RESUMEN
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.
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Cuidados Posteriores/métodos , Cuidados de Enfermería en el Hogar/métodos , Sepsis/terapia , Anciano , Protocolos Clínicos , Femenino , Humanos , Masculino , Alta del Paciente , Resultado del TratamientoRESUMEN
The purpose of the study was to obtain exploratory, descriptive information that would provide insights into the barriers to and facilitators of the implementation of fall prevention programs in home care settings. The study employed a qualitative approach through a series of focus groups with home care providers who work with patients with diabetes (N = 29). The study identified teamwork, resistance to change, and patient's readiness as major factors in fall prevention practice at home care. Understanding health-care providers' experiences with fall prevention in home care settings has the potential to facilitate better translation of evidence to practice for community-dwelling older adults.
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Accidentes por Caídas/prevención & control , Competencia Clínica/normas , Práctica Clínica Basada en la Evidencia/normas , Personal de Salud/normas , Servicios de Atención de Salud a Domicilio/normas , Guías de Práctica Clínica como Asunto , Investigación Biomédica Traslacional , Adulto , Femenino , Grupos Focales , Humanos , Masculino , Persona de Mediana Edad , Investigación CualitativaRESUMEN
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.
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Cuidados de Enfermería en el Hogar/métodos , Readmisión del Paciente , Actividades Cotidianas , Agencias de Atención a Domicilio/economía , Agencias de Atención a Domicilio/tendencias , Cuidados de Enfermería en el Hogar/economía , Visita Domiciliaria/economía , Visita Domiciliaria/tendencias , Humanos , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricosRESUMEN
Pain is a common problem for patients receiving home care, often limiting mobility and contributing to functional decline. Pharmacological pain management is common, but all drugs bring some risk of side effects and adverse reactions. The opioid epidemic has brought into question analgesic prescribing patterns across all care settings. This study, which used data collected between 2012 and 2014, examines the pain medications used by older adults with activity-limiting pain receiving home care physical therapy in a large metropolitan home care agency. Eighty-five percent of subjects took at least one analgesic medication on admission to home care, and of these, 51.3% were using an opioid, 33.1% used acetaminophen, and 23.2% used nonsteroidal anti-inflammatory drugs (NSAIDs). At the 60-day follow-up, the most common medication classes taken by participants included acetaminophen (38%), opioids (35.9%), and NSAIDs (31.6%). We found racial/ethnic differences in analgesic use at baseline but not at follow-up. At baseline, analgesic use differed by pain type, but there were no differences at follow-up. The high use of medications to control pain by patients receiving home care, particularly opioid use, underscores the importance of providers being alert to potential adverse drug reactions.
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Analgésicos no Narcóticos/uso terapéutico , Analgésicos/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Servicios de Atención de Salud a Domicilio/organización & administración , Manejo del Dolor/estadística & datos numéricos , Dolor/tratamiento farmacológico , Acetaminofén/uso terapéutico , Anciano , Analgésicos Opioides/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/epidemiologíaRESUMEN
Infection prevention is a high priority for home healthcare (HHC), but tools are lacking to identify patients at highest risk of developing infections. The purpose of this study was to develop and test a predictive risk model to identify HHC patients at risk of an infection-related hospitalization or emergency department visit. A nonexperimental study using secondary data was conducted. The Outcome and Assessment Information Set linked with relevant clinical data from 112,788 HHC admissions in 2014 was used for model development (70% of data) and testing (30%). A total of 1,908 patients (1.69%) were hospitalized or received emergency care associated with infection. Stepwise logistic regression models discriminated between individuals with and without infections. Our final model, when classified by highest risk of infection, identified a high portion of those who were hospitalized or received emergent care for an infection while also correctly categorizing 90.5% of patients without infection. The risk model can be used by clinicians to inform care planning. This is the first study to develop a tool for predicting infection risk that can be used to inform how to direct additional infection control intervention resources on high-risk patients, potentially reducing infection-related hospitalizations, emergency department visits, and costs.
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Servicios Médicos de Urgencia/estadística & datos numéricos , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Infecciones/diagnóstico , Infecciones/terapia , Medición de Riesgo/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Importance: Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. Objective: To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. Design, Setting, and Participants: This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. Exposures: Sepsis hospital discharge and 1 or more home health assessments within 1 week. Main Outcomes and Measures: Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. Results: Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001). Conclusions and Relevance: The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.
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Sepsis/epidemiología , Sobrevivientes/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Humanos , Masculino , Medicare/estadística & datos numéricos , Mortalidad , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
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.
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Servicios de Atención de Salud a Domicilio , Readmisión del Paciente , Sepsis , Sobrevivientes , Cuidado de Transición , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Medicare , Persona de Mediana Edad , Alta del Paciente , Factores de Riesgo , Factores de Tiempo , Estados UnidosRESUMEN
BACKGROUND/OBJECTIVES: New or worsened disabilities in functional, cognitive, or mental health following an intensive care unit (ICU) stay are referred to as post-intensive care syndrome (PICS). PICS has not been described in older adults receiving home care. Our aim was to examine the relationship between length of ICU stay and PICS among older adults receiving home care. We expected that patients in the ICU for 3 days or longer would demonstrate significantly more disability in all three domains on follow-up than those not in the ICU. A secondary aim was to identify patient characteristics increasing the odds of disability. DESIGN: Retrospective cohort study. SETTING: Hospitalization for sepsis in the United States. PARTICIPANTS: A total of 21 520 Medicare patients receiving home care and reassessed a median of 1 day (interquartile range 1-2 d) after hospital discharge. MEASUREMENTS: PICS was defined as a decline or worsening in one or more of 16 indicators tested before and after hospitalization using OASIS (Home Health Outcome and Assessment Information Set) and Medicare claims data. RESULTS: The sample was predominantly female and white. All had sepsis, and most (81.8%) had severe sepsis. In adjusted models, an ICU stay of 3 days or longer, compared with no ICU stay, increased the odds of physical disability. Overall, the declines were modest and found in specific activities of daily living (16% for feeding and lower body dressing to 26% for oral medicine management). No changes were identified in cognition or mental health. Significant determinants of new or worsened physical disabilities were sepsis severity, older age, depression, frailty, and dementia. CONCLUSION: Older adults receiving home care who develop sepsis and are in an ICU for 3 days or longer are likely to develop new or worsened physical disabilities. Whether these disabilities remain after the early postdischarge phase requires further study. J Am Geriatr Soc 67:520-526, 2019.
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Actividades Cotidianas , Cuidados Posteriores , Cuidados Críticos/métodos , Evaluación de la Discapacidad , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Rendimiento Físico Funcional , Sepsis , Cuidados Posteriores/métodos , Cuidados Posteriores/psicología , Cuidados Posteriores/estadística & datos numéricos , Anciano , Cognición , Femenino , Evaluación Geriátrica/métodos , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Alta del Paciente/estadística & datos numéricos , Factores de Riesgo , Sepsis/complicaciones , Sepsis/epidemiología , Sepsis/terapia , Sobrevivientes/psicología , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: This study sought to: 1) identify the predictors of hospice enrollment for patients with heart failure (HF); and 2) determine the impact of hospice enrollment on health care use. BACKGROUND: Patients with HF rarely enroll in hospice. Little is known about how hospice affects this group's health care use. METHODS: Using a propensity score-matched sample of Medicare decedents with ≥2 HF discharges within 6 months, an Outcome and Assessment Information Set (OASIS) assessment, and subsequent death, we used Medicare administrative, claims, and patient assessment data to compare hospitalizations, intensive care unit stays, and emergency department visits for those beneficiaries who enrolled in hospice and those who did not. RESULTS: The propensity score-matched sample included 3,067 beneficiaries in each group with a mean age of 82 years; 53% were female, and 15% were Black, Asian, or Hispanic. For objective 1, there were no differences in the characteristics, symptom burden, or functional status between groups that were associated with hospice enrollment. For objective 2, in the 6 months after the second HF discharge, the hospice group had significantly fewer emergency department visits (2.64 vs. 2.82; p = 0.04), hospital days (3.90 vs. 4.67; p < 0.001), and intensive care unit stays (1.25 vs. 1.51; p < 0.001); they were less likely to die in the hospital (3% vs. 56%; p < 0.001), and they had longer median survival (80 days vs. 71 days; log-rank test p = 0.004). CONCLUSIONS: Beneficiaries' characteristics, including symptom burden and functional status, do not predict hospice enrollment. Those patients who enrolled in hospice used less health care, survived longer, and were less likely to die in the hospital. A tailored hospice model may be needed to increase enrollment and offer benefits to patients with HF.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Insuficiencia Cardíaca/terapia , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Actividades Cotidianas , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Demencia/epidemiología , Femenino , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Humanos , Renta , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Tasa de SupervivenciaRESUMEN
Risk adjustment is a critical tool in public reporting of quality measures. Its aim is to level the playing field so that providers serving different patients can be meaningfully compared. We used a theory and evidence-based approach to develop risk-adjustment models for the 10 publicly reported home health quality measures and compared their performance with current models developed using a data-driven stepwise approach. Overall, the quality ratings for most agencies were similar regardless of approach. Theory and evidence-based models have the potential to simplify risk adjustment, and thereby improve provider and consumer understanding and confidence in public reporting.
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Agencias de Atención a Domicilio/normas , Medicare/normas , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Ajuste de Riesgo/métodos , Anciano , Benchmarking , Certificación , Investigación sobre Servicios de Salud , Agencias de Atención a Domicilio/estadística & datos numéricos , Humanos , Difusión de la Información , Notificación Obligatoria , Estados UnidosRESUMEN
Research on African American and white attitudes, perceptions, and knowledge of hospice care has focused predominantly on patients and providers in institutions and community-based care settings. Little is known about patients receiving home health services, despite growing trends toward noninstitutional care in the United States. This study of home health clients who are eligible for hospice, but not currently receiving it, found few differences between racial groups with regard to attitudes about end-of-life care. An alarming proportion of African American and white home health clients held erroneous ideas about hospice care and had not discussed this option with their providers. These findings suggest that increased referrals to home-based hospice care among home health clients depend on the availability and professional dissemination of accurate, spiritually sensitive information.
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Actitud Frente a la Salud/etnología , Negro o Afroamericano/etnología , Hispánicos o Latinos/etnología , Servicios de Atención de Salud a Domicilio/organización & administración , Cuidados Paliativos al Final de la Vida , Población Blanca/etnología , Negro o Afroamericano/educación , Anciano , Actitud del Personal de Salud , Conducta de Elección , Comunicación , Enfermería en Salud Comunitaria/organización & administración , Femenino , Conocimientos, Actitudes y Práctica en Salud , Accesibilidad a los Servicios de Salud , Necesidades y Demandas de Servicios de Salud , Hispánicos o Latinos/educación , Cuidados Paliativos al Final de la Vida/organización & administración , Cuidados Paliativos al Final de la Vida/psicología , Humanos , Masculino , Persona de Mediana Edad , New York , Relaciones Enfermero-Paciente , Investigación Metodológica en Enfermería , Evaluación de Resultado en la Atención de Salud , Religión y Psicología , Población Blanca/educaciónRESUMEN
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.
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Insuficiencia Cardíaca/terapia , Servicios de Atención de Salud a Domicilio , Servicios de Enfermería , Alta del Paciente , Readmisión del Paciente/tendencias , Pautas de la Práctica en Medicina , Cuidado de Transición , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Calidad de la Atención de SaludRESUMEN
OBJECTIVES: To describe racial/ethnic group differences in pain presentation and the prevalence of psychosocial factors among patients admitted to home health care, and to determine the extent of racial/ethnic group differences in the association of psychosocial factors with pain intensity and pain-related disability. METHODS: We analyzed cross-sectional data on 588 patients with activity-limiting pain admitted to home care for physical therapy. Three psychosocial factors were assessed: depressive symptoms, pain self-efficacy, and health literacy. Statistical methods included estimation of general linear models of pain intensity and pain-related disability. RESULTS: Hispanics and non-Hispanic blacks report a greater number of pain sites, worse pain intensity, and higher levels of pain-related disability than non-Hispanic whites and others. Racial/ethnic minority group patients also have a higher prevalence of adverse psychosocial factors than others, with evidence that race/ethnicity interacts with pain self-efficacy and depressive symptoms in their association with mean pain intensity and pain-related disability, respectively. DISCUSSION: The substantial racial/ethnic difference in the psychosocial profiles of older adults with activity-limiting pain highlights the importance of screening for these modifiable risk factors and tailoring interventions accordingly. Direct attention to the psychosocial needs of patients could help to address racial/ethnic disparities in pain outcomes.
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Disparidades en Atención de Salud/etnología , Servicios de Atención de Salud a Domicilio , Dolor/etnología , Modalidades de Fisioterapia , Anciano , Estudios Transversales , Depresión/etnología , Evaluación de la Discapacidad , Femenino , Humanos , Masculino , Dolor/psicología , Manejo del Dolor , Prevalencia , Estudios Prospectivos , AutoeficaciaRESUMEN
OBJECTIVES: To determine the effectiveness of a cognitive-behavioral pain self-management (CBPSM) protocol delivered by physical therapists (PTs) for use by older adults with activity-limiting pain receiving home care. DESIGN: A randomized pragmatic trial comparing delivery of the intervention plus usual care with usual care alone. SETTING: Community. PARTICIPANTS: Individuals aged 55 and older admitted with orders for physical therapy who endorsed activity-limiting pain and reported pain scores of 3 or greater on a scale from 0 to 10 (N = 588). INTERVENTION: A CBPSM protocol delivered by PTs. MEASUREMENTS: Primary outcomes were assessed at 60 days using validated measures of pain-related disability, pain intensity, gait speed, and number of activity of daily living (ADL) deficits. RESULTS: Of 588 participants, 285 received care from a PT randomized to the intervention and 303 from a PT randomized to the usual care group. Both groups had significant reductions in pain-related disability, pain intensity, and ADL limitations and improved gait speed. No significant treatment differences were identified. There were no consistent treatment differences when interactions and subgroups were examined. CONCLUSION: This real-world pragmatic trial found no effect of implementation of a pain self-management intervention in a home care setting. Despite the lack of positive findings, future studies are indicated to determine how similar protocols that have been found to be effective in efficacy studies can be successfully implemented in routine clinical care.
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Servicios de Atención de Salud a Domicilio , Manejo del Dolor/métodos , Autocuidado/métodos , Actividades Cotidianas , Humanos , Modalidades de Fisioterapia , Encuestas y CuestionariosRESUMEN
Activity-limiting pain is common among older home care patients and pain management is complicated by the high prevalence of physical frailty and multimorbidity in the home care population. A comparative effectiveness study was undertaken at a large urban home care agency to examine an evidence-based pain self-management program delivered by physical therapists (PTs). This article focuses on PT training, methods implemented to reinforce content after training and to encourage uptake of the program with appropriate patients, and therapists' fidelity to the program. Seventeen physical therapy teams were included in the cluster randomized controlled trial, with 8 teams (155 PTs) assigned to a control and 9 teams (165 PTs) assigned to a treatment arm. Treatment therapists received interactive training over two sessions, with a follow-up session 6 months later. Additional support was provided via emails, e-learning materials including videos, and a therapist manual. Program fidelity was assessed by examining PT pain documentation in the agency's electronic health record. PT feedback on the program was obtained via semistructured surveys. There were no between-group differences in the number of PTs documenting program elements with the exception of instruction in the use of imagery, which was documented by a higher percentage of intervention therapists (p = 0.002). PTs felt comfortable teaching the program elements, but cited time as the biggest barrier to implementing the protocol. Possible explanations for study results suggesting limited adherence to the program protocol by intervention-group PTs include the top-down implementation strategy, competing organizational priorities, program complexity, competing patient priorities, and inadequate patient buy-in. Implications for the implementation of complex new programs in the home healthcare setting are discussed.
Asunto(s)
Medicina Basada en la Evidencia/métodos , Servicios de Atención de Salud a Domicilio/organización & administración , Capacitación en Servicio/métodos , Manejo del Dolor/métodos , Modalidades de Fisioterapia/enfermería , Adulto , Anciano , Competencia Clínica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modalidades de Fisioterapia/educaciónRESUMEN
Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in hospital readmission rates. Database searches yielded 950 potential articles, of which 34 studies met inclusion criteria. Patient characteristics generally have a very modest effect on all-cause or heart failure-related readmission within 7 to 180 days of index hospital discharge. A range of cardiac diseases and other comorbidities only minimally increase readmission rates. No single patient characteristic stands out as a key contributor across multiple studies underscoring the challenge of developing successful interventions to reduce readmissions. Interventions may need to be general in design with the specific intervention depending on each patient's unique clinical profile.
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Insuficiencia Cardíaca/terapia , Readmisión del Paciente/estadística & datos numéricos , Humanos , Pacientes , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
The purpose of this randomized, controlled, home care intervention was to test the effectiveness of two nurse-targeted, e-mail-based interventions to increase home care nurses' adherence to pain assessment and management guidelines, and to improve patient outcomes. Nurses from a large urban non-profit home care organization were assigned to usual care or one of two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcomes measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized nursing workforce with limited recent exposure to state-of-the-art pain management practices.
Asunto(s)
Medicina Basada en la Evidencia/métodos , Servicios de Atención de Salud a Domicilio , Enfermeras y Enfermeros/psicología , Cuidados Paliativos , Pacientes/psicología , Sistemas Recordatorios , Adulto , Anciano , Femenino , Humanos , Internet , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
OBJECTIVE: To assess the impact and cost-effectiveness of two information-based provider reminder interventions designed to improve self-care management and outcomes of heart failure (HF) patients. DATA SOURCES/STUDY SETTING: Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF. STUDY DESIGN: Patients were treated by nurses randomly assigned to usual care or one of two intervention groups. The basic intervention was an e-mail to the patient's nurse highlighting six HF-specific clinical recommendations. The augmented intervention supplemented the initial nurse reminder with additional clinician and patient resources. DATA COLLECTION: Patient interviews were conducted 45 days post admission to measure self-management behaviors, HF-specific outcomes (Kansas City Cardiomyopathy Questionnaire-KCCQ), health-related quality of life (EuroQoL), and service use. PRINCIPAL FINDINGS: Both interventions improved the mean KCCQ summary score (15.3 and 12.9 percent, respectively) relative to usual care (p< or =.05). The basic intervention also yielded a higher EuroQoL score relative to usual care (p< or =.05). In addition, the interventions had a positive impact on medication knowledge, diet, and weight monitoring. The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes. CONCLUSIONS: This study demonstrates the positive impact of targeting evidence-based computer reminders to home health nurses to improve patient self-care behaviors, knowledge, and clinical outcomes. It also advances the field's limited understanding of the cost-effectiveness of selected strategies for translating research into practice.
Asunto(s)
Enfermería en Salud Comunitaria/normas , Manejo de la Enfermedad , Correo Electrónico , Medicina Basada en la Evidencia , Insuficiencia Cardíaca/prevención & control , Servicios de Atención de Salud a Domicilio/normas , Evaluación de Procesos y Resultados en Atención de Salud , Guías de Práctica Clínica como Asunto , Sistemas Recordatorios , Adulto , Anciano , Anciano de 80 o más Años , Difusión de Innovaciones , Femenino , Conocimientos, Actitudes y Práctica en Salud , Insuficiencia Cardíaca/enfermería , Insuficiencia Cardíaca/psicología , Humanos , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto , Autocuidado , Estados UnidosRESUMEN
OBJECTIVE: To test the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses caring for heart failure (HF) patients. DATA SOURCES/STUDY SETTING: Information on nurse practices was abstracted from the clinical records of patients admitted between June 2000 and November 2001 to the care of 354 study nurses at a large, urban, nonprofit home care agency. STUDY DESIGN: The study employed a randomized design with nurses assigned to usual care or one of two intervention groups upon identification of an eligible patient. The basic intervention was a one-time e-mail reminder highlighting six HF-specific clinical recommendations. The augmented intervention consisted of the initial e-mail reminder supplemented by provider prompts, patient education material, and clinical nurse specialist outreach. DATA COLLECTION: At each home health visit provided by a study nurse to an eligible HF patient during the 45-day follow-up period, a structured chart abstraction tool was used to collect information on whether the nurse provided the care practices highlighted in the e-mail reminder. PRINCIPAL FINDINGS: Both the basic and the augmented interventions greatly increased the practice of evidence-based care, according to patient records, in the areas of patient assessment and instructions about HF disease management. While not all results were statistically significant at conventional levels, intervention effects were positive in virtually all cases and effect magnitudes frequently were large. CONCLUSIONS: The results of this randomized trial strongly support the efficacy of just-in-time evidence-based reminders as a means of changing clinical practice among home health nurses who are geographically dispersed and spend much of their time in the field.
Asunto(s)
Enfermería en Salud Comunitaria/normas , Manejo de la Enfermedad , Correo Electrónico , Medicina Basada en la Evidencia , Insuficiencia Cardíaca/enfermería , Servicios de Atención de Salud a Domicilio/normas , Guías de Práctica Clínica como Asunto , Sistemas Recordatorios , Adulto , Difusión de Innovaciones , Femenino , Adhesión a Directriz , Humanos , Masculino , Persona de Mediana Edad , Enfermeras Clínicas/normas , Educación del Paciente como AsuntoRESUMEN
The Balanced Budget Act of 1997 mandated a major overhaul in Medicare payment for home health care with an interim payment system (IPS) preceding a prospective payment system (PPS). This study extends an earlier analysis of the impact of the IPS to determine whether home health use and spendingtrends changed after the introduction of the PPS. The rapid decline in the incidence of use and visits per user under the IPS slowed in its final year and then picked up again in the first year of the PPS. In addition, average payment per visit increased sharply under the PPS. Little is known about the impact of continued large reductions in home health services since 1999.