Teamwork and Nurse Care Coordination in Home Healthcare.

Home healthcare agencies provide interdisciplinary care to millions of individuals annually. Care is typically led by registered nurses who often determine additional disciplines need to be included in the plan of care. We found that, although persons living with dementia represent about 30% of the home healthcare population, data from our home healthcare system showed that over a 1-year period with 36,443 home care episodes, only 29.6% had one or more social worker visits. Recognizing Alzheimer's disease-related dementia as a terminal condition and shifting toward a palliative care approach can be a challenge in home healthcare where care is focused on restorative care or rehabilitative goals with a primary focus on improvement in condition. The goal of this article is to present insights into nurse-led care coordination and teamwork and provide implications for practice.

Variation in Hospice Aide Care by Residential Setting.

Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data from Medicare beneficiaries in the United States enrolled in the Medicare Current Beneficiary Survey (MCBS) who died between 2010 and 2019 and had hospice claims and available residential setting data in MCBS (n = 1,915). Analysis: Decedent hospice aide use was compared by residential settings; multivariable models controlling for sociodemographic, clinical/functional, and hospice characteristics examined factors associated with hospice aide care in different residential settings. Results: Hospice aide visits were least common in the community setting (64.4% vs. 76.6% vs. 72.6% with any hospice aide visits in community, assisted living, and nursing home, respectively, p = 0.001). In adjusted models, factors associated with hospice aide visits did not significantly differ by residential settings. Conclusions: Despite staff providing hands-on support in assisted livings and nursing homes, hospice aide visits were more common in residential as opposed to community settings, and factors associated with hospice aide visits were similar among settings. To maximize the potentially positive impact of hospice aides on overall care, additional work is needed to understand when hospice aides are used and how hospice aides collaborate with families and care teams. This will help to ensure that hospice care is appropriately tailored to individual care needs in all residential settings.

Clinician Perception of Likelihood of Death in the Next Year Is Associated With 1-Year Mortality and Hospice Use Among Older Adults Receiving Home Health Care.

Background: Given the complex care needs of older adults receiving home health care (HHC), it is important for HHC clinicians to identify those with limited prognosis who may benefit from a transition to hospice care. Objectives: To assess the association between HHC clinician-identified likelihood of death and (1) 1-year mortality, and (2) hospice use. Methods: Prospective cohort study from the National Health and Aging Trends Study (NHATS) waves 2011-2018, linked to the Outcomes and Assessment Information Set (OASIS) HHC assessment and Medicare data among 915 community-dwelling NHATS respondents. HHC clinician-identified likelihood of death/decline was determined using OASIS item M1034. Multivariable logistic regression was used to assess the association between clinician-identified likelihood of death/decline and 1-year mortality and hospice use. Results: HHC clinicians identified 42% of the sample as at increased risk of decline or death. One year mortality was 22.3% (n = 548), and 15.88% (n = 303) used hospice within 12 months of HHC. HHC clinician-perceived likelihood of death/decline was associated with greater odds of 1-year mortality (odds ratio [OR], 6.57; confidence interval (95% CI), 2.56-16.90) and was associated with greater likelihood of hospice use (OR, 1.61; 95% CI, 1.00-2.62). Conclusion: HHC clinician perception of patients' risk of death or decline is associated with 1-year mortality. A better understanding of HHC patients at high risk for mortality can facilitate improved care planning and identification of homebound older adults who may benefit from hospice.

Association of Hospice Agency Location and Neighborhood Socioeconomic Disadvantage in the U.S.

BACKGROUND: Despite the growing increase in the utilization of hospice in the U.S, disparities exist in the utilization of hospice. Accumulating evidence has shown that neighborhood characteristics have an impact on availability of hospice agencies. OBJECTIVE: To assess the association between neighborhood social vulnerability and hospice agency availability. METHODS: Using the Medicare Post-Acute Care and Hospice Provider Utilization and Payment Public Use Files (PAC PUF) for 2019. Hospice agency addresses were geocoded to the census tract level. Multivariable Poisson regression models were used to assess the association between socioeconomic status SVI theme and hospice agency availability adjusting for number of home health agencies, primary care health profession shortage, per cent Black, and Percent Hispanic at the census tract level and rurality. RESULTS: The socioeconomic status SVI subtheme was associated with decreased likelihood of hospice agency availability (adjusted IRR (aIRR), .56; 95% CI, .50- .63; P < .001). Predominantly Black, and predominantly Hispanic neighborhoods had lower rates of hospice agency availability (aIRR, .48; 95% CI, .39-.59; P < .001 and aIRR, .29; 95% CI, .24-.36; P < .001), respectively. CONCLUSION: Neighborhood socioeconomic disadvantage was associated with lower availability of hospice agencies. Policies aimed at increasing access to hospice should be cognizant of neighborhood socioeconomic disadvantage.

Association Between Documented Severe Pain and Cognitive Impairment in Home Health Care Patients: Results from the National Outcome and Assessment Information Set Data.

Background: Despite the growing importance of home health care (HHC) in the care of older adults with cognitive impairment, limited evidence exists about factors associated with documented severe pain among older adults receiving HHC. Methods: This secondary data analysis used a 5% random national sample of the 2017 national Outcome and Assessment Information Set (OASIS) data. Multivariable Poisson regression model was used to examine the association between documented severe pain, cognitive impairment, and a range of sociodemographic, clinical, and cognitive factors. Results: HHC patients (n = 183,038) were mean age 79.7 years, 61.7% female, and 78.6% non-Hispanic White. In multivariable models, cognitive impairment was associated with lower likelihood of documented severe pain (prevalence ratio [PR] = 0.96, confidence interval [CI] = [0.94-0.98]). Other factors independently associated with less documented severe pain included Hispanic ethnicity (PR = 0.92, CI = [0.89-0.95]), the oldest (≥85 years) groups (PR = 0.65, CI = [0.63-0.66]), male patients (PR = 0.83, CI = [0.82-0.85]), those with a formal diagnosis of Alzheimer's Disease Related Dementias (PR = 0.67, CI = [0.65-0.69]), and patients with verbal- and speech-related difficulty (PR = 0.83, CI = [0.80-0.86]). Patients with history of falls (PR = 1.18, CI = [1.16-1.20]), positive screen on the Patient Health Questionnaire-2 (PR = 1.36, CI = [1.31-1.41]), shortness of breath (PR = 1.14, CI = [1.12-1.14]), anxiety daily (PR = 1.16, CI = [1.14-1.18]), and anxiety daily or more often (PR = 1.40, CI = [1.37-1.43]) were more likely to have documented severe pain. Conclusions: HHC patients with cognitive impairment were less likely to have documented severe pain even with a range of sociodemographic, clinical, functional, and cognitive characteristics were considered. These findings may reflect a link between cognitive impairment missed opportunities for clinicians to provide pain management. Tailored interventions are needed to better assess and manage pain in this vulnerable group of HHC patients.

Hospice and Palliative Care for Undergraduate Nursing Education: Results from a Delphi Study.

There is an urgent need to strengthen the nursing workforce through hospice and palliative care education to support patients living with serious illness. The aim of this study was to identify skills/topics in hospice and palliative care for undergraduate nursing education. We conducted a two-round online Delphi Survey of hospice and palliative care leaders and clinicians in New York State between June and August 2022. Participants were asked to list and rate the importance of clinical skills and topics in hospice and palliative care for undergraduate nursing education. Twenty-eight participants completed Round One and 21 participants completed Round Two. Topics ranked as extremely important were goals of care, patient/family education, communication skills, advance directives, medication management, pain management, and symptom management. Our findings highlight the importance of including the perspective of healthcare systems leaders and clinicians in discussions about training of future nurses to meet the needs of patients with serious illness and their families.

Academic-Clinical Collaborations to Build Undergraduate Nursing Education in Hospice and Palliative Care.

With the current shortage of hospice/palliative care (HPC) workforce, there is an urgent need to train a generation of nurses with clinical competency in HPC to ensure equitable access and optimal care for patients living with serious illness or at the end of life. The recent demand for HPC teaching in nursing education calls for innovation in establishing clinical placements. Palliative care nursing experts in New York State were surveyed between June and August 2022 about facilitators of academic-clinical partnerships between nursing schools and clinical settings. Inductive content analysis of open-ended responses revealed six major interconnected themes: (a) Increase Awareness of HPC in the Nursing Program, (b) Build a Relationship With Administrators, (c) Look Beyond Acute Care Partnerships, (d) Offer Incentives, (e) Develop Direct Care Experiential Opportunities, and (f) Develop Non-Direct Care Experiential Opportunities. Findings provide rich insights into key considerations for successful collaboration between nursing schools and clinical sites. [Journal of Gerontological Nursing, 49(6), 13-18.].

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia.

INTRODUCTION: Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD. METHODS: Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month. RESULTS: For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates. DISCUSSION: APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD. HIGHLIGHTS: For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

The role of restrictive scope-of-practice regulations on the delivery of nurse practitioner-delivered home-based primary care.

BACKGROUND: Nurse practitioners (NPs) are the largest group of providers delivering home-based primary care (HBPC) in the U.S. We examined the association of scope-of-practice regulations and NP-HBPC rates. METHODS: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state-level analysis to examine the impact of scope-of-practice regulations on the utilization of NP-HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341-99,345, 99,347-99,350) and domiciliary settings (99324-99,328, 99,334-99,337). We used linear regression to compare NP-HBPC utilization rates between states of either restricted or reduced scope-of-practice laws to states with full scope-of-practice, adjusting for a number of NP-HBPC providers, state ranking of total assisted living, the proportion of fee-for-service (FFS) Medicare beneficiaries and neighborhood-level socio-economic status and race and ethnicity. RESULTS: Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope-of-practice, states with restricted or reduced scope-of-practice had higher adjusted rates of NP-HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP-HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full- scope-of-practice laws, respectively. The rate of NP-HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13-1.72; p = 0.023) and reduced scope-of-practice laws (Beta coefficient = 0.91; 95%CI 0.03-1.79; p = 0.043) compared to states with full scope-of-practice laws. CONCLUSION: Restricted state NP scope-of-practice regulations were associated with higher rates of FFS Medicare NP-HBPC care delivery compared with full or reduced scope-of-practice. Understanding underlying mechanisms of how scope-of-practice affects NP-HBPC delivery could help to develop scope-of-practice regulations that improve access to HBPC for the underserved homebound population.

"The Crossover to Hospice": Perspectives of Home Healthcare Nurses and Social Workers.

BACKGROUND: Although home healthcare(HHC) clinicians increasingly provide care to a homebound population with advanced illness and high symptom burden,  we know little about how HHC clinicians navigate discussions about hospice with patients and families in this setting. OBJECTIVE: We sought to explore perspectives on transition from HHC to hospice among HHC nurses and social workers. DESIGN: PQualitative study using semi-structured interviews and thematic analysis. RESULTS: Fifteen nurses and 3 Social workers participated in the study. Four main themes emerged from the interviews: (1) Regulatory Forces of Hospice and HHC; (2) Structure of HHC; (3) Individual beliefs-Hospice means giving up; and (4) Dynamics of Communication in HHC to Facilitate Transitions to Hospice. CONCLUSION: Introducing the option of hospice to patients and families nearing end-of-life in the HHC setting is complex and challenging.  Facilitators of hospice discussions in the HHC setting  include interdisciplinary team-based clinical review, clinical decision support tools to identify patients who are hospice-eligible, and staff training.  These factors provide targets for future interventions.

Growth of Fee-for-Service Medicare Home-Based Medical Care Within Private Residences and Domiciliary Care Settings in the U.S., 2012-2019.

OBJECTIVES: Home-based medical care (HBMC) delivers physician or advanced practice provider-led medical services for patients in private residences and domiciliary settings (eg, assisted living facilities, group/boarding homes). We aimed to examine the time trends in HBMC utilization by care settings. DESIGN: Analyses of HBMC utilization at the national and state levels during the years 2012-2019. SETTING AND PARTICIPANTS: With Medicare public use files, we calculated the state-level utilization rate of HBMC among fee-for-service (FFS) Medicare beneficiaries, measured by visits per 1000 FFS enrollees, in private residences and domiciliary settings, both separately and combined. METHODS: We assessed the trend of HBMC utilization over time via linear mixed models with random intercept for state, adjusting for the following state-level markers of HBMC supply and demand: number of HBMC providers, state ranking of total assisted living and residential care capacity, and the proportion of FFS beneficiaries with dementia, dual eligibility for Medicaid, receiving home health services, and Medicare Advantage. RESULTS: Total HBMC visits in the United States increased from 3,911,778 in 2012 to 5,524,939 in 2019. The median (interquartile range) state-level HBMC utilization rate per 1000 FFS population was 67.6 (34.1-151.3) visits overall, 17.3 (7.9-41.9) visits in private residences, and 47.7 (23.1-86.6) visits in domiciliary settings. The annual percentage increase of utilization rates was significant for all care settings in crude models (3%-8%), and remained significant for overall visits and visits in domiciliary settings (2%-4%), but not in private residences. CONCLUSIONS AND IMPLICATIONS: The national-level growth in HBMC from 2012-2019 was largely driven by a growth of HBMC occurring in domiciliary settings. To meet the needs of a growing aging population, future studies should focus efforts on policy and payment issues to address inequities in access to HBMC services for homebound older adults, and examine drivers of HBMC growth at regional and local levels.

A Description of Persons With Alzheimer Disease and Related Dementias Receiving Home Health Care: A National Analysis.

The end-of-life period of individuals with Alzheimer disease and related dementias receiving home health care (HHC) is understudied. We sought to describe characteristics of HHC patients with Alzheimer disease and related dementias at risk of death within a year, based on clinician assessment. We conducted a secondary data analysis of a 5% random sample of the Outcome and Assessment Information Set data set for the year 2017. We used Outcome and Assessment Information Set-C item M1034 to identify HHC patients with overall status of progressive condition leading to death within a year. Multivariable logistic regression model was used to examine the association between sociodemographic, functional, clinical, and caregiving factors and likelihood of decline leading to death within a year, as identified by HHC clinicians. Clinician perception of decline leading to death within a year was higher for Whites (vs Blacks or Hispanics) (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.69-0.80], and OR, 0.63 [95% CI, 0.57-0.69], respectively). Factors associated with increased odds of decline leading to death within a year included daily pain (OR, 1.11 [95% CI, 1.06-1.17]), anxiety daily or more often (OR, 1.58 [95% CI, 1.49-1.67]), shortness of breath (OR, 1.45 [95% CI, 1.34-1.57]), use of oxygen (OR, 1.60 [95% CI, 1.52-1.69]), disruptive behavior (OR, 1.26 [95% CI, 1.20-1.31]), and feeding difficulty (OR, 2.25 [95% CI, 2.09-2.43]). High symptom burden exists among HHC patients with Alzheimer disease and related dementias identified to have a status of decline leading to death within a year.

Barriers and Facilitators to Success in Undergraduate Nursing Education Among Minority Students: A Systematic Review.

BACKGROUND: Underrepresented minority (URM) students in nursing education are essential to address health disparities. PURPOSE: To determine barriers and facilitators to success among URM students in nursing education. METHODS: CINAHL, PubMed, Embase, and PsycINFO were searched for English language research studies published between 1980 and 2020, which focused on barriers and facilitators to success in nursing education in the United States among URM students. Using PRISMA guidelines, 2 reviewers independently reviewed and appraised the quality of relevant articles. RESULTS: Among the 4435 articles surveyed, 14 met inclusion criteria. Most studies were focused on Black and Hispanic/Latinx students, and 71% were qualitative. Barriers included social isolation, caregiving demands, lack of mentorship, and inadequate financial resources. Facilitators included mentorship, positive class and curriculum, family support, financial support, and diverse/inclusive learning environments. CONCLUSIONS: URM students face complex barriers to success in nursing education. Addressing these barriers requires a multilevel approach.

Symptom Burden and Activity of Daily Living (ADL) Dependency Among Home Health care Patients Discharged to Home Hospice.

Background: We sought to examine sociodemographic and clinical characteristics present on admission to HHC associated with discharge to hospice. Methods: We used a 5% random sample of 2017 national Outcome and Assessment Information Set (OASIS) data. A Cox proportional hazards regression model was estimated for the primary outcome (discharge to hospice) to examine the associations with sociodemographic and clinical characteristics of HHC patients. Results: Among 489, 230 HHC patients, 4268 were discharged to hospice. The median (interquartile range) length of HHC stay for patients discharged to hospice care was 33 (14-78) days. Compared to White patients, Black, Hispanic, and other race, (hazard ratio [HR] = .50 [95% confidence interval, CI = .44-.57]), (HR = .53 [95% CI = .46-.62]), and (HR = .49 [95% CI = .40-.61], respectively) was associated with shorter time to discharge to hospice care. Clinical characteristics including severe dependence in activities of daily (ADL) (HR = 1.68 [95% CI = 1.01-2.78]), cognitive impairment (HR = 1.10 [95% CI = 1.01-1.20]), disruptive behavior daily (HR = 1.11 [95% CI = 1.02-1.22]), and inability to feed oneself (HR = 4.78, 95% CI = 4.30, 5.31) was associated with shorter time to discharge to hospice. Symptoms of anxiety daily (HR = 1.55 [95% CI = 1.43-1.68]), and pain daily or all the time (HR = 1.54 [95% CI = 1.43-1.64]) were associated with shorter time to discharge to hospice. Conclusions: High symptom burden, ADL dependency, and cognitive impairment on admission to HHC services was associated with greater likelihood of discharge to hospice.

Facilitators of COVID-19 vaccine acceptance among Black and Hispanic individuals in New York: A qualitative study.

BACKGROUND: Black and Hispanic individuals experience poorer outcomes related to coronavirus disease (COVID-19), yet have alarmingly lower uptake of the COVID-19 vaccine compared to non-Hispanic White individuals. OBJECTIVE: To explore the perceptions of barriers and facilitators of COVID-19 vaccine acceptance among Black and Hispanic adults in the New York. METHODS: A qualitative study consisting of one-on-one semistructured interviews with Black and/ or Hispanic adults in New York state was conducted. Participants were recruited from local businesses, community-based social service agencies and Black and Hispanic churches and a college. All data were collected between February and March 2021. Transcripts were analyzed using qualitative thematic analysis. RESULTS: A total of 50 individuals (32 [64%] women; mean [SD] age, 42.04 [15.99] years) participated. The majority of participants identified as Black (n = 34, 68%), 9 (18%) identified as Hispanic, 3 (6%) as Black and Hispanic, and 4 (8%) as White and Hispanic. Twenty-two participants (44%) had high-school level education or less. Mistrust emerged as a central barrier to COVID-19 vaccine acceptance. Facilitators of effective COVID-19 vaccine messages include (1) key informants: like me, (2) personalized community outreach, (3) present the facts, and (4) communicate across multiple media platforms. CONCLUSIONS: This qualitative study found that among Black and Hispanic participants, receipt of reliable vaccine related information, social networks, seeing people like themselves receive the vaccination, and trusted doctors are key drivers of vaccine acceptance.

All alone: A qualitative study of home health aides' experiences during the COVID-19 pandemic in New York.

BACKGROUND: Despite their integral role, Home Health Aides (HHAs) are largely unrecognized as essential to implementing effective infection prevention and control practices in the home healthcare setting. We sought to understand the infection prevention and control needs and challenges associated with caring for patients during the pandemic from the perspective of HHAs. METHODS: From June to August 2020, data were collected from HHAs in the New York metropolitan area using semi-structured qualitative interviews by telephone; 12 HHAs were interviewed in Spanish. Audio-recorded interviews were transcribed, translated and analyzed using conventional content analysis. RESULTS: In total, 25 HHAs employed by 4 unique home care agencies participated. HHAs had a mean age of 49.8 (± 9.1), 24 (97%) female, 11 (44%) Black, 12 (48%) Hispanic. Three major themes related to the experience of HHA's working during the COVID-19 pandemic emerged: (1) all alone, (2) limited access to information and resources, and (3) dilemmas related to enhanced COVID-19 precautions. Hispanic HHAs with limited English proficiency faced additional difficulties related to communication. CONCLUSIONS: We found that HHA communication with nursing staff, plays a key role in infection control efforts in home care. Efforts to manage COVID-19 in home care should include improving communication between HHAs and nursing staff.

Impact of COVID-19: A Text Mining Analysis of Twitter Data in Spanish Language.

BACKGROUND: Latino communities in the United States and Latin America are disproportionately affected by the COVID-19 pandemic. We analyzed information shared on Twitter in Spanish language for insights into the public's communication and information needs about the COVID-19 pandemic. METHODS: We performed a mixed-methods analysis using a text mining approach. We used SAS Text Miner, an algorithmic-driven statistical program to capture 10,000 tweets posted between June 3, 2020, and June 10, 2020. We used the following search terms to capture relevant Twitter messages in Spanish language: "coronavirus," "covid-19," "corona," and the hash tags "#COVID19" and "#Coronavirus." Key text topics were identified and categorized into themes using an emergent content analysis. RESULTS: We identified 12 text topics and six themes: (1) prevention measures, (2) epidemiology/surveillance, (3) economic impact, (4) optimizing nursing workforce, (5) access to reliable information, and (6) call for a response from the local government. Top trending hashtags from our search included #COVID19 (n = 7,098), #Coronavirus (n = 6,394), and #SNTESALUD (n = 2,598). CONCLUSIONS: Spanish-language Tweets related to the COVID-19 pandemic contained information from health departments and labor unions on the surveillance, prevention, and impact of COVID-19. Public health officials should consider increasing their use of Twitter to ensure a wide dissemination of messages about COVID-19 in Spanish outlets.