Enabling and constraining successful reablement: Individual and neighbourhood factors.

Using multilevel logistic regression to analyse management data of reablement episodes collected by Essex County Council, a UK local authority, this article identifies constraining and enabling factors for successful reablement. Overall, 59.5% of reablement clients were classed as able to care for themselves when assessed after 13 weeks following the reablement intervention (N = 8,118). Several age-related, disability, referral, and social factors were found to constrain reablement, but some of the largest constraining effects were neighbourhood deprivation as measured through the Index of Multiple Deprivation and, particularly, unfavourable geodemographic profiles as measured through Experian Mosaic consumer classifications. The results suggest that in order to optimise reablement, programmes should consider broader social and environmental influences on reablement rather than only individual and organisational aspects. Reablement might also be better tailored and intensified for client groups with particular underlying disabilities and for those displaying specific geodemographic characteristics.

'The Elephant on the Table': Religious and Ethnic Diversity in Home Health Services.

Healthcare services are increasingly being provided in the home. At the same time, these home contexts are changing as global migration has brought unprecedented diversity both in the recipients of care, and home health workers. In this paper, we present findings of a Canadian study that examined the negotiation of religious and ethnic plurality in home health. Qualitative analysis of the data from interviews and observations with 46 participants-clients, administrators, home healthcare workers-revealed how religion is expressed and 'managed' in home health services.

Dynamically accepting and scheduling patients for home healthcare.

The importance of home healthcare is growing rapidly since populations of developed and even developing countries are getting older and the number of hospitals, retirement homes, and medical staff do not increase at the same rate. We consider the Home Healthcare Nurse Scheduling Problem where patients arrive dynamically over time and acceptance and appointment time decisions have to be made as soon as patients arrive. The objective is to maximise the average number of daily visits for a single nurse. For the sake of service continuity, patients have to be visited at the same day and time each week during their episode of care. We propose a new heuristic based on generating several scenarios which include randomly generated and actual requests in the schedule, scheduling new customers with a simple but fast heuristic, and analysing results to decide whether to accept the new patient and at which appointment day/time. We compare our approach with two greedy heuristics from the literature, and empirically demonstrate that it achieves significantly better results compared to these other two methods.

A Resource Guide to Improve Nursing Care and Transition to Self-Care for Patients With Ostomies.

Clinical management of patients with an ostomy can be complex and stressful. With only 10% of Wound Ostomy Incontinence Nurses working in home health, home healthcare nurses need to be knowledgeable about care of patients with new ostomies. This article provides an overview of the resources available to guide nurses caring for ostomy patients. In addition, resources nurses can share with patients as they transition into the community are provided.

Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program.

BACKGROUND: Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population. STUDY DESIGN: An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected. RESULTS: Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group. CONCLUSIONS: Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.

Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

OBJECTIVES: To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization. DESIGN: Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams). SETTING: Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone. PARTICIPANTS: Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306). INTERVENTION: The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks. MEASUREMENTS: Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments. RESULTS: The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants. CONCLUSION: Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services.

The Future of Home Health project: developing the framework for health care at home.

In addition to providing high-quality care to vulnerable patient populations, home healthcare offers the least costly option for patients and the healthcare system, particularly in postacute care. As the baby boom generation ages, policymakers are expressing concerns about rising costs, variation in home healthcare service use, and program integrity. The Alliance for Home Health Quality and Innovation seeks to develop a research-based strategic framework for the future of home healthcare for older Americans and those with disabilities. This article describes the initiative and invites readers to provide comments and suggestions.

A review of the present state and future policy alternatives for home visit nursing services in Korea.

OBJECTIVES: The aim of this study was to describe the current state of home visit nursing services in the Korean context and to suggest future policy directions. DESIGN: First, the three home visit nursing services that have developed in Korea are compared using the analytic framework provided by Gilbert and Terrell in 2012. The framework is based on four dimensions of social welfare: users, services, source of funds, and service delivery process. Second, we perform a strength, weakness, opportunity, and threat analysis to suggest comprehensive and constructive home visit nursing service policies for the future. RESULTS: Specifically, we advocate the creation of an organization that steers the central government to operate an integrated management organization to distribute services and reduce redundancy for preventing the waste of both medical and state financial resources. This study also recommends the development of educational programs to improve the quality of services and service evaluation criteria for the objective assessment of those services. CONCLUSIONS: These policy guidelines may prove useful both for Korea and for other countries that intend to prepare or revise their home visit nursing service systems.

Validating a multifactorial falls risk assessment.

Reducing risk of falls has been identified as a national safety goal by The Joint Commission (TJC). The purpose was to determine if the total score on the multifactorial Falls Risk Assessment accurately identifies the risk of falls in a homebound client. In addition, the study examined if any individual item had a higher predictive power with the incidence of falls. One hundred clients (> 65 years old) who sustained an avoidable fall during a home care episode of care, plus 25 home care clients in the same age range and time period, who did not fall. A retrospective chart review, including Falls Risk Assessment (FRA) performed at start of care, demographic information, specific physical therapy (PT) evaluation, and visit notes if necessary to determine if the fall met the inclusion criteria. Scores for each individual area of the assessment were collected for statistical analysis. Data were analyzed by a biostatistician using simple linear regression, t-tests, and regression of variable combinations. The total score on the multifactorial risk assessment tool was shown to have a strong relationship with incidence of falls. The average scores of individuals who fell after assessment were significantly higher than those of individuals who did not fall. No single factors were found to be highly predictive. A single approach to decreasing falls is likely to be less effective than a multipronged approach. Caregivers and providers are advised to consider the entirety of the falls risk and direct comprehensive interventions to address the multiple factors that lead to falls.

Health care technology at home: Issues in organization and delivery in Québec

INTRODUCTION: Most industrialized countries have initiated health care system reforms that are aiming to in-crease the number and scope of health services delivered on an ambulatory basis and at the pa-tient's home. In Québec, this shift is called the "virage ambulatoire". Traditional home health-care services include case management, nursing, personal care, home support (or homemaking), occupational and physical therapies, social work counseling, nutrition counseling, and respiratory therapy. More complex forms of clinical treatments at home are emerging, such as IV therapy, life support/ventilator assistance systems, cancer therapy, palliative care, and ser-vices for persons with AIDS or Alzheimer's dis-ease [CIHI, 2003a]. This report is mainly con-cerned with these latter forms of interventions, i.e. high-tech home care. Technology, we argue, cannot simply be seen as one of several factors driving change in home care, but should be viewed as a pervasive component of a new model of care. The aim of this report is to iden-tify the organizational issues associated with an increased use of health care technology at home and provide recommendations regarding the de-velopment of such services in Québec. This report is organized in six parts. First, we present the rationale for this investigation and describe the methods and data sources. Second, we summarize the features of home health care service developments in Canada and present four problems raised by the increased use of technol-ogy at home. Third, we describe in greater detail the prevalence and patterns of the use of tech-nology in home care services as provided by Québec local community health centres (CLSCs), and highlight potential barriers and opportunities in the expansion of such services. Fourth, we synthesize the organizational, social, ethical, and legal dimensions of technology-enhanced home care from a review of the inter-national literature. Fifth, we analyze how such dimensions could be addressed in the delivery and evaluation of home care services, referring specifically to the Québec health care reform. Finally, in conclusion, we formulate recommen-dations and identify the actors whose decisions and actions might be influenced by this report. TECHNOLOGY AT HOME IN QUÉBEC: A study was conducted in 1999-2001 by the first author of this report (PL) and her colleagues at Université de Montréal. The aim of the research was to identify the organizational, technical, and human factors influencing the use of certain technologies at home by CLSCs. A mail-back survey was sent to CLSCs; the response rate was close to 70%. Almost all responding CLSCs had been involved in the provision of home IV ther-apy. The two most common modes of IV deliv-ery were gravity (81.3% of CLSCs) and pro-grammable pumps (97.9%), whereas the mechanical delivery system was used less fre-quently (58.9%). Oxygen therapy was the second most frequent home care service provided by CLSCs (with fixed concentrators: 83.5% of CLSCs). The provision of services related to parenteral nutrition was limited but still signifi-cant (26.6%). A large proportion of CLSCs (78.1%) indicated that they had been involved in the delivery of peritoneal dialysis care. A major-ity of CLSCs had been involved in the provision of anticoagulant therapy services (87.9%), while a third (35.6%) had been involved in the delivery of IV chemotherapy. Despite the abundant litera-ture underscoring the rapid growth of home telecare, the use of various information technology -based home monitoring services was infrequent. ISSUES IN ORGANIZATION AND DELIVERY: Introducing sophisticated technologies into the home setting has created new types of patients, new treatment possibilities, new roles and re-sponsibilities for providers and caregivers, new ethical dilemmas, and new areas of accountabil-ity. Part 4 of the report is an attempt to clarify and summarize issues that are often entangled both in the literature and in practice. Organiza-tional dimensions of technology-enhanced home care are intimately linked to the characteristics of the home care delivery model, and to the par-ticular needs of patients in terms of care, tech-nology, and support. Social dimensions of the use of technology at home refer to the capacity of the patients and their relatives to maintain sat-isfying relationships, to engage in leisure activi-ties, to raise a family, to carry out social roles, to be employed and earn an income, and to live without discrimination. Several factors suggest that issues of legal liability in home care will in-crease [Kapp, 1995a]: home care is becoming increasingly high-tech; patients are being dis-charged "quicker and sicker"; and the coordina-tion of care provided by various professionals is becoming more complex (making it increasingly difficult to control legal risks). CONCLUSION: Current challenges in the organization and deliv-ery of home care call for immediate policy ac-tions. Sophisticated technology is changing the nature of health systems across industrialized countries, and one of its most significant devel-opments is the use of complex equipment in the patient's home. The use of such equipment often requires the clinical and technical expertise of secondary and tertiary level care providers, as well as a keen understanding of home care pa-tients' needs­an expertise that CLSC home care program staff have developed for particular clientele over the last two decades in Québec. One critical challenge, for the next decade, will be to bring these two types of expertise together in or-der to provide specialized home care that re-mains meaningful for the patients and their rela-tives, while being effective from clinical and organizational perspectives. In this endeavour, coordination among individual care providers and among health organizations is key, as is building the technical and clinical competence of providers, patients, and caregivers. Each of our four recommendations addresses a particular facet of the 'home care problem'. While a global vision of home care should help structure the fu-ture of this service in Québec, regional leader-ship is required to support and implement organ-izational incentives that will enable effective coordination between hospitals and CLSCs or the réseaux locaux de services in which they are now integrated.