Home Health Care: Nurse-Physician Communication, Patient Severity, and Hospital Readmission.

OBJECTIVE: To evaluate whether communication failures between home health care nurses and physicians during an episode of home care after hospital discharge are associated with hospital readmission, stratified by patients at high and low risk of readmission. DATA SOURCE/STUDY SETTING: We linked Visiting Nurse Services of New York electronic medical records for patients with congestive heart failure in 2008 and 2009 to hospitalization claims data for Medicare fee-for-service beneficiaries. STUDY DESIGN: Linear regression models and a propensity score matching approach were used to assess the relationship between communication failure and 30-day readmission, separately for patients with high-risk and low-risk readmission probabilities. DATA COLLECTION/EXTRACTION METHODS: Natural language processing was applied to free-text data in electronic medical records to identify failures in communication between home health nurses and physicians. PRINCIPAL FINDINGS: Communication failure was associated with a statistically significant 9.7 percentage point increase in the probability of a patient readmission (32.6 percent of the mean) among high-risk patients. CONCLUSIONS: Poor communication between home health nurses and physicians is associated with an increased risk of hospital readmission among high-risk patients. Efforts to reduce readmissions among this population should consider focusing attention on this factor.

Frequency and Risk Factors for Live Discharge from Hospice.

OBJECTIVES: To report frequencies and associated risk factors for 4 distinct causes of live discharge from hospice. DESIGN: Retrospective cohort study using electronic medical records of hospice patients who received care from a large urban not-for-profit hospice agency in New York City during a 3-year period between 2013 and 2015 (n = 9,190). RESULTS: Roughly one in five hospice patients were discharged alive (21%; n = 1911). Acute hospitalization was the most frequent reason for live discharge (42% of all live discharges; n = 802). Additional reasons included elective revocation to resume disease-directed treatments (18%; n = 343), disqualification (14%; n = 271), and service transfers or moves (26%; n = 495). Multinomial logistic regression analyses revealed that risk for acute hospitalization was higher among younger patients (age AOR = 0.98 [95% CI = 0.98-0.99] P < .01), racial/ethnic minorities (Hispanic AOR = 2.23 [CI = 1.82-2.73] P < .001; African American OR = 2.46 [CI = 2.00-3.03] P < .001; Asian/other OR = 1.63 [CI = 1.25-2.11] P < .001), and patients without advance directives (AOR = 1.41 [95% CI = 0.98-0.99] P < .001). Disqualification occurred much more frequently among patients with non-cancer diagnoses, including dementia (AOR = 13.14 [95% CI = 7.96-21.61] P < .001) and pulmonary disease (AOR = 11.68 [95% CI = 6.58-20.74] P < .001). Transfers and service moves were more common among Hispanics (AOR = 1.56 [95% CI = 1.45-2.34] P < .001), African Americans (AOR = 1.35 [95% CI = 1.03-1.79] P < .05), patients without a primary caregiver (AOR = 1.35 [95% CI = 1.09-1.67] P < .001), and those without advance directives (AOR = 1.30 [95% CI = 1.07-1.58] P < .01). CONCLUSION: Further research into factors that underlie live discharge events, especially acute hospitalization, is warranted given their cost and burden for patients/families. Hospices should develop strategies to address acute medical crises and thoroughly evaluate patients' suitability, unmet needs, and knowledge about end-of-life issues at the time of hospice enrollment, especially for those with non-cancer diagnoses.

Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow-Up.

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.

An Exploratory Analysis of Patient-Provider Language-Concordant Home Health Care Visit Patterns.

Approximately one in five households in the United States speaks a language other than English at home. This exploratory, descriptive study sought to examine language-concordant visit patterns in an urban home health care agency serving a diverse and multilingual population. Patient care record data combined with administrative data facilitated the exploratory work. In a 2-year period, results showed that among the 238,513 visits with 18,132 limited English proficiency patients, only 20% of visits were language concordant. The study suggests that home health care services may not be meeting the demand for language services, but more research is needed to determine the right "dose" of bilingual home care visits to optimize home care outcomes and establish a standard for care.

Home-based interventions for black patients with uncontrolled hypertension: a cluster randomized controlled trial.

AIM: Assess the comparative effectiveness of two blood pressure (BP) control interventions for black patients with uncontrolled hypertension. PATIENTS & METHODS: A total of 845 patients were enrolled in a three-arm cluster randomized trial. On admission of an eligible patient, field nurses were randomized to usual care, a basic or augmented intervention. RESULTS: Across study arms there were no significant 12 months differences in BP control rates (primary outcome) (25% usual care, 26% basic intervention, 22% augmented intervention); systolic BP (143.8 millimeters of mercury [mmHg], 146.9 mmHG, 143.9 mmHG, respectively); medication intensification (47, 43, 54%, respectively); or self-management score (18.7, 18.7, 17.9, respectively). Adjusted systolic BP dropped more than 10 mmHg from baseline to 12 months (155.5-145.4 mmHg) among all study participants. CONCLUSION: Neither the augmented nor basic intervention was more effective than usual care in improving BP control, systolic BP, medication intensification or patient self-management. Usual home care yielded substantial improvements, creating a high comparative effectiveness threshold. CLINICAL TRIAL REGISTRATION: NCT00139490.

Patient Characteristics Predicting Readmission Among Individuals Hospitalized for Heart Failure.

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.

Outcomes of clinical decision support (CDS) and correlates of CDS use for home care patients with high medication regimen complexity: a randomized trial.

RATIONALE, AIMS AND OBJECTIVES: To assess the outcomes of a clinical decision support (CDS) intervention designed for home care patients with high medication regimen complexity (MRC) and to examine correlates of CDS use. METHOD: The CDS consisted of a computerized algorithm that identified high MRC patients, electronic alerts and a care management module. Nurses were randomized upon identification of an eligible patient. Full intention to treat and intervention group-only analyses were completed. Regression-adjusted outcomes were hospitalization, emergency department use and reduction in MRC. RESULTS: Five hundred nurses were randomized with 7919 of their patients. Approximately 20% of the intervention group was hospitalized versus 21% in the control group; 16.5% versus 16.7% had an emergency department visit; and 6% in each group dropped below the high MRC threshold. No statistically significant differences were found in the intention to treat analysis. Eighty-two percent of intervention nurses used the CDS but for only 42% of their patients. Among intervention patients, CDS use (vs. non-use) was associated with reduced MRC and hospitalization. CDS use was associated with various clinician and patient characteristics. CONCLUSION: CDS use was limited, negating the impact of the intervention overall. Findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding short patient lengths of stay, improving continuity of care, increasing reliance on salaried nurses and/or increasing per diem nurses' incentives to use CDS.

Postdischarge Communication Between Home Health Nurses and Physicians: Measurement, Quality, and Outcomes.

OBJECTIVES: To use natural language processing (NLP) of text from electronic medical records (EMRs) to identify failed communication attempts between home health nurses and physicians, to identify predictors of communication failure, and to assess the association between communication failure and hospital readmission. DESIGN: Retrospective cohort study. SETTING: Visiting Nurse Service of New York (VNSNY), the nation's largest freestanding home health agency. PARTICIPANTS: Medicare beneficiaries with congestive heart failure who received home health care from VNSNY after hospital discharge in 2008-09 (N = 5,698). MEASUREMENTS: Patient-level measures of communication failure and risk-adjusted 30-day all-cause readmission. RESULTS: Identification of failed communication attempts using NLP had high external validity (kappa = 0.850, P < .001). A mean of 8% of communication attempts failed per episode of home care; failure rates were higher for black patients and lower for patients from higher median income ZIP codes. The association between communication failure and readmission was not significant with adjustment for patient, nurse, physician, and hospital factors. CONCLUSION: NLP of EMRs can be used to identify failed communication attempts between home health nurses and physicians, but other variables mostly explained the association between communication failure and readmission. Communication failures may contribute to readmissions in more-serious clinical situations, an association that this study may have been underpowered to detect.

Can the care transitions measure predict rehospitalization risk or home health nursing use of home healthcare patients?

The Care Transitions Measure (CTM) was designed to assess the quality of patient transitions from the hospital. Many hospitals are using the measure to inform their efforts to improve transitional care. We sought to determine if the measure would have utility for home healthcare providers by predicting newly admitted patients at heightened risk for emergency department use, rehospitalization, or increased home health nursing visits. The CTM was administered to 495 home healthcare patients shortly after hospital discharge and home healthcare admission. Follow-up interviews were completed 30 and 60 days post hospital discharge. Interview data were supplemented with agency assessment and service use data. We did not find evidence that the CTM could predict home healthcare patients having an elevated risk for emergent care, rehospitalization, or higher home health nursing use. Because Medicare/Medicaid-certified home healthcare providers already use a comprehensive, mandated start of care assessment, the CTM may not provide them additional crucial information. Process and outcome measurement is increasingly becoming part of usual care. Selection of measures appropriate for each service setting requires thorough site-specific evaluation. In light of our findings, we cannot recommend the CTM as an additional measure in the home healthcare setting.

Automating the medication regimen complexity index.

OBJECTIVE: To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting. MATERIALS AND METHODS: In phase 1, medication data from 89 645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics. RESULTS: The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve). DISCUSSION: Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count. CONCLUSIONS: An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes.

Patient activation and disparate health care outcomes in a racially diverse sample of chronically ill older adults.

The Patient Activation Measure (PAM) assesses people's ability to self-manage their health. Variations in PAM score have been linked with health behaviors, outcomes, and potential disparities. This study assessed the relative impacts of activation, socio-demographic and clinical factors on health care outcomes in a racially diverse sample of chronically ill, elderly homecare patients. Using survey and administrative data from 249 predominantly non-White patients, logistic regression was conducted to examine the effects of activation level and patient characteristics on the likelihood of subsequent hospitalization and emergency department (ED) use. Activation was not a significant predictor of hospitalization or ED use in adjusted models. Non-Whites were more likely than Whites to have a hospitalization or ED visit. Obesity was a strong predictor of both outcomes. Further research should examine potential sources of disadvantage among chronically ill homecare patients to design effective interventions to reduce health disparities in this population.

Diagnosed depression among Medicare home health patients: national prevalence estimates and key characteristics.

OBJECTIVES: This study estimated the prevalence of diagnosed depression among elderly Medicare fee-for-service home health patients and identified demographic, functional, and care utilization characteristics associated with the diagnosis. METHODS: Data from the 2007 National Home and Hospice Care Survey were analyzed to generate nationally representative estimates. Chi square and Wald tests, corrected for the sampling design, tested for differences in categorical and continuous measures, respectively. RESULTS: Nationally, 6.4% (N=42,192) of the study population received a diagnosis of depression, which was associated with younger age (p=.016), lack of a primary caregiver other than the home care agency (p<.001), a lower likelihood of receiving medical social services (p=.010), and a greater likelihood of using antidepressants (p<.001). CONCLUSIONS: The rate of diagnosed depression was higher than the rate found in a previous study but lower than rates in studies that used diagnostic interviews or screening tools. Diagnosed depression was associated with a limited number of patient characteristics.

Improving blood pressure control: results of home-based post-acute care interventions.

BACKGROUND: Blood pressure (BP) control remains elusive for many Americans. Although home health nurses are uniquely positioned to help vulnerable individuals achieve BP control, hypertension (HTN) management has not been a high priority in post-acute care. OBJECTIVE: To examine the effects of two home-based interventions designed to improve BP outcomes among high-risk African-American patients. DESIGN: Cluster randomized controlled trial. PARTICIPANTS: A total of 845 newly admitted patients with uncontrolled HTN (JNC7 stages 1 or 2). INTERVENTIONS: The "basic" intervention delivered key HTN information to clinicians and patients, and a home BP monitor to patients, while the patients received usual post-acute care. The "augmented" intervention provided more intensive and extensive HTN information, monitoring and feedback for 3 months beyond the index home care admission. MEASURES: Primary: BP control. Secondary: reductions in mmHG SBP and DBP, improvements in proportions improving JNC7 stage or achieving clinically meaningful reductions in SBP and DBP. METHODS: Multivariate regression models. KEY RESULTS: The basic intervention produced no significant BP improvements; the augmented intervention significantly improved stage 2 patients' outcomes. Among stage 2 patients, the augmented intervention increased BP control by 8.7 percentage points relative to usual care (8.9% vs. 17.6%; p=0.01), yielded an 8.3 mmHG relative reduction in SBP (p=0.01), and increased the proportion achieving at least a 20 mmHG reduction in SBP by 16.4 percentage points (p=0.01). CONCLUSION: Among stage 2 patients, a nurse-led intervention providing additional HTN medication review and patient self-management support during the 3-month post-acute care period yielded significant improvements in 3-month BP control, plus improvements in secondary BP outcomes.

Home-based blood pressure interventions for blacks.

Efforts to increase blood pressure (BP) control rates in blacks, a traditionally underserved high-risk population must address both provider practice and patient adherence issues. The home-based BP Intervention for blacks study is a 3-arm randomized controlled trial designed to test 2 strategies to improve hypertension management and outcomes in a decentralized service setting serving a vulnerable and complex home care population. The primary study outcomes are systolic BP, diastolic BP, and BP control; secondary outcomes are nurse adherence to hypertension management recommendations and patient adherence to medication, healthy diet, and other self-management strategies. Nurses (n=312) in a nonprofit Medicare-certified home health agency are randomized along with their eligible hypertensive patients (n=845). The 2 interventions being tested are (1) a "basic" intervention delivering key evidence-based reminders to home care nurses and patients while the patient is receiving traditional postacute home health care; and (2) an "augmented" intervention that includes that same as the basic intervention, plus transition to an ongoing Hypertension Home Support Program that extends support for 12 months. Outcomes are measured at 3 and 12 months after baseline interview. The interventions will be assessed relative to usual care and to each other. Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact. Results from this trial will provide important information on potential strategies to improve BP control in a low-income chronically ill patient population.

Understanding the complexity of hypertensive African American home care patients: challenges to intervention.

OBJECTIVE: To examine sociodemographic, clinical, and self-management characteristics of a sample of urban, African American patients admitted to home health care with uncontrolled hypertension and to determine the extent to which these factors are associated with disease severity. METHODS: We conducted a cross-sectional study of 498 hypertensive African American patients newly admitted to home health care. Data for this study were drawn from patient-level clinical and functional assessment data derived from the uniform home health assessment system mandated by the Centers for Medicare and Medicaid Services and patient in-home interviews. RESULTS: Forty percent of patients had stage 1 hypertension, and 60% had the more severe uncontrolled stage 2. Multivariate analyses found that factors associated with stage 2 were co-morbid diabetes, poor appointment keeping, low activation, and longer time since diagnosis. Protective factors associated with a lower likelihood of severe uncontrolled hypertension were older age and recent discharge from a hospital. More co-morbid conditions also appeared to be protective, although the association did not reach significance. CONCLUSIONS: Our findings highlight the need to address hypertension control among the African American, dually diagnosed diabetic hypertensive population and underscore the critical role of treatment adherence, widely recognized as a key issue in managing hypertension and other chronic conditions. Successful strategies will likely require more aggressive action by home health nurses, both to alert patients' primary care providers to ongoing, unsuccessfully treated hypertension and to remediate patients' inadequate self-management preparedness.

Just-in-time evidence-based e-mail "reminders" in home health care: impact on patient outcomes.

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.

Just-in-time evidence-based e-mail "reminders" in home health care: impact on nurse practices.

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.

Can just-in-time, evidence-based "reminders" improve pain management among home health care nurses and their patients?

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.

A randomized intervention to improve heart failure outcomes in community-based home health care.

This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses' support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home healthcare agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses'teaching and support skills. Outcome measures included home care,physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p < .05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur.

Social support, home health service use, and outcomes among four racial-ethnic groups.

PURPOSE: This study explored similarities and differences in social support, home health service utilization, and health outcomes across four racial-ethnic groups of elders. DESIGN AND METHODS: 1999 Outcomes Assessment Information Set records for 7,374 home care recipients who were 75 years of age or older and who were discharged to self-care were selected for bivariate and multivariate analyses. RESULTS: Similar levels of skilled service utilization were observed across racial or ethnic groups. Disparities were found in supportive assistance and physical and mental health outcomes. At discharge to self-care, more Black elders had no supportive assistance compared with all other groups; fewer Hispanics and Asians had improved physical functioning compared with Black and White elders. More White elders reported anxiety and depressive symptoms than any other racial or ethnic group. IMPLICATIONS: The findings suggest that racial-ethnic minorities and White elders may have differential needs for mental health and supportive services at discharge from home health care.