Hospital-to-Home-Health Transition Quality (H3TQ) Index: Further Evidence on its Validity and Recommendations for Implementation.

BACKGROUND: We developed the Hospital-to-Home-Health Transition Quality (H3TQ) Index for skilled home healthcare (HH) agencies to identify threats to safe, high-quality care transitions in real time. OBJECTIVE: Assess the validity of H3TQ in a large sample across diverse communities. RESEARCH DESIGN: A survey of recently hospitalized older adults referred for skilled HH services and their HH provider at two large HH agencies in Baltimore, MD, and New York, NY. SUBJECTS: There were five hundred eighty-seven participants (309 older adults, 141 informal caregivers, and 137 HH providers). Older adults, caregivers, and HH providers rated 747 unique transitions. Of these, 403 were rated by both the older adult/caregiver and their HH provider, whereas the remaining transitions were rated by either party. MEASURES: Construct, concurrent, and predictive validity were assessed via the overall H3TQ rating, correlation with the care transition measure (CTM), and the Medicare Outcome and Assessment Information Set (OASIS). RESULTS: Proportion of transitions with quality issues as identified by HH providers and older adults/caregivers, respectively; Baltimore 55%, 35%; NYC 43%, 32%. Older adults/caregivers across sites rated their transitions as higher quality than did providers (P<0.05). H3TQ summed scores showed construct validity with the CTM-3 and concurrent validity with OASIS measures. Summed H3TQ scores were not significantly correlated with 30-day ED visits or rehospitalization. CONCLUSIONS: The H3TQ identifies care transition quality issues in real-time and demonstrated construct and concurrent validity, but not predictive validity. Findings demonstrate value in collecting multiple perspectives to evaluate care transition quality. Implementing the H3TQ could help identify transition-quality intervention opportunities for HH patients.

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

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

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

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

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19.

BACKGROUND: Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge. METHODS: Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization. RESULTS: Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization. CONCLUSIONS: HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Is the patient speaking or the nurse? Automatic speaker type identification in patient-nurse audio recordings.

OBJECTIVES: Patient-clinician communication provides valuable explicit and implicit information that may indicate adverse medical conditions and outcomes. However, practical and analytical approaches for audio-recording and analyzing this data stream remain underexplored. This study aimed to 1) analyze patients' and nurses' speech in audio-recorded verbal communication, and 2) develop machine learning (ML) classifiers to effectively differentiate between patient and nurse language. MATERIALS AND METHODS: Pilot studies were conducted at VNS Health, the largest not-for-profit home healthcare agency in the United States, to optimize audio-recording patient-nurse interactions. We recorded and transcribed 46 interactions, resulting in 3494 "utterances" that were annotated to identify the speaker. We employed natural language processing techniques to generate linguistic features and built various ML classifiers to distinguish between patient and nurse language at both individual and encounter levels. RESULTS: A support vector machine classifier trained on selected linguistic features from term frequency-inverse document frequency, Linguistic Inquiry and Word Count, Word2Vec, and Medical Concepts in the Unified Medical Language System achieved the highest performance with an AUC-ROC = 99.01 ± 1.97 and an F1-score = 96.82 ± 4.1. The analysis revealed patients' tendency to use informal language and keywords related to "religion," "home," and "money," while nurses utilized more complex sentences focusing on health-related matters and medical issues and were more likely to ask questions. CONCLUSION: The methods and analytical approach we developed to differentiate patient and nurse language is an important precursor for downstream tasks that aim to analyze patient speech to identify patients at risk of disease and negative health outcomes.

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.

Online and In-Person Learning Preferences during the COVID-19 Pandemic among Students Attending the City University of New York.

The widespread disease outbreak of SARS-CoV-2 in early 2020 elicited mandated shutdowns of all facilities not considered essential to include academic institutions. Many educational institutions had to find a way to transition into online learning modalities rapidly. This study investigates whether a relationship between students' perceptions of online learning and their academic achievement during the coronavirus outbreak exists. We hypothesized that (i) students would rate the online modality more negatively than the in-person module, (ii) STEM courses would be rated more negatively than non-STEM courses, and (iii) there was a positive correlation between grades achieved and student perceptions of the online course modality. The study found that students rated online courses more negatively than in-person courses. There were significant differences in student achievement and perception based on the course type. The study found a weak yet positive relationship between student achievement and perception of learning modality. Future studies should continue to evaluate the effects of mandated online learning on the mastery and achievement of learning outcomes. The implications from these findings can help institutions improve e-learning modules.

Do nurses document all discussions of patient problems and nursing interventions in the electronic health record? A pilot study in home healthcare.

Objective: To assess the overlap of information between electronic health record (EHR) and patient-nurse verbal communication in home healthcare (HHC). Methods: Patient-nurse verbal communications during home visits were recorded between February 16, 2021 and September 2, 2021 with patients being served in an organization located in the Northeast United States. Twenty-two audio recordings for 15 patients were transcribed. To compare overlap of information, manual annotations of problems and interventions were made on transcriptions as well as information from EHR including structured data and clinical notes corresponding to HHC visits. Results: About 30% (1534/5118) of utterances (ie, spoken language preceding/following silence or a change of speaker) were identified as including problems or interventions. A total of 216 problems and 492 interventions were identified through verbal communication among all the patients in the study. Approximately 50.5% of the problems and 20.8% of the interventions discussed during the verbal communication were not documented in the EHR. Preliminary results showed that statistical differences between racial groups were observed in a comparison of problems and interventions. Discussion: This study was the first to investigate the extent that problems and interventions were mentioned in patient-nurse verbal communication during HHC visits and whether this information was documented in EHR. Our analysis identified gaps in information overlap and possible racial disparities. Conclusion: Our results highlight the value of analyzing communications between HHC patients and nurses. Future studies should explore ways to capture information in verbal communication using automated speech recognition.

Audio Recording Patient-Nurse Verbal Communications in Home Health Care Settings: Pilot Feasibility and Usability Study.

BACKGROUND: Patients' spontaneous speech can act as a biomarker for identifying pathological entities, such as mental illness. Despite this potential, audio recording patients' spontaneous speech is not part of clinical workflows, and health care organizations often do not have dedicated policies regarding the audio recording of clinical encounters. No previous studies have investigated the best practical approach for integrating audio recording of patient-clinician encounters into clinical workflows, particularly in the home health care (HHC) setting. OBJECTIVE: This study aimed to evaluate the functionality and usability of several audio-recording devices for the audio recording of patient-nurse verbal communications in the HHC settings and elicit HHC stakeholder (patients and nurses) perspectives about the facilitators of and barriers to integrating audio recordings into clinical workflows. METHODS: This study was conducted at a large urban HHC agency located in New York, United States. We evaluated the usability and functionality of 7 audio-recording devices in a laboratory (controlled) setting. A total of 3 devices-Saramonic Blink500, Sony ICD-TX6, and Black Vox 365-were further evaluated in a clinical setting (patients' homes) by HHC nurses who completed the System Usability Scale questionnaire and participated in a short, structured interview to elicit feedback about each device. We also evaluated the accuracy of the automatic transcription of audio-recorded encounters for the 3 devices using the Amazon Web Service Transcribe. Word error rate was used to measure the accuracy of automated speech transcription. To understand the facilitators of and barriers to integrating audio recording of encounters into clinical workflows, we conducted semistructured interviews with 3 HHC nurses and 10 HHC patients. Thematic analysis was used to analyze the transcribed interviews. RESULTS: Saramonic Blink500 received the best overall evaluation score. The System Usability Scale score and word error rate for Saramonic Blink500 were 65% and 26%, respectively, and nurses found it easier to approach patients using this device than with the other 2 devices. Overall, patients found the process of audio recording to be satisfactory and convenient, with minimal impact on their communication with nurses. Although, in general, nurses also found the process easy to learn and satisfactory, they suggested that the audio recording of HHC encounters can affect their communication patterns. In addition, nurses were not aware of the potential to use audio-recorded encounters to improve health care services. Nurses also indicated that they would need to involve their managers to determine how audio recordings could be integrated into their clinical workflows and for any ongoing use of audio recordings during patient care management. CONCLUSIONS: This study established the feasibility of audio recording HHC patient-nurse encounters. Training HHC nurses about the importance of the audio-recording process and the support of clinical managers are essential factors for successful implementation.