"At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19.

BACKGROUND/OBJECTIVES: COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide. DESIGN: Cross-sectional qualitative design using semi-structured interviews. SETTING: HBPC practices in the NYC metro area during spring 2020. PARTICIPANTS: HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices. MEASUREMENTS: Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. RESULTS: Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients. CONCLUSION: NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.

Home-Based Medical Care: High-Value Health Care During Coronavirus Disease 2019 and Beyond.

Ms. H is a 78-year-old woman with a history of congestive heart failure, chronic obstructive pulmonary disease, and recent stroke who was discharged 1 month ago from a subacute rehabilitation facility. She moved in with her son because she now requires a walker and cannot return to her third-floor apartment. One evening, Ms. H develops a low-grade fever and mild shortness of breath intermittently relieved by her albuterol inhaler. Her son is worried, but knows that his mom does not want to return to the hospital.

Beneficios de una unidad de mediana estancia en la rehabilitación de adultos mayores dependientes / Benefits of a subacute care unit in the rehabilitation of frail dependent older adults

Las Unidades de Mediana Estancia (UME) se definen como un recurso institucional con camas de hospitalización para pacientes ancianos, en donde ‒una vez superada la fase aguda de la enfermedad‒ sea posible efectuar un tratamiento a medio plazo, con recursos rehabilitadores, atención médica y cuidados de enfermería, todo ello con el propósito de conseguir la recuperación funcional y la reinserción en la comunidad. El objetivo de este trabajo fue efectuar un estudio cuasi experimental con propio individuo control antes-después con el fin de describir las características basales de los pacientes ingresados en la UME con objetivos de rehabilitación, así como su ganancia funcional luego de la intervención, medida como la diferencia entre el índice de Barthel al alta (valor final) y al ingreso en la UME (valor basal). Para ello se incluyeron 122 personas y se obtuvo como principal resultado una ganancia funcional positiva de 40 puntos y un parámetro de eficacia (ganancia funcional/días de internación) de 1,18. Los resultados obtenidos se consideran, de acuerdo con la literatura, como efectivos y eficaces. (AU)

Subacute Care Units are defined as an institutional resource with hospital beds where once a patient overcomes the acute phase of a disease, it is possible for him to undergo a rehabilitation treatment with the objective of achieving functional recovery and reintegration into the community. The purpose of this paper was to carry out a quasi-experimental before and after study where the subjects serve as their own controls, in order to describe the baseline characteristics of the patients admitted to the subacute care unit with rehabilitation objectives, as well as their functional gain after the intervention, measured as the difference between the Barthel index at discharge (final value) and admission to the EMU (baseline value). For this, 122 people were included, obtaining as main results a positive functional gain of 40 points (p <0.001) and an efficiency parameter (functional gain / days of hospitalization) of 1.18, considering the results obtained according to the literature as effective and efficient. (AU)

Nurses' competencies in health promotion for homebound older people.

OBJECTIVE: to identify competencies related to health promotion targeting homebound older people, as they appear in the literature. METHOD: systematic review using the LILACS, Scopus, CINAHL, PubMed and Cochrane Library databases. The search was performed in November 2017. Selected articles were analyzed according to nine competency domains: enable change; advocate for health; mediate through partnership; communication; leadership; assessment; planning; implementation, and evaluation and research. RESULTS: nine clinical trials were included. All health promotion competency domains were identified in the reviewed research interventions, performed with homebound older people. CONCLUSION: studies showed that the employed treatments were beneficial for the homebound older population. Interventions based on health promotion competencies were positively identified, and are linked to an effective and high-quality health care practice.

A Home-Based Older Person Upstreaming Prevention Physical Therapy (HOP-UP-PT) Program Utilizing Community Partnership Referrals.

Traditional home healthcare reimbursement models emphasize intervention after a medical or functional issue occurs, and there is little evidence of preventative home-based physical therapy services for those at highest risk of becoming homebound due to illness, injury, or functional limitation. The purpose of this study was to describe the development and initial pilot results of the Home-based Older Person Upstreaming Prevention Physical Therapy (HOP-UP-PT) Program. The prospective observational pilot study included five participants referred from a community center. The HOP-UP-PT Program utilized fall risk, functional, environmental, cognitive, and health-related assessments. Two males and three females aged 73 to 92 years were enrolled. Outcomes suggest that health, functional, and environmental benefits may be achieved when an older person participates in the HOP-UP-PT Program. Safety and health benefits gained by two individuals referred to the program, but who did not meet inclusion criteria, are also reported. Evidence emerging from this pilot study suggests trends toward improved functional outcomes associated with reduced fall risk and customized home-based safety recommendations among older adults participating in the HOP-UP-PT Program.

Key determinants to using telehealth technology to serve medically ill and depressed homebound older adults.

Despite the increasing evidence for the effectiveness of telehealth technology in screening and treating chronic diseases, and comorbid depression among older adults, they have been slowly adopted by home health care (HHC) agencies. Therefore, this study aimed to identify factors that determine telehealth technology adoption. Twenty directors from the National Association for Homecare & Hospice member agencies completed a 45-min telephone interview. Questions were asked regarding their perceptions of telehealth, the key determinants of telehealth adoption and use, and recommendations they would give on telehealth adoption. The majority of the participants perceived telehealth as effective for managing symptoms and reducing cost. Meanwhile, some participants had a mixed feeling toward telehealth for depression care as they did not recognize their agency as equipped with the necessary resources and trained staff. Moreover, significant determinants of telehealth adoption included the agency-related characteristics, the patient-home environment, reimbursement and cost-related factors, and staff telehealth perception. Findings imply that there is a need for financial support both at the state and the federal levels to encourage telehealth adoption among HHC agencies. Future studies should consider exploring strategies used by successful programs to overcome barriers.

Home-based family focused rehabilitation for adolescents with severe Chronic Fatigue Syndrome.

AIMS:: The purpose of this article is to describe and evaluate a home based, family focused rehabilitative approach for severely affected housebound adolescents with Chronic Fatigue Syndrome (CFS). The main aims were to facilitate a return to school, improve physical functioning, reduce fatigue and assess any adverse effects of the intervention. METHODS:: Six housebound adolescents aged 11-18, diagnosed with CFS by a paediatrician, were assessed and treated at home by an experienced cognitive behaviour therapist. Outcomes were assessed 12 months after discharge from treatment. RESULTS:: At 12 months follow-up all patients had returned to either school or college, and physical functioning had improved in most of the patients. Fatigue had reduced in some. No adverse effects of the intervention were reported. CONCLUSION:: Severely affected adolescents with CFS showed improved physical functioning and social adjustment after a home-based rehabilitative approach. Although several patients showed improvements in physical functioning, they did not all show substantial improvements in fatigue. At this crucial stage of development, it is important to offer young people and their parents hope by stating that improvement is possible.

Nurses' competencies in health promotion for homebound older people / Competencias del enfermero en torno a la promoción de la salud de ancianos en domicilio / Competências do enfermeiro para promoção da saúde de idosos no domicílio

ABSTRACT Objective: to identify competencies related to health promotion targeting homebound older people, as they appear in the literature. Method: systematic review using the LILACS, Scopus, CINAHL, PubMed and Cochrane Library databases. The search was performed in November 2017. Selected articles were analyzed according to nine competency domains: enable change; advocate for health; mediate through partnership; communication; leadership; assessment; planning; implementation, and evaluation and research. Results: nine clinical trials were included. All health promotion competency domains were identified in the reviewed research interventions, performed with homebound older people. Conclusion: studies showed that the employed treatments were beneficial for the homebound older population. Interventions based on health promotion competencies were positively identified, and are linked to an effective and high-quality health care practice.

RESUMEN Objetivo: identificar en la literatura las competencias del enfermero relacionadas a la promoción de la salud de ancianos en domicilio. Método: revisión sistemática realizada en las bases de datos LILACS, Scopus, CINAHL, portal PubMed y biblioteca Cochrane, en noviembre de 2017. Se hizo el análisis de los artículos seleccionados a partir de nueve dominios de competencias: permitir el cambio; preservar la salud; intermediar mediante asociación; comunicarse; liderar; evaluar; planificar; aplicar; y evaluar e investigar. Resultados: se incluyeron nueve ensayos clínicos. Se identificaron todos los dominios de las competencias en torno a la promoción de la salud en las intervenciones realizadas en las encuestas con los ancianos residentes en domicilio. Conclusión: los estudios demostraron que los tratamientos utilizados fueron beneficiosos para la población de ancianos en domicilio, y que las intervenciones con base en las competencias para promover la salud pueden ser identificadas, además de establecer una práctica asistencial eficaz y de calidad.

RESUMO Objetivo: identificar na literatura as competências do enfermeiro relacionadas à promoção da saúde de idosos no domicílio. Método: revisão sistemática realizada nas bases de dados LILACS, Scopus, CINAHL, no portal PubMed e na biblioteca Cochrane, em novembro de 2017. Os artigos selecionados foram analisados de acordo com os nove domínios de competências: permitir a mudança; advogado para a saúde; mediar através de parceria; comunicação; liderança; avaliação; planejamento; implementação; e avaliação e pesquisa. Resultados: foram incluídos nove ensaios clínicos. Todos os domínios de competências de promoção da saúde foram identificados nas intervenções realizadas nas pesquisas nos idosos residentes no domicílio. Conclusão: os estudos mostraram que os tratamentos utilizados foram benéficos para a população de idosos no domicílio e as intervenções baseadas em competências para a promoção da saúde podem ser identificadas e produzem uma prática assistencial eficaz e de qualidade.

Home and community-based services coordination for homebound older adults in home-based primary care.

BACKGROUND: Medically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients. METHODS: An online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members. RESULTS: Nearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated 'most' or 'all' of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was 'difficult.' The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was 'difficult' or 'very difficult' to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05). CONCLUSIONS: Despite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

An Interdisciplinary Intervention for Fear of Falling: Lessons Learned from Two Case Studies.

This article describes two case studies using an interdisciplinary intervention for homebound older adults who experience fear of falling, resulting in debility and isolation. The patients discussed received separate home visits from a physical therapist (two and four visits) and psychologist (six and eight visits) and intervention components included an initial assessment of physical ability, prescription of home exercise program, exposure therapy, and cognitive restructuring. Both patients reported satisfaction with the fear of falling intervention and showed improved ability to walk, both in distance and in requiring less assistance. These findings suggest significant positive treatment effects can be achieved through interdisciplinary exposure-based interventions aimed at reducing unrealistic fear of falling and associated avoidance behaviors. Similar interventions should be considered for more systematic evaluation of effects and mechanisms of change as well as inclusion in interdisciplinary treatment planning.

A cosmopolítica da gestação, do parto e do pós-parto: autoatenção e medicalização entre os índios Munduruku / The cosmopolitics of pregnancy, childbirth and postpartum: self-attention and medicalization among Munduruku Indians

A pesquisadora Raquel Paiva Dias-Scopel, do Instituto Leônidas e Maria Deane (ILMD/Fiocruz Amazônia), levanta questões sobre a valorização e respeito à diversidade étnica e cultural dos povos indígenas e a difícil interface com o processos de medicalização e do direito ao acesso aos serviços de saúde biomédicos. O livro é parte da Coleção Saúde dos Povos Indígenas, da Editora Fiocruz e partiu da tese de doutorado defendida em 2014 no Programa de Pós-Graduação em Antropologia Social da Universidade Federal de Santa Catarina (UFSC). Foi publicado pela primeira vez em 2015 pela Associação Brasileira de Antropologia com o título A Cosmopolítica da Gestação, Parto e Pós-Parto: práticas de autoatenção e processo de medicalização entre os índios Munduruku. No prefácio da primeira edição, sua orientadora, a doutora em antropologia e professora titular da UFSC, Esther Jean Langdon, ressalta que o conceito fundamental deste livro é da autoatenção, que aponta para o reconhecimento da autonomia e da criatividade da coletividade, principalmente da família, como núcleo que articula os diferentes modelos de atenção ou cuidado da saúde.

"Knowing I can be helpful makes me feel good inside, it makes me feel essential": community health care workers' experiences of conducting a home-based rehabilitation intervention for people living with HIV in KwaZulu-Natal, South Africa.

People living with HIV (PLHIV) are living longer lives on antiretroviral therapy and are prone to a wide range of disabilities. Innovative strategies are required to meet the rehabilitation needs of PLHIV, particularly in resource-poor communities where HIV is endemic and access to institution-based rehabilitation is limited. Home-based rehabilitation (HBR) is one such approach, but there is a paucity of research related to HBR programmes for PLHIV or the experiences of community care workers (CCWs) involved in these programmes. Following a four month randomised controlled trial of a HBR intervention designed specifically for PLHIV in KwaZulu-Natal, South Africa; four CCWs were interviewed. This study employed a qualitative research design, using semi-structured interviews to explore these workers' experiences of being involved in carrying out this intervention. Participants reported how their personal development, improvement in their own health and increased feelings of self-worth enabled them to successfully implement the intervention. Participants also described a number of inhibitors, including stigma and environmental challenges related to the distances between patients' homes, the steep terrain and the hot climate. Despite this, the participants felt empowered by acquiring knowledge and skills that enabled them to shift roles beyond rehabilitation provision. The findings of this study should be considered when employing a task shifting approach in the development and implementation of HBR interventions for PLHIV. By employing a less specialised cadre of community workers to conduct basic HBR interventions, both the relative lack of qualified rehabilitation professionals and the high levels of disability in HIV-epidemic communities can be simultaneously addressed.

Care of a Homebound Super Obese Patient: A Case Study.

Obesity is becoming more prevalent in the United States with almost 40% of the population being overweight or obese. A new category, defining super obesity as a body mass index of 50 or higher, has been added. The purpose of this article is to use a case study to develop a more thorough understanding of the complex care needs of the super obese patient and how home healthcare clinicians can use technology to advocate for super obese patients who are home and bedbound. A review of the literature and discussion will be provided. Potential technologies involved in provision of care will also be explored. Finally, a summary of the case along with proposed solutions will be offered.

Sense of coherence as a key to improve homebound status among older adults with urinary incontinence.

AIM: Being homebound is regarded as a negative condition for social participation in Japan. However, little is known about the possibility of psychological resilience to prevent being homebound among older adults with urinary incontinence. The present study aimed to examine the association between sense of coherence as a measure of psychological resilience and being homebound among older adults with urinary incontinence. METHODS: A cross-sectional study was carried out in Chiba, Japan. We trained 95 care managers as interviewers, and they collected the data from 411 community-dwelling frail older adults using a pretested structured questionnaire. Logistic regression analysis was run to identify factors associated with being homebound among the participants with urinary incontinence. RESULTS: Of the participants, 158 (38.4%) had urinary incontinence. Among the participants with urinary incontinence, 52 (32.9%) were homebound. As a result of logistic regression analysis adjusting for age, sex, living status, hobby, types of prevalent diseases, walking ability, perceived social support and subjective social capital, lower meaningfulness in their lives, which is a component of a sense of coherence, remained positively associated with being homebound (adjusted odds ratio 0.79, 95% confidence interval 0.65-0.96). CONCLUSIONS: Being homebound is less prevalent among those who feel challenges, or worthy of investment or engagement in daily life. By improving a sense of meaningfulness, homebound status might be improved among older adults with urinary incontinence. To encourage active social participation of the target population, their psychological resilience (particularly meaningfulness) should be addressed more.

A feasibility study of low-income homebound older adults' participation in an online chronic disease self-management program.

This study explored the feasibility of "Better Choices, Better Health" (BCBH), the online version of Stanford's Chronic Disease Self-Management Program, among 10 low-income homebound older adults with no or limited computer skills, compared with 10 peers with high computer skills. Computer training was provided before and at the beginning of the BCBH workshop. Feasibility data consisted of field notes by a research assistant who provided computer training, participants' weekly logs, and a semi-structured interview with each participant at 4 weeks after the completion of BCBH. All those who initially lacked computer skills were able to participate in BCBH with a few hours of face-to-face demonstration and training. The 4-week postintervention follow-up showed significant improvement in health and self-management outcomes. Aging-service agencies need to introduce BCBH to low-income homebound older adults and utilize their volunteer base to provide computer and Internet skills training for low-income homebound older adults in need of such training.

A daily adjustable progressive resistance exercise protocol and functional training to increase quadriceps muscle strength and functional performance in an elderly homebound patient following a total knee arthroplasty.

BACKGROUND AND PURPOSE: There is no routinely prescribed protocol to address quadriceps weakness and functional impairments following a total knee arthroplasty (TKA). The purpose of this case report is to introduce and describe the early use of a daily adjustable progressive resistance exercise (DAPRE) protocol as an adjunct to standard rehabilitation to maximize quadriceps muscle strength and functional performance in an elderly homebound patient following a TKA. CASE DESCRIPTION: A 61-year-old female was referred to home care physical therapy for 6 weeks following left TKA due to functional deficits and inability to activate the weak left quadriceps muscle. In phase I, the patient received three visits with emphasis on edema management, improving left knee range of motion, and reducing pain. Phase II consisted of two main components: (1) a DAPRE protocol aimed at maximizing the quadriceps strength and (2) functional training aimed at improving normal gait patterns, transfers, and dynamic balance. OUTCOMES: The patient made substantial improvements in both quadriceps muscle strength and functional performance in the first seven weeks following the TKA. The patient had a pain free return to daily living activities. DISCUSSION: The results suggest that early initiation of a DAPRE protocol was free of adverse events and improved quadriceps strength and functional performance for this patient.

Acceptance of home-based telehealth problem-solving therapy for depressed, low-income homebound older adults: qualitative interviews with the participants and aging-service case managers.

PURPOSE: To report low-income homebound older adults' experience of telehealth problem-solving therapy (tele-PST) and aging-service case managers' (CMs') experience/perception of client-level personal barriers to accessing psychotherapy in general and PST specifically. DESIGN AND METHODS: The study sample consisted of 42 homebound older adults who participated in the feasibility and efficacy trial of tele-PST and completed 36-week follow-up assessments and 12 CMs of a large home-delivered meals program who referred their clients to the tele-PST trial. In-depth interviews with the older adults and written feedback and focus group discussions with the CMs provided the data. RESULTS: Older adults reported a high rate of approval of PST procedures and acknowledged its positive treatment effect. Tele-PST participants were satisfied with videoconferenced sessions because they were convenient and allowed them to see their therapist. However, CMs reported that only about 10%-20% of potentially eligible older adults gave oral consent for PST. Significant treatment engagement barriers were the older adults' lack of motivation, denial of depression, perceived stigma, and other personal attitudinal factors. IMPLICATIONS: The real-world implementation of tele-PST or other psychotherapies needs to include educating and motivating depressed homebound elders to recognize their depression and accept treatment.