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.

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.

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.

Prospective study of thyroid function in the first year of life in infants with Down syndrome.

Current American Academy of Pediatrics (AAP) Guidelines recommend monitoring thyroid function in infants with Down syndrome (DS) at birth, 6 and 12 months, and annually thereafter. This study aimed to determine whether these guidelines are optimal for early diagnosis and treatment of (subclinical) hypothyroidism. Enrolled infants with DS less than age 7 months, born at ≥ 30 weeks gestation to monitor thyroid function test (TFT). A filter paper (FP) blood sample was analyzed for TSH and total T4 at ages 2 and 4 weeks and monthly thereafter until 12 months. Subjects with abnormal FP sample and confirmatory serum TFT for hypothyroidism promptly started treatment. Subjects with thyroid dysfunction identified had thyroid antibodies measured at diagnosis and 12 months. Descriptive statistics determined average time to diagnosis of abnormal TFT. Sixteen (30%) of 54 subjects were diagnosed with a thyroid disorder, the majority with subclinical hypothyroidism (SH) and 1 with hyperthyroidism. Diagnosis occurred in 6 (11%), 9 (17%), and 12 (22.2%) infants in the first 30, 60, and 90 days of life (DOL), respectively. Eight infants had an abnormal NBS and half were diagnosed with a thyroid disorder by DOL 8 and the remainder prior to 4 months. Among subjects with a normal NBS, four were diagnosed at a mean of 104 days and three at a mean of 101 days prior to the 6-month and 12-month routine screens, respectively.  Conclusion: Based on current AAP guidelines, thyroid disorder diagnosis would have been delayed in nearly 20% of the subjects. An additional TFT screen at 1 and 3 months can lead to earlier diagnosis and treatment. What is Known: • Current American Academy of Pediatrics (AAP) Guidelines recommend thyroid function tests (TFT) in infants with Down syndrome (DS) at birth and 6 and 12 months. • Peer- reviewed retrospective studies report an increased incidence of hypothyroidism in infants with DS undetected by the newborn screen (NBS) and prior to 6 months. What is New: • This prospective study monitored TFT in infants with DS at age 2 weeks and monthly throughout the first year of life. • The findings in this study support additional TFT screens at 1 and 3 months in infants with DS.

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.

Assessing the influence of patient language preference on 30 day hospital readmission risk from home health care: A retrospective analysis.

BACKGROUND: In home health care, language barriers are understudied. Language barriers between patients and providers are known to affect a variety of patient outcomes. How a patient's language preference influences hospital readmission risk from home health care has yet to be determined. OBJECTIVE: To determine if home care patients' language preference is associated with their risk for hospital readmission from home health care within 30 days of hospital discharge. DESIGN: Retrospective cross-sectional study of hospital readmissions from an urban home health care agency's administrative records and the national electronic home health care record for the United States, captured between 2010 and 2015. SETTING: New York City, New York, USA. PARTICIPANTS: The dataset comprised 90,221 post-hospitalization patients and 6.5 million home health care visits. METHODS: First, a Chi-square test was used to determine if there were significant differences in crude readmission rates based on language group. Inverse probability of treatment weighting was used to adjust for significant differences in known hospital readmission risk factors between to examine all-cause hospital readmission during a home health care stay. The final matched sample included 87,561 patients with a language preference of English, Spanish, Russian, Chinese, or Korean. English-speaking patients were considered the comparison group to the non-English speaking patients. A Marginal Structural Model was applied to estimate the impact of non-English language preference against English language preference on rehospitalization. The results of the marginal structural model were expressed as an odds ratio of likelihood of readmission to the hospital from home health care. RESULTS: Home health patients with a non-English language preference had a higher hospital readmission risk than English-speaking patients. Crude readmission rate for the limited English proficiency patients was 20.4% (95% CI, 19.9-21.0%) overall compared to 18.5% (95% CI, 18.7-19.2%) for English speakers (p < 0.001). Being a non-English-speaking patient was associated with an odds ratio of 1.011 (95% CI, 1.004-1.018) in increased hospital readmission rates from home health care (p = 0.001). There were also statistically significant differences in readmission rate by language group (p < 0.001), with Korean speakers having the lowest rate and Spanish speakers having the highest, when compared to English speakers. CONCLUSIONS: People with a non-English language preference have a higher readmission rate from home health care. Hospital and home healthcare agencies may need specialized care coordination services to reduce readmission risk for these patients. Tweetable abstract: A new US-based study finds that home care patients with language barriers are at higher risk for hospital readmission.

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.

"Doing the Right Thing": Family Caregivers Managing Medical and Nursing Tasks in the Postacute Home Health Care Setting.

Family caregivers often manage complex medical and nursing tasks (MNTs) for older adults transitioning from hospital to home. To explore caregivers' experiences managing MNTs in the postacute home health care (HHC) setting, we interviewed by phone 20 caregivers of older adults who received HHC following a hospitalization. Interviews were recorded, transcribed, and analyzed using directed content analysis. Caregivers highlighted the technical complexity and emotional impact of performing MNTs, as well as social (e.g., family, friends) and environmental (e.g., neighborhood, housing) resources they leveraged to meet the older adults' care needs. Caregivers also identified challenges coordinating care and services within HHC and the larger health care system. Caregiver engagement in the postacute HHC setting should incorporate tailored training and support, assessments of socioenvironmental context and resources, and facilitated navigation of the health care system. Future research should elucidate factors associated with successful collaborative relationships among HHC providers, older adults, and their caregivers in the postacute HHC setting.

Home Health Care Use and Post-Discharge Outcomes After Heart Failure Hospitalizations.

OBJECTIVES: This study compared the characteristics of Medicare beneficiaries who were hospitalized for heart failure (HF) and then discharged home who received home health care (HHC) to the characteristics of those who did not, and examined associations among HHC and readmission and mortality rates. BACKGROUND: After hospitalization for HF, some patients receive HHC. However, the use of HHC over time, the factors associated with its use, and the post-discharge outcomes after receiving it are not well studied. METHODS: This study used Get With The Guidelines-HF data, merged with Medicare fee-for-service claims. Propensity score matching and Cox proportional hazards models were used to evaluate the associations between HHC and post-discharge outcomes. RESULTS: From 2005 to 2015, 95,531 patients were admitted for HF, and 32,697 (34.2%) received HHC after discharge. The rate of HHC increased over time from 31.4% to 36.1% (p < 0.001). HHC recipients were older, more likely to be female, and had more comorbidities. HHC was associated with a higher risk of all-cause 30-day readmission (hazard ratio [HR]: 1.25; 95% confidence interval [CI]: 1.20 to 1.30), HF-specific 30-day readmission (HR: 1.20; 95% CI: 1.13 to 1.28), all-cause 90-day readmission (HR: 1.23; 95% CI: 1.19 to 1.26), HF-specific 90-day readmission (HR: 1.16; 95% CI: 1.11 to 1.22), and all-cause 30-and 90-day mortality, respectively (HR: 1.70; 95% CI: 1.56 to 1.86) and HR: 1.49; 95% CI: 1.41 to 1.57) compared to those who did not receive HHC. CONCLUSIONS: Use of HHC after HF hospitalization increased among Medicare beneficiaries. HHC recipients were older and sicker than non-HHC recipients. Although HHC was associated with a higher risk of readmissions and mortality, this finding should be interpreted cautiously, given the presence of unmeasured variables that could affect receipt of HHC. Research is needed to determine whether the results reflect appropriate health care use.

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.

Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors.

OBJECTIVE: To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. DESIGN: Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. SETTING AND PARTICIPANTS: National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N = 165,228). METHODS: We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. RESULTS: The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. CONCLUSIONS AND IMPLICATIONS: Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.

Does Early Follow-Up Improve the Outcomes of Sepsis Survivors Discharged to Home Health Care?

BACKGROUND: There is little evidence to guide the care of over a million sepsis survivors following hospital discharge despite high rates of hospital readmission. OBJECTIVE: We examined whether early home health nursing (first visit within 2 days of hospital discharge and at least 1 additional visit in the first posthospital week) and early physician follow-up (an outpatient visit in the first posthospital week) reduce 30-day readmissions among Medicare sepsis survivors. DESIGN: A pragmatic, comparative effectiveness analysis of Medicare data from 2013 to 2014 using nonlinear instrumental variable analysis. SUBJECTS: Medicare beneficiaries in the 50 states and District of Columbia discharged alive after a sepsis hospitalization and received home health care. MEASURES: The outcomes, protocol parameters, and control variables were from Medicare administrative and claim files and the home health Outcome and Assessment Information Set (OASIS). The primary outcome was 30-day all-cause hospital readmission. RESULTS: Our sample consisted of 170,571 mostly non-Hispanic white (82.3%), female (57.5%), older adults (mean age, 76 y) with severe sepsis (86.9%) and a multitude of comorbid conditions and functional limitations. Among them, 44.7% received only the nursing protocol, 11.0% only the medical doctor protocol, 28.1% both protocols, and 16.2% neither. Although neither protocol by itself had a statistically significant effect on readmission, both together reduced the probability of 30-day all-cause readmission by 7 percentage points (P=0.006; 95% confidence interval=2, 12). CONCLUSIONS: Our findings suggest that, together, early postdischarge care by home health and medical providers can reduce hospital readmissions for sepsis survivors.

The Homecare Aide Workforce Initiative: Implementation and Outcomes.

Improved training and support are thought to improve retention among direct care workers. However, few studies have examined actual retention. This study examined satisfaction and retention among home health aides enrolled in the "Homecare Aide Workforce Initiative" (HAWI) at three New York agencies. Data included surveys of HAWI trainees and new hires and payroll data for HAWI graduates and others. Three months after hire, 91% of HAWI hires reported they were "very satisfied" or "satisfied" with the job; 57% reported they were "not at all likely" to leave their job in the coming year. At 365 days, 60% were still working. In logistic regression, the odds of being retained at 3, 6, and 12 months were significantly higher among HAWI graduates than non-HAWI new hires. Although not a randomized trial, the study demonstrates an association between participation in an innovative entry-level workforce program and superior 3-, 6-, and 12-month retention.

Black/Hispanic Disparities in a Vulnerable Post-Stroke Home Care Population.

Significant racial and ethnic disparities in stroke risk factors, occurrence, and outcomes persist in the USA. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP > 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients' SBP-the leading modifiable cause of stroke-and physical function-a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy, and current alcohol drinking (vs. abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.

An Exploratory Analysis of Patient-Provider Language-Concordant Home Health Care Visit Patterns.

Approximately one in five households in the United States speaks a language other than English at home. This exploratory, descriptive study sought to examine language-concordant visit patterns in an urban home health care agency serving a diverse and multilingual population. Patient care record data combined with administrative data facilitated the exploratory work. In a 2-year period, results showed that among the 238,513 visits with 18,132 limited English proficiency patients, only 20% of visits were language concordant. The study suggests that home health care services may not be meeting the demand for language services, but more research is needed to determine the right "dose" of bilingual home care visits to optimize home care outcomes and establish a standard for care.

Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow-Up.

OBJECTIVE: To compare the effectiveness of two "treatments"-early, intensive home health nursing and physician follow-up within a week-versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care. DATA SOURCES: National Medicare administrative, claims, and patient assessment data. STUDY DESIGN: Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week. DATA EXTRACTION METHODS: All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files. PRINCIPAL FINDINGS: Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p < .001; confidence interval = -12.3, -4.1). Results are robust to changes in implementation of the nonlinear IV estimator, sample, outcome measure, and length of follow-up. CONCLUSIONS: Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.

Home-based interventions for black patients with uncontrolled hypertension: a cluster randomized controlled trial.

AIM: Assess the comparative effectiveness of two blood pressure (BP) control interventions for black patients with uncontrolled hypertension. PATIENTS & METHODS: A total of 845 patients were enrolled in a three-arm cluster randomized trial. On admission of an eligible patient, field nurses were randomized to usual care, a basic or augmented intervention. RESULTS: Across study arms there were no significant 12 months differences in BP control rates (primary outcome) (25% usual care, 26% basic intervention, 22% augmented intervention); systolic BP (143.8 millimeters of mercury [mmHg], 146.9 mmHG, 143.9 mmHG, respectively); medication intensification (47, 43, 54%, respectively); or self-management score (18.7, 18.7, 17.9, respectively). Adjusted systolic BP dropped more than 10 mmHg from baseline to 12 months (155.5-145.4 mmHg) among all study participants. CONCLUSION: Neither the augmented nor basic intervention was more effective than usual care in improving BP control, systolic BP, medication intensification or patient self-management. Usual home care yielded substantial improvements, creating a high comparative effectiveness threshold. CLINICAL TRIAL REGISTRATION: NCT00139490.