Continuity of Care Versus Language Concordance as an Intervention to Reduce Hospital Readmissions From Home Health Care.

BACKGROUND: Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact. OBJECTIVE: The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. DESIGN: A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care. PARTICIPANTS: The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge. MEASURES: The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis. RESULTS: When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%). CONCLUSION: In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.

A multi-language qualitative study of limited English proficiency patient experiences in the United States.

Objective: The purpose of this study was to understand the limited English proficiency patient experience with health care services in an urban setting in the United States. Methods: Through a narrative analysis approach, 71 individuals who spoke either Spanish, Russian, Cantonese, Mandarin, or Korean shared their experiences through semi-structured interviews between 2016 and 2018. Analyses used monolingual and multilingual open coding approaches to generate themes. Results: Six themes illustrated patient experiences and identified sources of structural inequities perpetuating language barriers at the point of care. An important thread throughout all interviews was the sense that the language barrier with clinicians posed a threat to their safety when receiving healthcare, citing an acute awareness of additional risk for harm they might experience. Participants also consistently identified factors they felt would improve their sense of security that were specific to clinician interactions. Differences in experiences were specific to culture and heritage. Conclusions: The findings highlight the ongoing challenges spoken language barriers pose across multiple points of care in the United States' health care system. Innovation: The multi-language nature of this study and its methodological insights are innovative as most studies have focused on clinicians or patient experiences in a single language.

Occupational Firefighting: A Detriment to Good Health.

OBJECTIVE: The purpose of the study is to evaluate the effect of an online educational module in increasing awareness of depression, substance use disorder, and sleep deprivation among firefighters in Monroe County, New York. METHOD: Firefighters were recruited via work e-mail and the snowball technique. A quantitative preintervention and postintervention study was used. Participants completed four surveys before and after completing educational online modules. RESULTS: There was a 5.11% increase in overall knowledge about sleep deprivation, depression, and substance (alcohol) use and a small decrease in the group mean for the depression and sleep deprivation scores after completion of the educational modules. CONCLUSION: Increasing content knowledge had a positive effect to participants' self-awareness during the project. Incorporating educational modules into annual firefighting training could provide opportunities to improve sleep deprivation, depression, and substance use.

Assessing the influence of patient language preference on 30 day hospital readmission risk from home health care: A retrospective analysis.

BACKGROUND: In home health care, language barriers are understudied. Language barriers between patients and providers are known to affect a variety of patient outcomes. How a patient's language preference influences hospital readmission risk from home health care has yet to be determined. OBJECTIVE: To determine if home care patients' language preference is associated with their risk for hospital readmission from home health care within 30 days of hospital discharge. DESIGN: Retrospective cross-sectional study of hospital readmissions from an urban home health care agency's administrative records and the national electronic home health care record for the United States, captured between 2010 and 2015. SETTING: New York City, New York, USA. PARTICIPANTS: The dataset comprised 90,221 post-hospitalization patients and 6.5 million home health care visits. METHODS: First, a Chi-square test was used to determine if there were significant differences in crude readmission rates based on language group. Inverse probability of treatment weighting was used to adjust for significant differences in known hospital readmission risk factors between to examine all-cause hospital readmission during a home health care stay. The final matched sample included 87,561 patients with a language preference of English, Spanish, Russian, Chinese, or Korean. English-speaking patients were considered the comparison group to the non-English speaking patients. A Marginal Structural Model was applied to estimate the impact of non-English language preference against English language preference on rehospitalization. The results of the marginal structural model were expressed as an odds ratio of likelihood of readmission to the hospital from home health care. RESULTS: Home health patients with a non-English language preference had a higher hospital readmission risk than English-speaking patients. Crude readmission rate for the limited English proficiency patients was 20.4% (95% CI, 19.9-21.0%) overall compared to 18.5% (95% CI, 18.7-19.2%) for English speakers (p < 0.001). Being a non-English-speaking patient was associated with an odds ratio of 1.011 (95% CI, 1.004-1.018) in increased hospital readmission rates from home health care (p = 0.001). There were also statistically significant differences in readmission rate by language group (p < 0.001), with Korean speakers having the lowest rate and Spanish speakers having the highest, when compared to English speakers. CONCLUSIONS: People with a non-English language preference have a higher readmission rate from home health care. Hospital and home healthcare agencies may need specialized care coordination services to reduce readmission risk for these patients. Tweetable abstract: A new US-based study finds that home care patients with language barriers are at higher risk for hospital readmission.

An Outreach Phone Call Project: Using Home Health to Reach Isolated Community Dwelling Adults During the COVID 19 Lockdown.

Home health care (HHC) focuses on delivering skilled health care services to patients in their homes. Over 82% of HHC patients are 65 and older, and living with chronic health conditions. In an effort to respond to the risk the COVID-19 pandemic presented for patients, a HHC agency designed "The Outreach Phone Call Project". This program was developed to provide telephone support to at-risk patients who had received HHC prior to the COVID-19 lockdown. In total, 16 Care Transition Managers participated in the project and over 4,000 patients received a call from the clinical team. Approximately 44% of the calls did not require any further follow up, 20% of the patients did not answer the call, and 3% of patients were referred back to HHC. Another 13% needed education and assistance with social issues. The calls provided a means of safe connection and support between providers and patients during the pandemic and facilitated access to health and social resources. However, the most beneficial aspect of the program was the opportunity for seasoned HHC nurses to identify clinical changes in the health of patients and to assist them in the triage process. Results of this study demonstrate that the implementation of a calling project during the pandemic shutdown provided invaluable connection and outreach to vulnerable populations. This simple change in practice enabled HHC professionals to reach patients who were isolated and in need of education and assistance. As a result of the implementation of an "Outreach Phone Call Project", the HHC agency learned many lessons which may be helpful to others who would like to create a similar program in the future. It facilitated clinical assessment, education and intervention for isolated patients during the COVID 19 pandemic and implementation of similar practice should be considered in the post-pandemic world.

Continuity of Nursing Care in Home Health: Impact on Rehospitalization Among Older Adults With Dementia.

BACKGROUND: Home health care (HHC) is a leading form of home and community-based services for persons with dementia (PWD). Nurses are the primary providers of HHC; however, little is known of nursing care delivery and quality. OBJECTIVE: The objective of this study was to examine the association between continuity of nursing care in HHC and rehospitalization among PWD. RESEARCH DESIGN: This is a retrospective cohort study using multiple years (2010-2015) of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency. SUBJECTS: This study included 23,886 PWD receiving HHC following a hospitalization. MEASURES: Continuity of nursing care was calculated using the Bice and Boxerman method, which considered the number of total visits, nurses, and visits from each nurse during an HHC episode. The outcome was all-cause rehospitalization during HHC. Risk-adjusted logistic regression was used for analysis. RESULTS: Approximately 24% of PWD were rehospitalized. The mean continuity of nursing care score was 0.56 (SD=0.33). Eight percent of PWD received each nursing visit from a different nurse (no continuity), and 26% received all visits from one nurse during an HHC episode (full continuity). Compared with those receiving high continuity of nursing care (third tertile), PWD receiving low (first tertile) or moderate (second tertile) continuity of nursing care had an adjusted odds ratio of 1.33 (95% confidence interval: 1.25-1.46) and 1.30 (95% confidence interval: 1.22-1.43), respectively, for being rehospitalized. CONCLUSIONS: Wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.

Language barriers between nurses and patients: A scoping review.

OBJECTIVE: Global migration and linguistic diversity are at record highs, making healthcare language barriers more prevalent. Nurses, often the first contact with patients in the healthcare system, can improve outcomes including safety and satisfaction through how they manage language barriers. This review aimed to explore how research has examined the nursing workforce with respect to language barriers. METHODS: A systematic scoping review of the literature was conducted using four databases. An iterative coding approach was used for data analysis. Study quality was appraised using the CASP checklists. RESULTS: 48 studies representing 16 countries were included. Diverse healthcare settings were represented, with the inpatient setting most commonly studied. The majority of studies were qualitative. Coding produced 4 themes: (1) Interpreter Use/Misuse, (2) Barriers to and Facilitators of Quality Care, (3) Cultural Competence, and (4) Interventions. CONCLUSION: Generally, nurses noted like experiences and applied similar strategies regardless of setting, country, or language. Language barriers complicated care delivery while increasing stress and workload. PRACTICE IMPLICATIONS: This review identified gaps which future research can investigate to better support nurses working through language barriers. Similarly, healthcare and government leaders have opportunities to enact policies which address bilingual proficiency, workload, and interpreter use.

Graduate level health professions education: how do previous work experiences influence perspectives about interprofessional collaboration?

Understanding how previous experiences with interprofessional education and collaboration inform health care provider perspectives is important for developing interprofessional interventions at the graduate level. The purpose of this study was to examine how previous work experiences of graduate level health professions students inform perspectives about interprofessional education and collaboration. Drawing from program evaluation data of two separate graduate level interprofessional education interventions based in primary care and home health care, we conducted a qualitative secondary data analysis of 75 interviews generated by focus groups and individual interviews with graduate students from 4 health professions cadres. Using directed content analysis, the team coded to capture descriptions of interprofessional education or collaboration generated from participants' previous work experiences. Coding revealed 173 discrete descriptions related to previous experiences of interprofessional education or collaboration. Three themes were identified from the analysis that informed participant perspectives: Previous educational experiences (including work-based training); previous work experiences; and organizational factors and interprofessional collaboration. Experiences varied little between professions except when aspects of professional training created unique circumstances. The study reveals important differences between graduate and undergraduate learners in health professions programs that can inform interprofessional education and collaboration intervention design.

Designing a Program to Serve Older Adult LGBTQ+ Populations in Home Healthcare.

When compared with their heterosexual cisgender (nontransgender) counterparts, LGBTQ+ older adults are more likely to delay or not seek medical care, often due to fear of real or perceived discrimination from healthcare providers. HCR Home care is a home healthcare agency in Upstate New York that has been delivering high-quality in-home healthcare services for over 40 years. We recognized that we had a unique opportunity to address the vulnerabilities of older adults in the LGBTQ+ community and to better meet their health needs as they age in place. We developed a five-step process to implement a program to better serve the home healthcare needs of the LGBTQ+ population in our community. The goal of this initiative is to provide ongoing community education on home healthcare, awareness of the social and health issues surrounding LGBTQ+ older adults, and ultimately to improve care and decrease health disparities. This article describes the five-step process, the challenges, successes, and implications for the future. Ensuring there are healthcare solutions available for vulnerable and marginalized individuals is key to changing the way home healthcare is structured and improving quality of life and health outcomes for all.

Provider Perspectives of Medication Complexity in Home Health Care: A Qualitative Secondary Data Analysis.

A primary service provided by home care is medication management. Issues with medication management at home place older adults at high risk for hospital admission, readmission, and adverse events. This study sought to understand medication management challenges from the home care provider perspective. A qualitative secondary data analysis approach was used to analyze program evaluation interview data from an interprofessional educational intervention study designed to decrease medication complexity in older urban adults receiving home care. Directed and summative content analysis approaches were used to analyze data from 90 clinician and student participants. Medication safety issues along with provider-provider communication problems were central themes with medication complexity. Fragmented care coordination contributed to medication management complexity. Patient-, provider-, and system-level factors influencing medication complexity and management were identified as contributing to both communication and coordination challenges.

Home health care services to persons with dementia and language preference.

Despite the rapid increase in the number of persons with dementia (PWD) receiving home health care (HHC), little is known of HHC services patterns to PWD of varied backgrounds, including language preference other than English. Analyzing data of 12,043 PWD from an urban home health agency, we found on average PWD received 2.48 skilled visits or 1.88-hour skilled care and 5.81 aide visits or 24.13-hour aide care weekly. Approximately 63% of the skilled visits were from nurses. More non-English preferred PWD received aide visits, compared to English preferred PWD (44% vs. 36%). The type and intensity of HHC services were associated with language preference; when stratified by insurance, non-English preference was still significantly associated with more HHC aide care. Our study indicated that HHC services (both type and amount) varied by language preference and insurance type as an indicator of access disparities was a significant contributor to the observed differences.

A Concept Analysis of Transitions of Care for Population Health.

BACKGROUND: Compelling evidence indicates that gaps in quality, safety, and experiences occur when patients encounter transitions across the care continuum. Differences in the organization of healthcare services as well as disparities in health across the globe, may have a unique impact on processes associated with transitions of care for client populations. PURPOSE: Increased attention to the concept of transitions of care has resulted in disparate meanings and lack of clarity about its nature. Therefore, the purpose of this manuscript is to address this knowledge gap by analyzing the concept of transitions of care at the population level. METHODOLOGY: To address the knowledge gap of what constitutes transitions of care at the population level, a concept analysis was done guided by the methodology of Walker and Avant. A comprehensive search of the literature yielded a small but relevant number of publications. RESULTS: This analysis identified four defining attributes, together with antecedents and consequences of transitions of care at the macro-system level of healthcare. A synthesized definition of transitions of care was developed. IMPLICATIONS FOR PRACTICE: This analysis provides conceptual clarity for the concept of transitions of care at the macro-system level of care. It can be used to guide the development of a middle-range theory to inform clinical practice and health policy.

How language barriers influence provider workload for home health care professionals: A secondary analysis of interview data.

BACKGROUND: Increasingly, patients with limited English proficiency are accessing home health care services in the United States. Few studies have examined how language barriers influence provider role implementation or workload in the home health care setting. OBJECTIVES: To explore home health care professionals' perspectives about how workload changes from managing language barriers influence quality and safety in home health care. DESIGN: A qualitative secondary data analysis using a summative content analysis approach was used to analyze existing semi-structured interview data. SETTING: A large urban home health care agency located on the East Coast of the United States. PARTICIPANTS: Thirty five home health care providers [31 registered nurses, 3 physical therapists, 1 occupational therapist]. RESULTS: A total of 142 discrete incidents emerged from the analysis. Overall, home health care providers experienced distinct shifts in how they implemented their roles that added to their workload and time spent with Limited English Proficiency patients and family members. Providers were concerned about interpretation accuracy and perceived it as potentially posing risks to patient safety. Changes in work patterns, therefore, sought to maximize patient safety. CONCLUSIONS: Home health care providers decision-making about how they adapt practice when faced with a language barrier is a sequence of actions based on awareness of the patient's language preference and if they spoke another language. Subsequent choices showed proactive behaviors to manage increased workload shaped by their perceived risk of the threats posed by the quality of interpreter services. Future research should develop quantitative models examining differences in workload when caring for limited English proficiency versus English speaking patients as well as the relationship between visit length and patient outcomes to determine optimal quality models.

Medication Literacy and Somali Older Adults Receiving Home Care.

Medication literacy is the ability of individuals to access and understand medication information and then use that information to act and take their medication in a safe and appropriate way. The purpose of this study was to explore medication literacy in a group of Somali older adults and their families using qualitative secondary analysis. We conducted an analytic expansion of an existing qualitative study that explored the home healthcare perceptions of Somali older adults and their families. Qualitative data collected from 14 Somali families about home healthcare were reviewed and analyzed for material related to medication literacy. Data analysis revealed a number of important findings related to medication literacy and resulted in the discovery of four themes: Medication literacy is needed among Somali older adults and their families, Using home healthcare (HHC) to improve medication literacy, Better communication is essential to improving medication literacy, and Medication literacy is an intersecting family and social issue. The results of this study indicate that HHC has a role to play in improving the health and medication literacy of these families. They also highlight the need to further explore what techniques, tools, and/or supports HHC professionals need to care for non-English speaking populations. Future research needs to address how to meet the needs of diverse and vulnerable patients like Somali older adults, and how best to prepare HHC providers to do this.

Somali Older Adults' and Their Families' Perceptions of Adult Home Health Services.

Many studies have identified the vulnerability of ethnic elders, and there is promising evidence indicating home health care (HHC) services can improve the health outcomes of Somali older adults. This study used a community-engaged qualitative descriptive approach with the participation of non-profit organization Refugees Helping Refugees. The purpose of this study was to explore and describe Somali older adults' and their families' perceptions of and experiences with HHC services in order to improve its use and access. Data collection included home visits (n = 15), semi-structured interviews (n = 17) and debriefing sessions (n = 16) with 19 individuals from 14 Somali families. Somali families recognized HHC services were needed and believed having services in the home facilitated learning but HHC agencies should work more with the Somali community. HHC agencies need to work with community organizations to facilitate cultural and health understanding, and better health care for Somali older adults.

Using a Clinical Outreach Project to Foster a Community-Engaged Research Partnership With Somali Families.

BACKGROUND: Community-engaged research partnerships build the capacity of community and educational organizations to work together toward addressing important health issues and disparities for vulnerable populations, such as refugees or immigrants. A critical step for building a community-engaged research partnership is the Thrst contact or entrée into the community. PURPOSE: The purpose of this paper is to describe how a successful home health community-engaged partnership became the entrée and foundation for a community-engaged research partnership to explore the home health needs of Somali older adults and their families. METHODS: A number of strategies were used to engage the Somali community, initially in a clinical home health project and subsequently in an academic research study. LESSONS LEARNED: Valuable lessons were learned on delivering home health care (HHC) services to Somali older adults and their families as well as conducting research with this population. The most important lesson was that none of the work could be done without the involvement of the Somali community. The partnership described is one of the Thrst to address the home health needs and experiences of Somali older adults and their families. The project illustrates a mutually beneThcial relationship that can occur when a community-engaged clinical project expanded to address an issue of importance to the community through research. CONCLUSIONS: This foundation served to create an opportunity for more comprehensive community-academic partnerships with the potential to improve the delivery of HHC to Somali older adults, as well as open avenues for research in other areas that are relevant to the Somali, medical, and academic communities.

Meeting the Needs of Older Adult Refugee Populations With Home Health Services.

The United States resettles close to 70,000 refugees each year more than any other country in the world. Adult refugees are at risk for negative health outcomes and inefficient health resource use, and meeting the multiple health needs of this vulnerable population is a challenge. The purpose of this study was to assess the impact of a home health care (HHC) pilot project on meeting the needs of older adult refugee patients. A retrospective chart review of 40 refugee adult patients who participated in an HHC pilot was done to analyze their health outcomes using OASIS-C data. Participants' pain level, anxiety level, medication management, and activities of daily living management all significantly improved over the course of their HHC episode. Results of this study indicate that HHC has great potential to improve the health of vulnerable refugee populations and assist the families involved in their care.

Feasibility of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

PURPOSE: The purpose of this study was to evaluate the feasibility of a new Web-based intermittent catheter self-management intervention. DESIGN: We tested the acceptability and usability of intervention components, which included multiple Web-based materials (an online urinary diary adapted for mobile phone use and an educational booklet), 3 phone calls with a nurse, and a peer-led discussion forum. SUBJECTS AND SETTING: Thirty adults with spinal cord injury using intermittent catheterization for bladder drainage were enrolled; 26 participants received the nurses' phone-based consultations. METHODS: Preliminary effectiveness of new self-efficacy and self-management scales were evaluated using baseline and 3-month online surveys. Participants' perceived value of the intervention components, self-management changes, and suggestions were assessed with data from the 3-month surveys, followed by brief tape-recorded interviews. RESULTS: Several catheter practices improved somewhat over 3 months. The frequency of catheterizations every 4 to 6 hours increased from 71% to 77%. Self-management of neurogenic bladder dysfunction increased significantly (P = .032); participant comments indicated that fluid intake was the biggest change. Catheter-related self-efficacy and quality-of-life scores increased but not significantly. The frequency of urinary tract infection and pain did not change significantly. For feasibility, intervention components, with the exception of the forum, were rated highly by the majority of participants for usefulness, satisfaction (desired information), and Web-based usability. CONCLUSION: Further testing of this intervention is recommended in a multisite randomized clinical trial.

Development of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

While Web-based interventions have proliferated recently, information in the literature is often lacking about how the intervention was developed. In response to that gap, this is a report of the development of a Web-based self-management intervention for intermittent urinary catheter users and pretesting with four adults with spinal cord injury living in the community. Two Web sites were created, one for recruitment and the other for the intervention itself. The intervention involved developing new Web-based technology, including an interactive urinary diary (with fluid intake/urine output and a journal), extensive catheter products information, three intervention nurse phone call consultations, and user-community discussion forums. Study participants completed an online survey and were interviewed twice about the enrollment process and their perceptions of their involvement in the intervention. Suggestions from the pretesting participants were used to revise the Web site applications prior to the next stage of research (a feasibility study). Numerous recommendations and comments were received related to content, interactivity of components, and usability. This article provides a description of how the Web sites were developed (including the technology and software programs used), issues encountered and what was done to address them, and how the Web-based intervention was modified for improvements.