipate this study to take 24 months between September 1, 2022, and August 31, 2024. RESULTS: The A-SHIFT study protocol will yield (1) optimal points in the hospital workflow for care partner inclusion, (2) a prioritized list of potentially modifiable barriers and facilitators to including care partners in the hospitalization of people living with ADRD, and (3) a converged-upon, ready for feasibility testing of the toolkit to guide the inclusion of care partners of people living with ADRD in hospital care. CONCLUSIONS: We anticipate that the resultant A-SHIFT will provide health systems with a readiness checklist, implementation plan, and resources for identifying, assessing, and training care partners on how to fulfill their caregiving roles for people living with ADRD after hospital discharge. A-SHIFT has the potential to not only improve care partner preparedness but also help reduce health and service use outcomes for people living with ADRD after hospital discharge. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45274.
RESUMEN
Older adults and caregivers play an essential role in medication safety; however, self-perception of their and health professionals' roles in medication safety is not well-understood. The objective of our study was to identify the roles of patients, providers, and pharmacists in medication safety from the perspective of older adults. Semi-structured qualitative interviews were held with 28 community-dwelling older adults over 65 years who took five or more prescription medications daily. Results suggest that older adults' self-perceptions of their role in medication safety varied widely. Older adults perceived that self-learning about their medications and securing them are critical to avoiding medication-related harm. Primary care providers were perceived as coordinators between older adults and specialists. Older adults expected pharmacists to inform them of any changes in the characteristics of medications to ensure medications were taken correctly. Our findings provide an in-depth analysis of older adults' perceptions and expectations of their providers' specific roles in medication safety. Educating providers and pharmacists about the role expectations of this population with complex needs can ultimately improve medication safety.
RESUMEN
BACKGROUND: Despite providing frequent care to heart failure (HF) patients, home health care workers (HHWs) are generally considered neither part of the health care team nor the family, and their clinical observations are often overlooked. To better understand this workforce's involvement in care, we quantified HHWs' scope of interactions with clinicians, health systems, and family caregivers. METHODS: Community-partnered cross-sectional survey of English- and Spanish-speaking HHWs who cared for a HF patient in the last year. The survey included 6 open-ended questions about aspects of care coordination, alongside demographic and employment characteristics. Descriptive statistics were performed. RESULTS: Three hundred ninety-one HHWs employed by 56 unique home care agencies completed the survey. HHWs took HF patients to a median of 3 doctor appointments in the last year with 21.9% of them taking patients to ≥ 7 doctor appointments. Nearly a quarter of HHWs reported that these appointments were in ≥ 3 different health systems. A third of HHWs organized care for their HF patient with ≥ 2 family caregivers. CONCLUSIONS: HHWs' scope of health-related interactions is large, indicating that there may be novel opportunities to leverage HHWs' experiences to improve health care delivery and patient care in HF.