Nursing documentation of symptoms is associated with higher risk of emergency department visits and hospitalizations in homecare patients.

BACKGROUND: Nurses often document patient symptoms in narrative notes. PURPOSE: This study used a technique called natural language processing (NLP) to: (1) Automatically identify documentation of seven common symptoms (anxiety, cognitive disturbance, depressed mood, fatigue, sleep disturbance, pain, and well-being) in homecare narrative nursing notes, and (2) examine the association between symptoms and emergency department visits or hospital admissions from homecare. METHOD: NLP was applied on a large subset of narrative notes (2.5 million notes) documented for 89,825 patients admitted to one large homecare agency in the Northeast United States. FINDINGS: NLP accurately identified symptoms in narrative notes. Patients with more documented symptom categories had higher risk of emergency department visit or hospital admission. DISCUSSION: Further research is needed to explore additional symptoms and implement NLP systems in the homecare setting to enable early identification of concerning patient trends leading to emergency department visit or hospital admission.

Usability Evaluation of a Dashboard for Home Care Nurses.

The introduction of electronic health records has produced many challenges for clinicians. These include integrating technology into clinical workflow and fragmentation of relevant information across systems. Dashboards, which use visualized data to summarize key patient information, have the potential to address these issues. In this article, we outline a usability evaluation of a dashboard designed for home care nurses. An iterative design process was used, which consisted of (1) contextual inquiry (observation and interviews) with two home care nurses; (2) rapid feedback on paper prototypes of the dashboard (10 nurses); and (3) usability evaluation of the final dashboard prototype (20 nurses). Usability methods and assessments included observation of nurses interacting with the dashboard, the system usability scale, and the Questionnaire for User Interaction Satisfaction short form. The dashboard prototype was deemed to have high usability (mean system usability scale, 73.2 [SD, 18.8]) and was positively evaluated by nurse users. It is important to ensure that technology solutions such as the one proposed in this article are designed with clinical users in mind, to meet their information needs. The design elements of the dashboard outlined in this article could be translated to other electronic health records used in home care settings.

Covid-19: Home Health Aides' Perceived Preparedness and Self-Reported Availability for Work: Six Month Survey Results.

Throughout the COVID-19 pandemic New York City home health aides continuously provided care, including to patients actively infected or recovering from COVID-19. Analyzing survey data from 1316 aides, we examined factors associated with perceptions of how well their employer prepared them for COVID-19 and their self-reported availability for work (did they "call out" more than usual). Organizational work environment and COVID-19-related supports were predominant predictors of self-reported perceptions of preparedness. Worker characteristics and COVID-19-related stressors were predominant predictors of self-reported availability. Mental distress, satisfaction with employer communications, and satisfaction with supervisor instructions were significantly associated with both outcomes. The study uniquely describes self-reported perceptions of preparedness and availability as two separate worker outcomes potentially modifiable by different interventions. Better public health emergency training and adequate protective equipment may increase aides' perceived preparedness; more household supports could facilitate their availability. More effective employer communications and mental health initiatives could potentially improve both outcomes. Industry collaboration and systemic changes in federal, state, and local policies should enhance intervention impacts.

A Qualitative Study of Home Health Aides' Perspectives towards COVID-19 Vaccination.

Home health aides provide care to homebound older adults and those with chronic conditions. Aides were less likely to receive COVID-19 vaccines when they became available. We examined aides' perspectives towards COVID-19 vaccination. Qualitative interviews were conducted with 56 home health aides at a large not-for-profit home care agency in New York City. Results suggested that aides' vaccination decisions were shaped by (1) information sources, beliefs, their health, and experiences providing care during COVID-19; (2) perceived susceptibility and severity of COVID-19; (3) perceived benefits of vaccination including protection from COVID-19, respect from colleagues and patients, and fulfillment of work-related requirements; (4) perceived barriers to vaccination including concerns about safety, efficacy, and side effects; and (5) cues to action including access to vaccination sites/appointments, vaccination mandates, question and answer sessions from trusted sources, and testimonials. Providing tailored information with support to address vaccination barriers could lead to improved vaccine uptake.

Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial.

BACKGROUND: Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures. METHODS: This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures. RESULTS: Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants. CONCLUSIONS: The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.

Risk of Rehospitalization or Emergency Department Visit is Significantly Higher for Patients who Receive Their First Home Health Care Nursing Visit Later than 2 Days After Hospital Discharge.

OBJECTIVES: This study explored the association between the timing of the first home health care nursing visits (start-of-care visit) and 30-day rehospitalization or emergency department (ED) visits among patients discharged from hospitals. DESIGN: Our cross-sectional study used data from 1 large, urban home health care agency in the northeastern United States. SETTING/PARTICIPANTS: We analyzed data for 49,141 home health care episodes pertaining to 45,390 unique patients who were admitted to the agency following hospital discharge during 2019. METHODS: We conducted multivariate logistic regression analyses to examine the association between start-of-care delays and 30-day hospitalizations and ED visits, adjusting for patients' age, race/ethnicity, gender, insurance type, and clinical and functional status. We defined delays in start-of-care as a first nursing home health care visit that occurred more than 2 full days after the hospital discharge date. RESULTS: During the study period, we identified 16,251 start-of-care delays (34% of home health care episodes), with 14% of episodes resulting in 30-day rehospitalization and ED visits. Delayed episodes had 12% higher odds of rehospitalization or ED visit (OR 1.12; 95% CI: 1.06-1.18) compared with episodes with timely care. CONCLUSIONS AND IMPLICATIONS: The findings suggest that timely start-of-care home health care nursing visit is associated with reduced rehospitalization and ED use among patients discharged from hospitals. With more than 6 million patients who receive home health care services across the United States, there are significant opportunities to improve timely care delivery to patients and improve clinical outcomes.

Improving Patient Prioritization During Hospital-Homecare Transition: Protocol for a Mixed Methods Study of a Clinical Decision Support Tool Implementation.

BACKGROUND: Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient's capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits. OBJECTIVE: This study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT. METHODS: Employing a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data. RESULTS: The study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021. CONCLUSIONS: Mixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT04136951; https://clinicaltrials.gov/ct2/show/NCT04136951. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/20184.

Factors Associated with Timing of the Start-of-Care Nursing Visits in Home Health Care.

OBJECTIVES: Home health care patients have critical needs requiring timely care following hospital discharge. Although Medicare requires timely start-of-care nursing visits, a significant portion of home health care patients wait longer than 2 days for the first visit. No previous studies investigated the pattern of start-of-care visits or factors associated with their timing. This study's purpose was to examine variation in timing of start-of-care visits and characterize patients with visits later than 2 days postdischarge. DESIGN: Retrospective cohort study. SETTING/PARTICIPANTS: Patients admitted to a large, Northeastern US, urban home health care organization during 2019. The study included 48,497 home care episodes for 45,390 individual patients. MEASUREMENT: We calculated time to start of care from hospital discharge for 2 patient groups: those seen within 2 days vs those seen >2 days postdischarge. We examined patient factors, hospital discharge factors, and timing of start of care using multivariate logistic regression. RESULTS: Of 48,497 episodes, 16,251 (33.5%) had a start-of-care nursing visit >2 days after discharge. Increased odds of this time frame were associated with being black or Hispanic and having solely Medicaid insurance. Odds were highest for patients discharged on Fridays, Saturdays, and Mondays. Factors associated with visits within 2 days included surgical wound presence, urinary catheter, pain, 5 or more medications, and intravenous or infusion therapies at home. CONCLUSIONS AND IMPLICATIONS: Findings provide the first publication of clinical and demographic characteristics associated with home health care start-of-care timing and its variation. Further examination is needed, and adjustments to staff scheduling and improved information transfer are 2 suggested interventions to decrease variation.

Exploring Reasons for Delayed Start-of-Care Nursing Visits in Home Health Care: Algorithm Development and Data Science Study.

BACKGROUND: Delayed start-of-care nursing visits in home health care (HHC) can result in negative outcomes, such as hospitalization. No previous studies have investigated why start-of-care HHC nursing visits are delayed, in part because most reasons for delayed visits are documented in free-text HHC nursing notes. OBJECTIVE: The aims of this study were to (1) develop and test a natural language processing (NLP) algorithm that automatically identifies reasons for delayed visits in HHC free-text clinical notes and (2) describe reasons for delayed visits in a large patient sample. METHODS: This study was conducted at the Visiting Nurse Service of New York (VNSNY). We examined data available at the VNSNY on all new episodes of care started in 2019 (N=48,497). An NLP algorithm was developed and tested to automatically identify and classify reasons for delayed visits. RESULTS: The performance of the NLP algorithm was 0.8, 0.75, and 0.77 for precision, recall, and F-score, respectively. A total of one-third of HHC episodes (n=16,244) had delayed start-of-care HHC nursing visits. The most prevalent identified category of reasons for delayed start-of-care nursing visits was no answer at the door or phone (3728/8051, 46.3%), followed by patient/family request to postpone or refuse some HHC services (n=2858, 35.5%), and administrative or scheduling issues (n=1465, 18.2%). In 40% (n=16,244) of HHC episodes, 2 or more reasons were documented. CONCLUSIONS: To avoid critical delays in start-of-care nursing visits, HHC organizations might examine and improve ways to effectively address the reasons for delayed visits, using effective interventions, such as educating patients or caregivers on the importance of a timely nursing visit and improving patients' intake procedures.

Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial.

BACKGROUND: Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS: A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS: Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION: The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION: Trial Number NCT01918891.

Technology Solutions to Support Care Continuity in Home Care: A Focus Group Study.

BACKGROUND: Elevated hospital readmission rates from home care are an indicator of poor care quality, and rates are particularly high for patients with heart failure. Readmissions may be avoided by optimizing continuity of care. PURPOSE: To explore perceptions among home care clinicians of the barriers they face and the information they need to improve care continuity for patients with heart failure. METHODS: Focus groups were conducted with teams of home care clinicians at a large certified home healthcare agency in the Northeastern United states. RESULTS: In total, there were 61 participants across 6 focus groups. Three overarching themes emerged: continuity of care and communication on care transitions, maintaining continuity of care during a home care episode (with subthemes tracking signs and symptoms and patient teaching), and health information technology (HIT) characteristics to support communication and care continuity. CONCLUSIONS: Our study highlights areas of improvement for HIT solutions that could support care delivery for patients with heart failure in a home care setting. IMPLICATIONS: Home care agencies planning to introduce technology can use these findings to assess if and how potential systems can support nurses to provide continuity of care across healthcare organizations and home care visits.

The impact of home care nurses' numeracy and graph literacy on comprehension of visual display information: implications for dashboard design.

Objective: To explore home care nurses' numeracy and graph literacy and their relationship to comprehension of visualized data. Materials and Methods: A multifactorial experimental design using online survey software. Nurses were recruited from 2 Medicare-certified home health agencies. Numeracy and graph literacy were measured using validated scales. Nurses were randomized to 1 of 4 experimental conditions. Each condition displayed data for 1 of 4 quality indicators, in 1 of 4 different visualized formats (bar graph, line graph, spider graph, table). A mixed linear model measured the impact of numeracy, graph literacy, and display format on data understanding. Results: In all, 195 nurses took part in the study. They were slightly more numerate and graph literate than the general population. Overall, nurses understood information presented in bar graphs most easily (88% correct), followed by tables (81% correct), line graphs (77% correct), and spider graphs (41% correct). Individuals with low numeracy and low graph literacy had poorer comprehension of information displayed across all formats. High graph literacy appeared to enhance comprehension of data regardless of numeracy capabilities. Discussion and Conclusion: Clinical dashboards are increasingly used to provide information to clinicians in visualized format, under the assumption that visual display reduces cognitive workload. Results of this study suggest that nurses' comprehension of visualized information is influenced by their numeracy, graph literacy, and the display format of the data. Individual differences in numeracy and graph literacy skills need to be taken into account when designing dashboard technology.

Does Level of Numeracy and Graph Literacy Impact Comprehension of Quality Targets? Findings from a Survey of Home Care Nurses.

Clinical dashboards that display targets compared to performance metrics are increasingly used by healthcare organizations in their quality improvement efforts. However, few studies have evaluated the extent to which healthcare professionals can readily understand and interpret these data. This study explored associations between measures of graph literacy and numeracy in home care nurses from two agencies (N=195) with comprehension of quality targets presented in a graphical dashboard format. Data were collected using an online survey. Results from linear regression models indicated that nurses' levels of graph literacy and numeracy were positively associated with comprehension of quality targets. Nurses with low levels of both graph literacy and numeracy tended to have the lowest target comprehension scores compared to those who had high levels of both graph literacy and numeracy. Nurses with low graph literacy and high numeracy also had significantly lower scores for comprehension of quality targets compared to those with high graph literacy and numeracy. These findings suggest that developers of clinical dashboards that incorporate quality target information need to evaluate users' ability to understand the information displayed in graphs and tables before they release the product for general use in healthcare settings.