Early versus late COVID-19 Home Health Care patient population: Shifting sociodemographics and comparable outcomes.

Early in the pandemic when hospitals reached capacity, Home Health Care (HHC) became a critical source of care for COVID-19 patients and continues to be an important source of care for recovering COVID-19 patients. Little is known about the COVID-19 patient population treated in HHC. This retrospective observational cohort follows 1614 HHC patients with a COVID-19 diagnosis and compares an "Early Cohort" between March 31 and May 31, 2020 to a "Late Cohort" between June 1 and December 31, 2020 for differences in: (1) sociodemographic and clinical characteristics (2) health care utilization, and (3) outcomes. Early patients were younger, more likely to be a minority, referred from hospitals or directly from emergency departments, started their care with greater independence in functional abilities, and had fewer comorbidities. Early patients were more likely to have COVID-19 as their primary diagnosis (88.5% vs. 79.4%, p < 0.001), and were assessed as having more severe COVID-19 symptoms. Early and Late Cohorts were assessed similarly for dyspnea at the start of care. COVID-19 patients in the Early Cohort were more likely to have their vital signs monitored remotely (7.3% vs. 1.4%; p < 0.001), have received oxygen in their home (27.8% vs. 15.3%; p < 0.001), and received more virtual care than patients in the Late Cohort (2.04 visits vs. 0.86 visits; p < 0.001), although they had approximately two fewer total visits (12.48 vs. 14.45; p < 0.001). Patients in both cohorts had substantial improvement in dyspnea and functional ability during the course of HHC.

Description, Health Care Utilization, and Outcomes for Home Health Care (HHC) COVID-19 Patients Early in the Pandemic: A Comparison to the General HHC Population.

COVID-19 patients represent a new and distinct population in home health care. Little is known about health care utilization and incremental improvements in health for recovering COVID-19 patients after admission to home health care. Using a retrospective observational cohort study of 5452 episodes of home health care admitted to a New Jersey Home Health Agency between March 15 and May 31, 2020, this study describes COVID-19 Home Health Care (HHC) patients (n = 842) and compare them to the general HHC population (n = 4610). COVID HHC patients differ in significant ways from the typical HHC population. COVID patients were more likely to be 65 years of age and younger (41% vs 26%), be from a racial/ethnic minority (60% vs 31%), live with another person (85% vs 76%), have private insurance (28% vs 16%), and began HHC with greater independence in activities-of-daily-living (ADL/IADLs). COVID patients received fewer overall visits than their non-COVID counterparts (11.7 vs 16.3), although they had significantly more remote visits (1.7 vs 0.3). Multivariate analyses show that COVID patients early in the pandemic were 34% (CI, 28%-40%) less likely to be hospitalized and demonstrated significantly greater improvement in all the outcome measures examined compared to the general home health population.

COVID-19 infection rates early in the pandemic among full time clinicians in a home health care and hospice organization.

BACKGROUND: Patient-facing health care workers (HCW) experience higher rates of COVID-19 infection, particularly at the start of the COVID-19 pandemic. However, rates of COVID-19 among front-line home health and hospice clinicians are relatively unknown. METHODS: Visit data from a home health care and hospice agency in New Jersey early in the pandemic was analyzed to examine COVID-19 infection rates separately for clinicians exposed to COVID-19-contagious patients, and those without exposure to known COVID-19 contagious patients. RESULTS: Between March 5 and May 31, 2020, among home health clinicians providing in-person care, clinicians treating at least one COVID-19 contagious patient had a case rate of 0.8% compared to 15.7% for clinicians with no exposure to known COVID-19 contagious patients. Among hospice clinicians providing in-person care, those who treated at least one COVID-19 contagious patient had a case rate of 6.5%, compared to 12.9% for clinicians with no known exposure to COVID-19 contagious patients. Non-White clinicians had a higher COVID-19 case rate than White clinicians (10.9% vs 6.2%). DISCUSSION: Lower rates of COVID-19 infection among clinicians providing care to COVID-19-contagious patients may result from greater attentiveness to infection control protocols and greater precautions in clinicians' personal lives. Greater exposure to COVID-19-contagious patients prior to patient diagnosis ("unknown exposures") may explain differences in infection rates between home health and hospice clinicians with workplace exposures. CONCLUSION: Clinicians providing in-person care to COVID-19-contagious patients experience lower rates of COVID-19 infection than clinicians providing face-to-face care with no known exposure to COVID-19 contagious patients. Our findings suggest there was a low incidence of potential workplace infections.

An emerging model of primary care for older adults: the house call-home care practice.

House calls to older adults have become more common, in part related to the emergence of medical practices that either emphasize or exclusively provide house calls. In this article we seek to describe organizational, clinician, and patient characteristics of house call-home medical care practices in the United States. We conducted telephone interviews with clinicians representing 36 randomly selected practices from across the United States. This study found that house call-home care practices typically are recently formed small groups of physicians and nurse practitioners that provide in-home primary care, especially chronic disease care, to Medicare beneficiaries. Clinicians are motivated by the opportunity to improve care and to maintain autonomy. This emerging model may represent a mutually beneficial trend for older adults and physicians.

Home care: a key to the future of family medicine?

This essay is about my transition from family medicine residency into house call/home-based primary care practice. Though some aspects of making home visits have been difficult and uncomfortable, I have found a higher level of satisfaction and sense of purpose than I had as a resident in a traditional outpatient clinic. This enhanced satisfaction is, in part, due to my discovery that a lower-volume, time-intensive house call practice is a more appropriate way than the brief office visit to care for older patients who have multiple morbidities. In light of the aging population, advances in portable medical technology, and changes in Medicare reimbursement, home care could become a key to the future success and ongoing relevance of family medicine.

Mini-cog performance: novel marker of post discharge risk among patients hospitalized for heart failure.

BACKGROUND: Heart failure (HF) guidelines recommend screening for cognitive impairment (CI) but do not identify how. The Mini-Cog is an ultrashort cognitive "vital signs" measure that has not been studied in patients hospitalized for HF. The purpose of this study was to evaluate whether CI as assessed by the Mini-Cog is associated with increased readmission or mortality risk after hospitalization for HF. METHODS AND RESULTS: We analyzed 720 consecutive patients who completed the Mini-Cog as a part of routine clinical care during hospitalization for HF. Our primary outcome was time between hospital discharge and first occurrence of readmission or mortality. There was a high prevalence of CI as quantified by Mini-Cog performance (23% of cohort). During a mean follow-up time of 6 months, 342 (48%) patients were readmitted, and 24 (3%) died. Poor Mini-Cog performance was an independent predictor of composite outcome (adjusted hazard ratio, 1.90; 95% confidence interval, 1.47-2.44; P<0.0001) and was identified as the most important predictor among 55 variables by random survival forest analysis. Inclusion of Mini-Cog performance in risk models improved accuracy (bootstrapped c-index, 0.602 versus 0.624) and risk reclassification (category-free net reclassification improvement, 27%; 95% confidence interval, 14%-40%; P<0.001). Secondary analysis of initial 30 days post discharge showed effect modification by venue of discharge, whereby patients with CI discharged to a facility had longer time to outcome as compared with those discharged home. CONCLUSIONS: Mini-Cog performance is a novel marker of posthospitalization risk. Discharge to facility rather than home may be protective for those patients with HF and CI. It is unknown whether structured in-home support would yield similar outcomes.

Health care lobbying in the United States.

PURPOSE: To assess the relative political influence of different organizations, we examined the efforts of health care organizations to influence policy decisions by lobbying lawmakers. METHODS: We reviewed reports filed by lobbyists from 1997 to 2000, as required by the Lobbying Disclosure Act, to characterize health care lobbying at the federal level in the United States. RESULTS: Health care lobbying expenditures totaled 237 million dollars in 2000. These expenditures accounted for 15% of all federal lobbying and were larger than the lobbying expenditures of every other sector, including agriculture, communications, and defense. A total of 1192 organizations were involved in health care lobbying. Pharmaceutical and health product companies spent the most (96 million dollars), followed by physicians and other health professionals (46 million dollars). Disease advocacy and public health organizations spent 12 million dollars. From 1997 to 2000, lobbying expenditures by physicians and other health professionals grew more slowly than lobbying by other organizations (10% vs. 26%). CONCLUSION: Although policy decisions are influenced by many factors, our findings may indicate a limited political influence of disease advocacy and public health organizations and a declining political influence of physicians and other health professionals.

Prediction of 30-day heart failure-specific readmission risk by echocardiographic parameters.

It is unknown whether echocardiographic morphologic and hemodynamic parameters have incremental value in predicting 30-day heart failure (HF)-specific readmission risk among patients admitted with HF. We performed a prospective cohort study of adult patients entering a transitional care program after HF hospitalization to assess the role of echocardiographic parameters in predicting 30-day HF-specific readmission risk. Patients were followed for at least 30 days postdischarge, and readmission outcomes were ascertained prospectively. A previously validated 30-day HF readmission score (Yale Center for Outcome Research and Evaluation [CORE]) was calculated using 20 clinical and pathology parameters. Atrial and ventricular morphologic and hemodynamic variables were obtained from the index hospitalization echocardiogram. A Cox proportional hazards model was used to identify variables associated with 30-day HF specific readmission risk. Among 283 patients (mean age 72 ± 14 years, 57% men, 54% ischemic HF, ejection fraction 35% ± 17%) who underwent echocardiography during index admission there were 46 HF specific readmissions. After risk adjustment, elevated echocardiographic right atrial pressure (RAP; hazard ratio [HR] 3.70, 95% confidence interval [CI] 1.82 to 7.52, p <0.001), left ventricular filling pressures (HR 7.46, 95% CI 2.31 to 24.14, p = 0.001), and weight change during admission (HR 0.93, 95% CI 0.87 to 0.99, p = 0.02) were independently associated with 30-day HF-specific readmission risk. However, only elevated RAP and left ventricular filling pressure added incremental prognostic value to the Yale-CORE HF readmission score. An E/e' threshold of 23 identified a subgroup at highest risk of readmission and provided a net 29% reclassification improvement over the Yale-CORE HF readmission score (p = 0.005).

The case for "connected health" at home.

Communication and health monitoring technology and devices will enhance the potential for improved home health care services over the next decade. The technology exists to improve patients' access to specialized care, to monitor in-home risks for patients who have dementia or limitations in activities of daily living, and to minimize annoyances such as delays and long waiting times. Certain barriers must be addressed, however, such as third-party reimbursement restrictions, regulatory issues, and technologic limitations. Innovative clinicians will find ways to use these technologies to improve care while lowering costs and increasing value.

Trends in physician house calls to Medicare beneficiaries.

OBJECTIVE: House calls (HCs) to older adults seemed to be headed for extinction in recent decades. HCs may be a tool to ensure access and reduce institutionalization of the elderly population. This study determines the number and distribution of HCs by physician specialty over time and analyzes associations of providing HCs with physician and area-level characteristics. METHODS: This study was a cross-sectional analysis of 3 complete Medicare Part B claims data for national state-representative samples of physicians in 2000, 2003, and 2006. Multilevel logistic regression determined associations between physician and area-level characteristics and provision of HCs in 2006. RESULTS: Physicians made 478,088 HCs in 2000; 700,661 in 2003; and 995,294 in 2006. Over the same period, the proportion of physicians making HCs decreased from 7.22 (standard error, ±0.20) to 5.26 (±0.19). Physicians in the top decile of HC volume made an increasing number of HCs (median, 56 in 2000 and 86 in 2006). In 2006, physicians who made HCs were more likely to be older, geriatricians, and osteopaths, be in solo practice, and reside in rural areas compared with those who did not make HCs. CONCLUSIONS: Between 2000 and 2006, the number of physician HCs to Medicare beneficiaries more than doubled, whereas the number of physicians making HCs declined.