Continuity of Care Versus Language Concordance as an Intervention to Reduce Hospital Readmissions From Home Health Care.

BACKGROUND: Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact. OBJECTIVE: The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. DESIGN: A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care. PARTICIPANTS: The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge. MEASURES: The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis. RESULTS: When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%). CONCLUSION: In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.

The identification of clusters of risk factors and their association with hospitalizations or emergency department visits in home health care.

AIMS: To identify clusters of risk factors in home health care and determine if the clusters are associated with hospitalizations or emergency department visits. DESIGN: A retrospective cohort study. METHODS: This study included 61,454 patients pertaining to 79,079 episodes receiving home health care between 2015 and 2017 from one of the largest home health care organizations in the United States. Potential risk factors were extracted from structured data and unstructured clinical notes analysed by natural language processing. A K-means cluster analysis was conducted. Kaplan-Meier analysis was conducted to identify the association between clusters and hospitalizations or emergency department visits during home health care. RESULTS: A total of 11.6% of home health episodes resulted in hospitalizations or emergency department visits. Risk factors formed three clusters. Cluster 1 is characterized by a combination of risk factors related to "impaired physical comfort with pain," defined as situations where patients may experience increased pain. Cluster 2 is characterized by "high comorbidity burden" defined as multiple comorbidities or other risks for hospitalization (e.g., prior falls). Cluster 3 is characterized by "impaired cognitive/psychological and skin integrity" including dementia or skin ulcer. Compared to Cluster 1, the risk of hospitalizations or emergency department visits increased by 1.95 times for Cluster 2 and by 2.12 times for Cluster 3 (all p < .001). CONCLUSION: Risk factors were clustered into three types describing distinct characteristics for hospitalizations or emergency department visits. Different combinations of risk factors affected the likelihood of these negative outcomes. IMPACT: Cluster-based risk prediction models could be integrated into early warning systems to identify patients at risk for hospitalizations or emergency department visits leading to more timely, patient-centred care, ultimately preventing these events. PATIENT OR PUBLIC CONTRIBUTION: There was no involvement of patients in developing the research question, determining the outcome measures, or implementing the study.

Clinical notes: An untapped opportunity for improving risk prediction for hospitalization and emergency department visit during home health care.

BACKGROUND/OBJECTIVE: Between 10 and 25% patients are hospitalized or visit emergency department (ED) during home healthcare (HHC). Given that up to 40% of these negative clinical outcomes are preventable, early and accurate prediction of hospitalization risk can be one strategy to prevent them. In recent years, machine learning-based predictive modeling has become widely used for building risk models. This study aimed to compare the predictive performance of four risk models built with various data sources for hospitalization and ED visits in HHC. METHODS: Four risk models were built using different variables from two data sources: structured data (i.e., Outcome and Assessment Information Set (OASIS) and other assessment items from the electronic health record (EHR)) and unstructured narrative-free text clinical notes for patients who received HHC services from the largest non-profit HHC organization in New York between 2015 and 2017. Then, five machine learning algorithms (logistic regression, Random Forest, Bayesian network, support vector machine (SVM), and Naïve Bayes) were used on each risk model. Risk model performance was evaluated using the F-score and Precision-Recall Curve (PRC) area metrics. RESULTS: During the study period, 8373/86,823 (9.6%) HHC episodes resulted in hospitalization or ED visits. Among five machine learning algorithms on each model, the SVM showed the highest F-score (0.82), while the Random Forest showed the highest PRC area (0.864). Adding information extracted from clinical notes significantly improved the risk prediction ability by up to 16.6% in F-score and 17.8% in PRC. CONCLUSION: All models showed relatively good hospitalization or ED visit risk predictive performance in HHC. Information from clinical notes integrated with the structured data improved the ability to identify patients at risk for these emergent care events.

Nurse perspectives on the psychosocial care of patients with urinary incontinence in home hospice: A qualitative study.

BACKGROUND: Urinary incontinence is prevalent among patients receiving home hospice and presents multiple care management challenges for nurses and family caregivers. AIM: This study sought to understand how urinary incontinence influences the psychosocial care of patients receiving home hospice and the strategies that nurses employ to maximize patient and family comfort. DESIGN: Qualitative descriptive study using semi-structured interviews. SETTING/PARTICIPANTS: Nurses employed at a large not-for-profit hospice agency in New York City. RESULTS: Analyses of 32 interviews revealed three primary themes. First, nurses considered urinary incontinence to be associated with multiple psychosocial issues including embarrassment for patients and caregiver burden. Second, nurses described urinary incontinence as a threat to patient dignity and took steps to preserve their continence function. Third, nurses assisted patients and their families to cope with urinary incontinence through normalization, reframing incontinence as part of the disease process, mobilizing caregiving assistance, and encouraging use of continence supplies such as diapers and liners. CONCLUSION: Urinary incontinence influences the psychosocial care of patients receiving home hospice and nurses employ strategies to maximize patient and family comfort. Additional research is needed to examine the psychosocial benefits of facilitated discussions with patients and family members about incontinence, provision of caregiving support, and distribution of comprehensive incontinence supplies to patients with fewer resources.

Detecting Language Associated With Home Healthcare Patient's Risk for Hospitalization and Emergency Department Visit.

BACKGROUND: About one in five patients receiving home healthcare (HHC) services are hospitalized or visit an emergency department (ED) during a home care episode. Early identification of at-risk patients can prevent these negative outcomes. However, risk indicators, including language in clinical notes that indicate a concern about a patient, are often hidden in narrative documentation throughout their HHC episode. OBJECTIVE: The aim of the study was to develop an automated natural language processing (NLP) algorithm to identify concerning language indicative of HHC patients' risk of hospitalizations or ED visits. METHODS: This study used the Omaha System-a standardized nursing terminology that describes problems/signs/symptoms that can occur in the community setting. First, five HHC experts iteratively reviewed the Omaha System and identified concerning concepts indicative of HHC patients' risk of hospitalizations or ED visits. Next, we developed and tested an NLP algorithm to identify these concerning concepts in HHC clinical notes automatically. The resulting NLP algorithm was applied on a large subset of narrative notes (2.3 million notes) documented for 66,317 unique patients ( n = 87,966 HHC episodes) admitted to one large HHC agency in the Northeast United States between 2015 and 2017. RESULTS: A total of 160 Omaha System signs/symptoms were identified as concerning concepts for hospitalizations or ED visits in HHC. These signs/symptoms belong to 31 of the 42 available Omaha System problems. Overall, the NLP algorithm showed good performance in identifying concerning concepts in clinical notes. More than 18% of clinical notes were detected as having at least one concerning concept, and more than 90% of HHC episodes included at least one Omaha System problem. The most frequently documented concerning concepts were pain, followed by issues related to neuromusculoskeletal function, circulation, mental health, and communicable/infectious conditions. CONCLUSION: Our findings suggest that concerning problems or symptoms that could increase the risk of hospitalization or ED visit were frequently documented in narrative clinical notes. NLP can automatically extract information from narrative clinical notes to improve our understanding of care needs in HHC. Next steps are to evaluate which concerning concepts identified in clinical notes predict hospitalization or ED visit.

Continuity of Nursing Care in Home Health: Impact on Rehospitalization Among Older Adults With Dementia.

BACKGROUND: Home health care (HHC) is a leading form of home and community-based services for persons with dementia (PWD). Nurses are the primary providers of HHC; however, little is known of nursing care delivery and quality. OBJECTIVE: The objective of this study was to examine the association between continuity of nursing care in HHC and rehospitalization among PWD. RESEARCH DESIGN: This is a retrospective cohort study using multiple years (2010-2015) of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency. SUBJECTS: This study included 23,886 PWD receiving HHC following a hospitalization. MEASURES: Continuity of nursing care was calculated using the Bice and Boxerman method, which considered the number of total visits, nurses, and visits from each nurse during an HHC episode. The outcome was all-cause rehospitalization during HHC. Risk-adjusted logistic regression was used for analysis. RESULTS: Approximately 24% of PWD were rehospitalized. The mean continuity of nursing care score was 0.56 (SD=0.33). Eight percent of PWD received each nursing visit from a different nurse (no continuity), and 26% received all visits from one nurse during an HHC episode (full continuity). Compared with those receiving high continuity of nursing care (third tertile), PWD receiving low (first tertile) or moderate (second tertile) continuity of nursing care had an adjusted odds ratio of 1.33 (95% confidence interval: 1.25-1.46) and 1.30 (95% confidence interval: 1.22-1.43), respectively, for being rehospitalized. CONCLUSIONS: Wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.

Effect of Nurse Practitioner Interventions on Hospitalizations in the Community Transitions Intervention Trial.

BACKGROUND: Despite improvements in hypertension treatment in the United States, Black and Hispanic individuals experience poor blood pressure control and have worse hypertension-related outcomes compared to Whites. OBJECTIVE: The aim of the study was to determine the effect on hospitalization of supplementing usual home care (UHC) with two hypertension-focused transitional care interventions-one deploying nurse practitioners (NPs) and the other NPs plus health coaches. METHODS: We examined post hoc the effect of two hypertension-focused NP interventions on hospitalizations in the Community Transitions Intervention trial-a three-arm, randomized controlled trial comparing the effectiveness of (a) UHC with (b) UHC plus a 30-day NP transitional care intervention or (c) UHC plus NP plus 60-day health coach intervention. RESULTS: The study comprised 495 participants: mean age = 66 years; 57% female; 70% Black, non-Hispanic; 30% Hispanic. At the 3- and 12-month follow-up, all three groups showed a significant decrease in the average number of hospitalizations compared to baseline. The interventions were not significantly different from UHC. CONCLUSION: The results of this post hoc analysis show that, during the study period, decreases in hospitalizations in the intervention groups were comparable to those in UHC, and deploying NPs provided no detectable value added. Future research should focus on testing ways to optimize UHC services.

Implications of a US study on infection prevention and control in community settings in the UK.

Healthcare-associated infections are a significant reason for readmission to hospital post-discharge to the community. In this paper, the authors describe some of the key findings from a programme of work conducted in a home care agency (community care organisation) in the US. A survey was conducted to explore home care nurses' knowledge, attitudes and beliefs around infection control (n=415); 400 nurse-patient visits were observed, and 50 nurses were interviewed about their infection control practices. Nurses reported high compliance with infection control practices. However, the overall average adherence rate to observed hand hygiene practices was 45.6%. Interview data provided valuable insights into specific challenges faced by nurses in a home care setting. This study provides insights that can be used to enhance infection control practice in community care in the UK.

Mining fall-related information in clinical notes: Comparison of rule-based and novel word embedding-based machine learning approaches.

BACKGROUND: Natural language processing (NLP) of health-related data is still an expertise demanding, and resource expensive process. We created a novel, open source rapid clinical text mining system called NimbleMiner. NimbleMiner combines several machine learning techniques (word embedding models and positive only labels learning) to facilitate the process in which a human rapidly performs text mining of clinical narratives, while being aided by the machine learning components. OBJECTIVE: This manuscript describes the general system architecture and user Interface and presents results of a case study aimed at classifying fall-related information (including fall history, fall prevention interventions, and fall risk) in homecare visit notes. METHODS: We extracted a corpus of homecare visit notes (n = 1,149,586) for 89,459 patients from a large US-based homecare agency. We used a gold standard testing dataset of 750 notes annotated by two human reviewers to compare the NimbleMiner's ability to classify documents regarding whether they contain fall-related information with a previously developed rule-based NLP system. RESULTS: NimbleMiner outperformed the rule-based system in almost all domains. The overall F- score was 85.8% compared to 81% by the rule based-system with the best performance for identifying general fall history (F = 89% vs. F = 85.1% rule-based), followed by fall risk (F = 87% vs. F = 78.7% rule-based), fall prevention interventions (F = 88.1% vs. F = 78.2% rule-based) and fall within 2 days of the note date (F = 83.1% vs. F = 80.6% rule-based). The rule-based system achieved slightly better performance for fall within 2 weeks of the note date (F = 81.9% vs. F = 84% rule-based). DISCUSSION & CONCLUSIONS: NimbleMiner outperformed other systems aimed at fall information classification, including our previously developed rule-based approach. These promising results indicate that clinical text mining can be implemented without the need for large labeled datasets necessary for other types of machine learning. This is critical for domains with little NLP developments, like nursing or allied health professions.

Geriatric Interdisciplinary Team Training 2.0: A collaborative team-based approach to delivering care.

Interprofessional collaborative education and practice has become a cornerstone of optimal person-centered management in the current complex health care climate. This is especially important when working with older adults, many with multiple chronic conditions and challenging health care needs. This paper describes a feasibility study of the Geriatric Interdisciplinary Team Training 2.0 (GITT 2.0) program focused on providing interprofessional care to complex and frail older adults with multiple chronic conditions. A concurrent triangulation mixed-methods design facilitated program implementation and evaluation. Over three years (2013-2016), 65 graduate students from nursing, midwifery, social work, and pharmacy participated along with 25 preceptors. Participants were surveyed on their attitudes toward interprofessional collaboration pre and post-intervention and participated in focus groups. While attitudes toward interprofessional collaboration did not change quantitatively, focus groups revealed changes in language and enhanced perspectives of participants. Based on the evaluation data, the GITT 2.0 Toolkit was refined for use in interprofessional education and practice activities related to quality initiatives.

Self-care management questionnaire for long-term indwelling urinary catheter users.

AIMS: Self-management is believed to be an important behavioral capacity in people with chronic illness, and self-efficacy is an important component contributing to self-management. Two new and related measures for urinary catheter self-efficacy (C-SE) and self-management (C-SMG) were developed based on existing tools and tested for psychometrics for use in a randomized clinical trial (RCT) teaching urinary catheter self-management. METHODS: The instruments were evaluated at baseline (intake face to face interview) with 202 persons and with 158 of the same individuals 6 months later by telephone interviews. Exploratory factor analysis was conducted in an iterative process related to items' theoretical and statistical appropriateness. To assess construct validity and goodness of fit for model testing, confirmatory factor analysis was conducted with the samples at intake and 6 months. Also, bivariate analyses were conducted of the measures in relation to each other. RESULTS: Both scales were modified reducing the items to 13 in each, with four factors in C-SE and three factors in C-SMG. Reliability testing (Cronbach's alpha) was viewed as satisfactory for both scales, though some of the subscale (factors) reliabilities were lower in the self-management measure. Confirmatory factor analysis was adequate. Correlation of the two instruments (r = 0.25, P < 001) suggests that they are related scales. CONCLUSION: With a change in the C-SMG scale from 3- to 5-level responses and subsequent testing, both new scales are appropriate for use separately or together as a questionnaire related to catheter self-care management in intervention research with long-term indwelling urinary catheter users. Neurourol. Urodynam. 35:492-496, 2016. © 2015 Wiley Periodicals, Inc.

Testing a Model of Self-Management of Fluid Intake in Community-Residing Long-term Indwelling Urinary Catheter Users.

BACKGROUND: Urinary tract infection and blockage are serious and recurrent challenges for people with long-term indwelling catheters, and these catheter problems cause worry and anxiety when they disrupt normal daily activities. OBJECTIVE: The goal was to determine whether urinary catheter-related self-management behaviors focusing on fluid intake would mediate fluid intake-related self-efficacy toward decreasing catheter-associated urinary tract infection (CAUTI) and/or catheter blockage. METHODS: The sample involved data collected from 180 adult community-living, long-term indwelling urinary catheter users. The authors tested a model of fluid intake self-management related to fluid intake self-efficacy for key outcomes of CAUTI and blockage. To account for the large number of zeros in both outcomes, a zero-inflated negative binomial (ZINB) structural equation model was tested. RESULTS: Structurally, fluid intake self-efficacy was positively associated with fluid intake self-management, suggesting that higher fluid intake self-efficacy predicts more (higher) fluid intake self-management; however, fluid intake self-management was not associated with either the frequency of CAUTIs or the presence or absence of CAUTI. Fluid intake self-efficacy was positively related to fluid intake self-management, and fluid intake self-management predicted less frequency of catheter blockage, but neither fluid intake self-efficacy nor fluid intake self-management predicted the presence or absence of blockage. DISCUSSION: Further research is needed to better understand determinants of CAUTI in long-term catheter users and factors which might influence or prevent its occurrence. Increased confidence (self-efficacy) and self-management behaviors to promote fluid intake could be of value to long-term urinary catheter users to decrease catheter blockage.

Self-management intervention for long-term indwelling urinary catheter users: randomized clinical trial.

BACKGROUND: People using long-term indwelling urinary catheters experience multiple recurrent catheter problems. Self-management approaches are needed to avoid catheter-related problems. OBJECTIVES: The aim was to determine effectiveness of a self-management intervention in prevention of adverse outcomes (catheter-related urinary tract infection, blockage, and accidental dislodgement). Healthcare treatment associated with the adverse outcomes and catheter-related quality of life was also studied. METHODS: A randomized clinical trial was conducted. The intervention involved learning catheter-related self-monitoring and self-management skills during home visits by a study nurse (twice during the first month and at 4 months-with a phone call at 2 months). The control group received usual care. Data were collected during an initial face-to-face home interview followed by bimonthly phone interviews. A total of 202 adult long-term urinary catheter users participated. Participants were randomized to treatment or control groups following collection of baseline data. Generalized estimating equations were used for the analysis of treatment effect. RESULTS: In the intervention group, there was a significant decrease in reported blockage in the first 6 months (p = .02), but the effect did not persist. There were no significant effects for catheter-related urinary tract infection or dislodgment. Comparison of baseline rates of adverse outcomes with subsequent periods suggested that both groups improved over 12 months. DISCUSSION: A simple-to-use catheter problems calendar and the bimonthly interviews might have functioned as a modest self-monitoring intervention for persons in both groups. A simplified intervention using a self-monitoring calendar is suggested-with optimal and consistent fluid intake likely to add value.

A hybrid process fidelity assessment in a home-based randomized clinical trial.

A process fidelity assessment was conducted as a nested study within a home-based randomized clinical trial teaching self-management to 101 long-term indwelling urinary catheter users in the treatment group. Our hybrid model combined external assessments (outside observations and tape recordings) with internal evaluation methods (through study nurse forms and notes) for a comprehensive process fidelity assessment. Barriers, patient-related issues, and nurse perspectives were identified demonstrating the complexity in home care intervention research. The complementary and synergistic approaches provided in-depth information about the context of the delivery and the impact of the intervention on study outcomes.

Successful recruitment methods in the community for a two-site clinical trial.

Effective screening and recruitment are essential to the success of randomized clinical trials. This report is to describe key screening and recruitment strategies in a two site randomized clinical trial (RCT) conducted in community settings with a vulnerable chronically ill population and to suggest valuable approaches when planning trials. Differences between sites in a complex study with two considerably different environments (academic versus home care) and their participant pools presented challenges which required different screening and recruitment methods. A high level of communication between sites, creative problem solving and the ability to be flexible when problems were encountered were needed for successful screening and recruitment.

Utilizing patient-nurse verbal communication in building risk identification models: the missing critical data stream in home healthcare.

BACKGROUND: In the United States, over 12 000 home healthcare agencies annually serve 6+ million patients, mostly aged 65+ years with chronic conditions. One in three of these patients end up visiting emergency department (ED) or being hospitalized. Existing risk identification models based on electronic health record (EHR) data have suboptimal performance in detecting these high-risk patients. OBJECTIVES: To measure the added value of integrating audio-recorded home healthcare patient-nurse verbal communication into a risk identification model built on home healthcare EHR data and clinical notes. METHODS: This pilot study was conducted at one of the largest not-for-profit home healthcare agencies in the United States. We audio-recorded 126 patient-nurse encounters for 47 patients, out of which 8 patients experienced ED visits and hospitalization. The risk model was developed and tested iteratively using: (1) structured data from the Outcome and Assessment Information Set, (2) clinical notes, and (3) verbal communication features. We used various natural language processing methods to model the communication between patients and nurses. RESULTS: Using a Support Vector Machine classifier, trained on the most informative features from OASIS, clinical notes, and verbal communication, we achieved an AUC-ROC = 99.68 and an F1-score = 94.12. By integrating verbal communication into the risk models, the F-1 score improved by 26%. The analysis revealed patients at high risk tended to interact more with risk-associated cues, exhibit more "sadness" and "anxiety," and have extended periods of silence during conversation. CONCLUSION: This innovative study underscores the immense value of incorporating patient-nurse verbal communication in enhancing risk prediction models for hospitalizations and ED visits, suggesting the need for an evolved clinical workflow that integrates routine patient-nurse verbal communication recording into the medical record.

Natural Language Processing to Identify Home Health Care Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates.

OBJECTIVES: Home health care patients who are at risk for becoming Incapacitated with No Evident Advance Directives or Surrogates (INEADS) may benefit from timely intervention to assist them with advance care planning. This study aimed to develop natural language processing algorithms for identifying home care patients who do not have advance directives, family members, or close social contacts who can serve as surrogate decision-makers in the event that they lose decisional capacity. DESIGN: Cross-sectional study of electronic health records. SETTING AND PARTICIPANTS: Patients receiving post-acute care discharge services from a large home health agency in New York City in 2019 (n = 45,390 enrollment episodes). METHODS: We developed a natural language processing algorithm for identifying information documented in free-text clinical notes (n = 1,429,030 notes) related to 4 categories: evidence of close relationships, evidence of advance directives, evidence suggesting lack of close relationships, and evidence suggesting lack of advance directives. We validated the algorithm against Gold Standard clinician review for 50 patients (n = 314 notes) to calculate precision, recall, and F-score. RESULTS: Algorithm performance for identifying text related to the 4 categories was excellent (average F-score = 0.91), with the best results for "evidence of close relationships" (F-score = 0.99) and the worst results for "evidence of advance directives" (F-score = 0.86). The algorithm identified 22% of all clinical notes (313,290 of 1,429,030) as having text related to 1 or more categories. More than 98% of enrollment episodes (48,164 of 49,141) included at least 1 clinical note containing text related to 1 or more categories. CONCLUSIONS AND IMPLICATIONS: This study establishes the feasibility of creating an automated screening algorithm to aid home health care agencies with identifying patients at risk of becoming INEADS. This screening algorithm can be applied as part of a multipronged approach to facilitate clinician support for advance care planning with patients at risk of becoming INEADS.

Leveraging home health aides to improve outcomes in heart failure: A pilot study protocol.

Heart failure (HF) affects six million people in the U.S., is associated with high morbidity, mortality, and healthcare utilization.(1, 2) Despite a decade of innovation, the majority of interventions aimed at reducing hospitalization and readmissions in HF have not been successful.(3-7) One reason may be that most have overlooked the role of home health aides and attendants (HHAs), who are often highly involved in HF care.(8-13) Despite their contributions, studies have found that HHAs lack specific HF training and have difficulty reaching their nursing supervisors when they need urgent help with their patients. Here we describe the protocol for a pilot randomized control trial (pRCT) assessing a novel stakeholder-engaged intervention that provides HHAs with a) HF training (enhanced usual care arm) and b) HF training plus a mobile health application that allows them to chat with a nurse in real-time (intervention arm). In collaboration with the VNS Health of New York, NY, we will conduct a single-site parallel arm pRCT with 104 participants (HHAs) to evaluate the feasibility, acceptability, and effectiveness (primary outcomes: HF knowledge; HF caregiving self-efficacy) of the intervention among HHAs caring for HF patients. We hypothesize that educating and better integrating HHAs into the care team can improve their ability to provide support for patients and outcomes for HF patients as well (exploratory outcomes include hospitalization, emergency department visits, and readmission). This study offers a novel and potentially scalable way to leverage the HHA workforce and improve the outcomes of the patients for whom they care. Clinical trial.gov registration: NCT04239911.

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.

Long-term urinary catheter users self-care practices and problems.

AIMS AND OBJECTIVES: To characterise a sample of 202 adult community-living long-term indwelling urinary catheter users, to describe self-care practices and catheter problems, and to explore relationships among demographics, catheter practices and problems. BACKGROUND: Long-term urinary catheter users have not been well studied, and persons using the device indefinitely for persistent urinary retention are likely to have different patterns of catheter practices and problems. DESIGN: The study was a cross-sectional descriptive and exploratory analysis. METHODS: Home interviews were conducted with catheter users who provided information by self-reported recall over the previous two months. Data were analysed by descriptive statistics and tests of association between demographics, catheter practices and catheter problems. RESULTS: The sample was widely diverse in age (19-96 years), race and medical diagnosis. Urethral catheters were used slightly more often (56%) than suprapubic (44%), for a mean of six years (SD 7 years). Many persons were highly disabled, with 60% having difficulty in bathing, dressing, toileting and getting out of the bed; 19% also required assistance in eating. A high percentage of catheter problems were reported with: 43% experiencing leakage (bypassing of urine), 31% having had a urinary tract infection, 24% blockage of the catheter, 23% catheter-associated pain and 12% accidental dislodgment of the catheter. Treatments of catheter-related problems contributed to additional health care utilisation, including extra nurse or clinic visits, trips to the emergency department or hospitalisation. Symptoms of catheter-associated urinary tract infections were most often related to changes in the colour or character of urine or generalised symptoms. CONCLUSIONS: Catheter-related problems contribute to excess morbidity and health care utilisation and costs. RELEVANCE TO CLINICAL PRACTICE: More research is needed in how to minimise catheter-associated problems in long-term catheter users. Information from this study could help inform the development of interventions in this population.