Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic.

BACKGROUND: Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation. OBJECTIVE: To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system. DESIGN: Prospective case series. SETTING: Atrium Health, a large integrated health care organization in the southeastern United States. PATIENTS: 1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH. INTERVENTION: A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19. MEASUREMENTS: Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data. RESULTS: 1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission. LIMITATION: Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols. CONCLUSION: Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond. PRIMARY FUNDING SOURCE: Atrium Health.

Capturing At-Home Health and Care Information for Children With Medical Complexity Using Voice Interactive Technologies: Multi-Stakeholder Viewpoint.

Digital health tools and technologies are transforming health care and making significant impacts on how health and care information are collected, used, and shared to achieve best outcomes. As most of the efforts are still focused on clinical settings, the wealth of health information generated outside of clinical settings is not being fully tapped. This is especially true for children with medical complexity (CMC) and their families, as they frequently spend significant hours providing hands-on medical care within the home setting and coordinating activities among multiple providers and other caregivers. In this paper, a multidisciplinary team of stakeholders discusses the value of health information generated at home, how technology can enhance care coordination, and challenges of technology adoption from a patient-centered perspective. Voice interactive technology has been identified to have the potential to transform care coordination for CMC. This paper shares opinions on the promises, limitations, recommended approaches, and challenges of adopting voice technology in health care, especially for the targeted patient population of CMC.

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.

Supporting older people with multimorbidity: The care burden of home health-care assistants in Ireland.

The treatment burden inherent in self-managing multiple chronic conditions (multimorbidity) is recognized, but there has been little examination of the care burden experienced by paid home health-care assistants (HCAs) who support older people with multimorbidity. Focus groups were conducted with HCAs in Ireland and data were coded using a thematic analysis approach. Care burden of HCAs was linked with lack of knowledge and information, poor communication, insufficient time and resources, gaps in medication support and work-related stress. Strategies are required to reduce the care burden of HCAs, who are essential stakeholders supporting growing numbers of older people with multimorbidity.

Conceptualisations on home care for pressure ulcers in Spain: perspectives of patients and their caregivers.

BACKGROUND: Pressure ulcers represent an important worldwide public health problem, which substantially decrease the quality of life of those affected. Yet, few studies to date have analysed the perceptions regarding home care for pressure ulcers. AIMS: To explore the conceptualisations regarding home care of pressure ulcers from the perspective of affected patients and their caregivers. METHODS: A qualitative study design based on Grounded Theory. In-depth interviews were conducted on a theoretical sample of 10 people currently suffering from a pressure ulcer, or who had experienced one in the past, and 15 caregivers of patients who had suffered from this pathology, all of whom came from the four health districts of Puertollano (Ciudad Real, Spain). FINDINGS: Two categories emerged to explain the conceptualisations regarding pressure ulcers: (a) Cause of the pressure ulcer with three subcategories (unavoidable injuries, caregiver's lack of knowledge and painful wounds) and (b) Preferences regarding caring for pressure ulcers with two subcategories (home care as the best approach to treatment and noninstitutionalisation). CONCLUSIONS: This research provides a novel perspective on the specific problems surrounding home care for pressure ulcers, including the perceptions of both patients and their caregivers. It is important to give a voice to patients and their caregivers as this will help understand their needs and improve the care provided. Further studies are required to improve current treatment protocols and clinical practice guidelines for the prevention and treatment of this pathology.

Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care.

Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them. We conducted 10 observations of home care agency admissions with five admission nurses in rural Pennsylvania. We collected screenshots and recorded the admission process. We asked the nurses questions outside the point of care. We coded the nurses' strategies at the data-entry screen level. Using thematic analysis, we investigated the influence of nursing goals on documentation strategies. Subject matter experts reviewed our findings. Several goals affect nurses' documentation strategies: ensure data accuracy, reduce time in the patient's home, and prevent infection. Home care admission nurses distribute the electronic documentation temporally due to their goals. Nurses developed memory aids to support completion of the documentation after leaving the patients' homes. Design and training should support the distributed manner in which home care nurses document patient encounters.

'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.

Home Health Nurses' Perspectives and Care Processes Related to Older Persons with Frailty and Depression: A Mixed Method Pilot Study.

The objectives of this study were (1) to describe home health care (HHC) nurses' perception of and care processes related to geriatric depression and frailty, and (2) to identify barriers to care delivery for older persons with these two conditions. Ten semi-structured interviews were conducted with HHC nurses, and 16 HHC nursing visits to 16 older patients (≥65 years) were observed. Mixed method analysis showed that HHC nurses did not routinely assess for frailty and depression. Major barriers to care delivery included insufficient training, documentation burden, limited reimbursement, and high caseload. Addressing these barriers would facilitate HHC nursing care for frail, depressed elders.

Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials.

BACKGROUND: We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types. METHODS AND RESULTS: Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112-1605) of follow-up, 218 patients died and 17 917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2-92.0] versus 87.2% [95% confidence interval, 85.1-89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50-0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0-1.3] versus 0.36 [0-2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%-65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%-61%). CONCLUSIONS: These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease. CLINICAL TRIAL REGISTRATION: URL: http://www.anzctr.org.au. Unique identifiers: 12610000221055, 12608000022369, 12607000069459.

Fistula Isolation and the Use of Negative Pressure to Promote Wound Healing: A Case Study.

BACKGROUND: A 54-year-old morbidly obese woman with a small bowel obstruction and large ventral hernia was admitted to hospital. She underwent an exploratory laparotomy, lysis of adhesions, and ventral hernia repair with mesh placement. She subsequently developed an enteroatmospheric fistula; several months of hospital care was required to effectively manage the wound and contain effluent from the fistula. METHODS: Several approaches were used to manage output from the fistula during her hospital course. She was initially discharged to a skilled nursing facility where a fistula management pouch was used for several months to encompass the wound and contain effluent, but this method ultimately proved ineffective. The fistula was then isolated using a collapsible enteroatmospheric fistula isolation device and an ostomy appliance to contain effluent. CONCLUSION: The application of the collapsible enteroatmospheric fistula isolation and effluent containment devices in conjunction with negative-pressure wound therapy produced positive patient outcomes; it improved patient satisfaction with fistula management, promoted wound healing, and diminished cost.

The future of community nursing: Hospital in the Home.

With an increasing ageing population who often have multiple long-term conditions, there is a growing need to provide an alternative type of care to the traditional hospital-based model. 'Hospital in the Home' is a model that provides integrated care for patients in their home. The @home service was established in 2013 by Guy's and St Thomas' NHS Foundation Trust. The service provides health care in patients' home, supporting early discharge from hospital as well as preventing avoidable admissions and readmissions saving valuable hospital bed days and reducing length of stay. This article describes the service available with the use of a case study of a 78-year-old lady who was referred by the London Ambulance Service with exacerbation of chronic obstructive pulmonary disease (COPD). This case study highlights the ability to assess, treat and manage an acutely unwell patient with newly diagnosed heart failure in the community without the need for hospitalisation. This type of integrated care model with a multidisciplinary team is a feasible alternative to the traditional models of care in both the acute and community settings.

Encouraging Patient Portal Use in the Patient-Centered Medical Home: Three Stakeholder Perspectives.

BACKGROUND: Health care organizations are increasingly offering patients access to their electronic medical record and the ability to communicate with their providers through Web-based patient portals, thus playing a prominent role within the patient-centered medical home (PCMH). However, despite enthusiasm, adoption remains low. OBJECTIVE: We examined factors in the PCMH context that may affect efforts to improve enrollment in a patient portal. METHODS: Using a sociotechnical approach, we conducted qualitative, semistructured interviews with patients and providers from 3 primary care clinics and with national leaders from across a large integrated health care system. RESULTS: We gathered perspectives and analyzed data from 4 patient focus groups and one-on-one interviews with 1 provider from each of 3 primary care clinics and 10 program leaders. We found that leaders were focused on marketing in primary care, whereas patients and providers were often already aware of the portal. In contrast, both patients and providers cited administrative and logistical barriers impeding enrollment. Further, although leadership saw the PCMH as the logical place to focus enrollment efforts, providers and patients were more circumspect and expressed concern about how the patient portal would affect their practice and experience of care. Further, some providers expressed ambivalence about patients using the portal. Despite absence of consensus on how and where to encourage portal adoption, there was wide agreement that promoting enrollment was a worthwhile goal. CONCLUSIONS: Patients, clinicians, and national leaders agreed that efforts were needed to increase enrollment in the patient portal. Opinions diverged regarding the suitability of the PCMH and, specifically, the primary care clinic for promoting patient portal enrollment. Policymakers should consider diverse stakeholder perspectives in advance of interventions to increase technology adoption.

Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting.

OBJECTIVES: We evaluated whether a brief, universal, postnatal nurse home-visiting intervention can be implemented with high penetration and fidelity, prevent emergency health care services, and promote positive parenting by infant age 6 months. METHODS: Durham Connects is a manualized 4- to 7-session program to assess family needs and connect parents with community resources to improve infant health and well-being. All 4777 resident births in Durham, North Carolina, between July 1, 2009, and December 31, 2010, were randomly assigned to intervention and control conditions. A random, representative subset of 549 families received blinded interviews for impact evaluation. RESULTS: Of all families, 80% initiated participation; adherence was 84%. Hospital records indicated that Durham Connects infants had 59% fewer infant emergency medical care episodes than did control infants. Durham Connects mothers reported fewer infant emergency care episodes and more community connections, more positive parenting behaviors, participation in higher quality out-of-home child care, and lower rates of anxiety than control mothers. Blinded observers reported higher quality home environments for Durham Connects than for control families. CONCLUSIONS: A brief universal home-visiting program implemented with high penetration and fidelity can lower costly emergency medical care and improve family outcomes.

Effect of maternal-child home visitation on pregnancy spacing for first-time Latina mothers.

OBJECTIVES: We examined the impact of a maternal-child home visitation program on birth spacing for first-time Latina mothers, focusing on adolescents and women who identified as Mexican or Puerto Rican. METHODS: This was a retrospective cohort study. One thousand Latina women enrolled in the Pennsylvania Nurse-Family Partnership between January 1, 2003, and December 31, 2007, were matched to nonenrolled Latina women using propensity scores. The primary outcome was the time to second pregnancy that resulted in a live birth (interpregnancy interval). Proportional hazards models and bootstrap methods compared the time to event. RESULTS: Home visitation was associated with a small decrease in the risk of a short interpregnancy interval (≤ 18 months) among Latina women (hazards ratio [HR] = 0.86; 95% confidence interval [CI] = 0.75, 0.99). This effect was driven by outcomes among younger adolescent women (HR = 0.80; 95% CI = 0.65, 0.96). There was also a trend toward significance for women of Mexican heritage (HR = 0.74; 95% CI = 0.49, 1.07), although this effect might be attributed to individual agency performance. CONCLUSIONS: Home visitation using the Nurse-Family Partnership model had measurable effects on birth spacing in Latina women.

Use of home telemonitoring to support multidisciplinary care of heart failure patients in Finland: randomized controlled trial.

BACKGROUND: Heart failure (HF) patients suffer from frequent and repeated hospitalizations, causing a substantial economic burden on society. Hospitalizations can be reduced considerably by better compliance with self-care. Home telemonitoring has the potential to boost patients' compliance with self-care, although the results are still contradictory. OBJECTIVE: A randomized controlled trial was conducted in order to study whether the multidisciplinary care of heart failure patients promoted with telemonitoring leads to decreased HF-related hospitalization. METHODS: HF patients were eligible whose left ventricular ejection fraction was lower than 35%, NYHA functional class ≥2, and who needed regular follow-up. Patients in the telemonitoring group (n=47) measured their body weight, blood pressure, and pulse and answered symptom-related questions on a weekly basis, reporting their values to the heart failure nurse using a mobile phone app. The heart failure nurse followed the status of patients weekly and if necessary contacted the patient. The primary outcome was the number of HF-related hospital days. Control patients (n=47) received multidisciplinary treatment according to standard practices. Patients' clinical status, use of health care resources, adherence, and user experience from the patients' and the health care professionals' perspective were studied. RESULTS: Adherence, calculated as a proportion of weekly submitted self-measurements, was close to 90%. No difference was found in the number of HF-related hospital days (incidence rate ratio [IRR]=0.812, P=.351), which was the primary outcome. The intervention group used more health care resources: they paid an increased number of visits to the nurse (IRR=1.73, P<.001), spent more time at the nurse reception (mean difference of 48.7 minutes, P<.001), and there was a greater number of telephone contacts between the nurse and intervention patients (IRR=3.82, P<.001 for nurse-induced contacts and IRR=1.63, P=.049 for patient-induced contacts). There were no statistically significant differences in patients' clinical health status or in their self-care behavior. The technology received excellent feedback from the patient and professional side with a high adherence rate throughout the study. CONCLUSIONS: Home telemonitoring did not reduce the number of patients' HF-related hospital days and did not improve the patients' clinical condition. Patients in the telemonitoring group contacted the Cardiology Outpatient Clinic more frequently, and on this way increased the use of health care resources. TRIAL REGISTRATION: Clinicaltrials.gov NCT01759368; http://clinicaltrials.gov/show/NCT01759368 (Archived by WebCite at http://www.webcitation.org/6UFxiCk8Z).

An organizational intervention to influence evidence-informed decision making in home health nursing.

OBJECTIVE: The aims of this study were to field test and evaluate a series of organizational strategies to promote evidence-informed decision making (EIDM) by nurse managers and clinical leaders in home healthcare. BACKGROUND: EIDM is central to delivering high-quality and effective healthcare. Barriers exist and organizational strategies are needed to support EIDM. METHODS: Management and clinical leaders from 4 units participated in a 20-week organization-focused intervention. Preintervention (n = 32) and postintervention (n = 17) surveys and semistructured interviews (n = 15) were completed. RESULTS: Statistically significant increases were found on 4 of 31 survey items reflecting an increased organizational capacity for participants to acquire and apply research evidence in decision making. Support from designated facilitators with advanced skills in finding, appraising, and applying research was the highest rated intervention strategy. CONCLUSIONS: Results are useful to inform the development of organizational infrastructures to increase EIDM capacity in community-based healthcare organizations.

Trials, tribulations, and triumphs of a pilot initiative to optimize the management of wounds complicated by diabetes within the home.

To support home health care nurses in their efforts to optimize the management of patients with wounds complicated by diabetes, an initiative was introduced that incorporated a standardized assessment tool, electronic data entry, and the provision of written treatment recommendations with supporting rationale prepared by nurses with expertise in diabetes and wound care. A pilot study was conducted that provided preliminary evidence of the feasibility of this initiative as well as its potential effect on outcomes for patients, nurses, and the home care program.

Frontloading and intensity of skilled home health visits: a state of the science.

Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home health patients. Upon review of the frontloading evidence, visit intensity emerged as being closely related. This state of the science presents a critique and synthesis of the published empirical evidence related to frontloading and visit intensity. OVID/Medline, PubMed, and Scopus were searched. Seven studies were eligible for inclusion. Further research is required to define frontloading and visit intensity, identify patients most likely to benefit, and to provide a better understanding of how home health agencies can best implement these strategies.

Pilot Study to Determine the Effectiveness of a Home Health Nursing Simulation.

Demand for home care has increased due to the expansion of preventive care, people living longer with chronic conditions, and the need for healthcare services as the baby boom population ages. Nurses must be prepared to meet the needs of patients and families in the home setting. Home care nursing simulations have been utilized as a teaching-learning strategy in baccalaureate nursing education, yet less is known about their use with practicing home care nurses and associate degree nursing students. The purpose of this pilot study using simulation was to prepare practicing nurses and student nurses to respond using nursing skills and clinical judgment. The convenience sample consisted of associate degree nursing students (n = 9), practicing home healthcare nurses (n = 8), and nursing faculty (n = 2). The Simulation Effectiveness Tool - Modified (SET-M) Survey (Leighton et al., 2015) was utilized for data collection. Participants perceived the home healthcare simulation to be an effective practice experience with high overall agreement for Pre-briefing, Scenario-Confidence, Scenario-Learning, and Debriefing. The findings of this study provide data to support partnerships to provide home care simulation experiences for associate degree nursing students and practicing home care nurses.

Medication management at home: enhancing nurse's skills and improving patient satisfaction--a longitudinal study.

The purpose of this longitudinal study was to improve nurse medication management skills during home care (HC) visits, and thus improve care quality and the related patient ratings of nurse performance. Nurses completed presurveys asking how often they asked to see, taught about, and explained side effects of patient medications. Two focus groups were held with HC nurses to determine barriers to provision of such medication interventions, followed by presentation of a series of 5 medication-related educational sessions. HC nurse's surveys 6 months later reveal an increased frequency of medication skill performance, and patient ratings in these same areas improved statistically significantly, nearing or surpassing national benchmarks.