Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors.

OBJECTIVE: To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. DESIGN: Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. SETTING AND PARTICIPANTS: National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N = 165,228). METHODS: We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. RESULTS: The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. CONCLUSIONS AND IMPLICATIONS: Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.

Sustainability of partnership projects: a conceptual framework and checklist.

BACKGROUND: There is growing recognition that the health care delivery system in the United States must make major changes. Intervention projects focusing on quality and patient safety offer the potential for reshaping the future of medicine. Sustainability of the Partnerships for Quality (PFQ) projects and other patient safety and quality improvement projects that provide evidence of effectiveness is essential if progress is to be made. METHODS: For the purposes of these projects, a conceptual framework and a checklist for sustainability were developed. The framework consists of two dimensions: (1) the goals--what is to be sustained--and (2) elements for sustainability--infrastructure, incentives, incremental opportunities for involvement, and integration. The checklist is designed to trigger planning for sustainability early in a project's design. Specific questions about each of the elements can cue planners and project leaders to build in the goals for sustainability and change processes. RESULTS: A pilot test showed that the framework and checklist are relevant and helpful across a variety of projects. DISCUSSION AND CONCLUSION: Two extended examples of planning and action for sustainability from the PFQ projects are described. It is too early to claim sustainability for these project. However, continued monitoring for at least three years with the checklist could result in valuable national data with which to design and implement future projects.

Advancing the agenda for home healthcare quality: conference proceedings and findings.

On March 31 to April 1, 2005, the Center for Home Care Policy and Research of the Visiting Nurse Service of New York assembled approximately 80 home healthcare stakeholders from across the country to advance the action strategy for measuring, improving, and assuring quality in home healthcare. A specific aim of the conference was to disseminate relevant research on organizational change and evidence-based practices to influence patient safety and quality of care. Attendees worked together to identify high-priority action steps and recommendations at both the organizational and policy levels. This article reports the conference's proceedings and findings.

Challenged to care: informal caregivers in a changing health system.

This report is from a 1998 national survey of 1,002 informal caregivers. Each year 23 percent of Americans provide unpaid assistance to ill, disabled, or elderly persons. Most caregivers (71 percent) do not live with care recipients. Primary caregivers provide more care of all types. Nonprimary caregivers also provide substantial care and services. Caregivers perform complex medical tasks, including medication administration, and errors can result. Few receive assistance from paid professionals or aides because of quality or financial concerns. In many areas, support and instruction could lighten caregivers' burdens and help to ensure high-quality care at home.

Charting the course for home health care quality: action steps for achieving sustainable improvement: conference proceedings.

On June 30 and July 1, 2003, the first national meeting Charting the Course for Home Health Care Quality: Action Steps for Achieving Sustainable Improvement convened in New York City. The Center for Home Care Policy & Research of the Visiting Nurse Service of New York (VNSNY) hosted the meeting with support from the Robert Wood Johnson Foundation. Fifty-seven attendees from throughout the United States participated. The participants included senior leaders and managers and nurses working directly in home care today. The meeting's objectives were to: 1. foster dialogue among key constituents influencing patient safety and home care, 2. promote information-sharing across sectors and identify areas where more information is needed, and, 3. develop an agenda and strategy for moving forward. This article reports the meeting's proceedings.

The role of patient activation in improving blood pressure outcomes in Black patients receiving home care.

Variations in patients' self-management knowledge, skills, and confidence as measured by the Patient Activation Measure (PAM) have been linked to variations in health behavior and outcomes. In a randomized trial, we tested two blood pressure (BP) control interventions, one grounded in activation principles. Study participants were Black home care patients (N = 587) with uncontrolled hypertension. This article examines intervention impacts on 12-month PAM score change, other predictors of PAM change, and associations between PAM change and BP outcomes. In multivariate models, the interventions did not significantly affect PAM change. Baseline characteristics associated with increased PAM were lower PAM score, higher income, higher health literacy, younger age, lower systolic BP, diabetes, and fewer medications. PAM increase was associated with a modest reduction in diastolic BP but not with improved systolic BP or BP control. Although studies suggest that increasing activation may lead to improved patient outcomes, this study did not find it to be so.

The preferences for everyday living inventory: scale development and description of psychosocial preferences responses in community-dwelling elders.

PURPOSE OF THE STUDY: Assessing preferences for daily life is the foundation for person-centered care delivery. This study tested a new measure, the Preferences for Everyday Living Inventory (PELI), with a large sample of community-dwelling older adults. We sought to evaluate the tool's convergent and divergent validity, identify the most commonly held preferences within the sample, and explore relationships between gender and race and strength of preferences. DESIGN AND METHODS: Randomly selected African American and Caucasian home health agency clients (N = 437) were interviewed using the PELI. Respondents self-reported functional ability, physical health, affect, mental health, and five domains of psychosocial preferences. The study examined correlations among descriptive variables and preference items and used logistic regression to estimate relationships between gender and race and 55 PELI items and 10 descriptive covariates. RESULTS: The study found support for the PELI's construct validity, identified seniors' most strongly held preferences across domains, and revealed significant differences in preferences by gender and race. IMPLICATIONS: The PELI captures strongly held personal preferences and shows promise as a practical tool that allows providers to document client preferences and customize care accordingly.

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.

Improving functional outcomes in home care patients: impact and challenges of disseminating a quality improvement initiative.

Most older adults are admitted to home health care with some functional impairment related to chronic illness and/or hospitalization. This article describes: (1) the impact of a quality improvement initiative (QI) on functional outcomes of older, chronically ill patients served by a large homecare organization; and (2) key implementation challenges affecting intervention outcomes. Over 6,000 patients were included in two dissemination phases. Phase 1 randomly assigned service delivery teams to intervention (QI) or usual care (UC). Phase 2 spread the intervention to UC teams. Phase 1 yielded statistically significant, albeit modest, functional improvements among intervention team patients relative to UC. Phase 2 improvements in the original intervention group were smaller, suggesting some regression to the mean. UC teams did not "catch up" when exposed to the intervention in Phase 2. Analysis of the implementation process suggested that modification of improvement strategies and "dilution" of peer-to-peer communication hindered additional Phase 2 improvements. The findings highlight the challenges of relying on peer-to-peer spread, and of distinguishing the core elements of an effective improvement strategy that must be spread consistently from those that can be adapted to variations within and across organizations.

Translating research into practice: transitional care for older adults.

RATIONALE: Over the last decade, in order to close the safety and health care quality chasm, there has been a growing imperative to translate evidence-based research into practice. AIMS AND OBJECTIVES: This study examines the major facilitators and barriers of implementing in a large US insurance organization - Aetna Corporation - an evidence-based model of care, the Transitional Care Model, which has been rigorously tested over the past twenty years by a multidisciplinary team at the University of Pennsylvania. METHODS: Semi-structured interviews of 19 project leaders, case managers, and transitional care nurses were conducted during two phases of translation - start-up and roll out. Qualitative analysis was used to identify more than a dozen key barriers to and facilitators of translation in these two critical phases. Results Six facilitators and seven barriers that are consistent with the literature were identified during and categorized as either start-up or roll-out. CONCLUSION: The combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence-based practice with "real world" management.

Spreading improvement strategies within a large home healthcare organization.

This article describes the process of the spread of improvement strategies to improve relationships between professional and paraprofessional service providers within a large home healthcare organization and its partnering home health aide vendors. We describe the method for spreading the strategies, which emerged from a learning collaborative, and the successes and challenges of the spread. Two case studies highlight how the attributes of innovations and the methods for spreading them can influence the effectiveness of an improvement effort.

Team structure and adverse events in home health care.

OBJECTIVE: To identify relationships between variations in team structure and risk-adjusted adverse events across 86 teams in a large US home health care organization. METHODS: Patient episode data were collected for two 6-month periods, January-June 2002 (N = 54,732 episodes) and January-June 2003 (N = 51,560 episodes). An adverse event was defined as having 1 or more events defined by the Centers for Medicare and Medicaid Services for home health care episodes. Events were risk adjusted using 2 alternative approaches-a Z-score and a Fixed Effects (FE)-score, for each team in each period. These scores (1 for each team in each period) were then regressed against objective measures of team structure. RESULTS: The regressions based on the FE-score as the measure of quality performed better than the traditional Z-score. Based on these regressions we find that volume (number of episodes) (P = 0.03), number of weekend visits (P = 0.02), and workload distribution (P = 0.02) were negatively associated with the occurrence of adverse events, whereas higher weekend admissions (P = 0.01) were positively associated with adverse events. CONCLUSIONS: Our analysis identifies a number of key team-level organizational variables that influence adverse events in home health care services. We also have demonstrated that the FE-score is a more accurate measure of team quality, as opposed to the Z-score, given that it focuses only on "team attributable" adverse events by isolating and excluding random variation from the quality score.

ReACH National Demonstration Collaborative: early results of implementation.

The Reducing Acute Care Hospitalization (ReACH) National Demonstration Collaborative is a two-year multi-wave initiative using a "virtual" Collaborative Learning Model to reduce acute care hospitalization rates among home care patients. ReACH aims to reduce hospitalization to 23%, as recommended by the Centers for Medicare and Medicaid Services in its 8th Scope of Work for Quality Improvement Organizations. This article reports on the early implementation experience of a sample of 17 of 65 home health agencies participating in Wave I of ReACH. It examines agency challenges in implementing a structured practice improvement initiative, improving hospital to home transitions and focusing appropriate resources on high risk patients. Lessons learned will inform future home health care quality improvement initiatives.

Exploring the utility of automated drug alerts in home healthcare.

Computerized drug utilization review (DUR) can potentially reduce adverse drug events. We examined automated DUR for home healthcare patients with diabetes or hypertension. Sixty-eight percent of diabetes patients and 50.7% of hypertension patients triggered severe, moderate, or duplicative alerts. Among diabetes patients, 74.3% of duplicative alerts were trivial or inappropriate, compared with 3.9% among hypertension patients. Experts judged that 40.5% of high-risk diabetes patients and 53.6% of hypertension patients had alerts requiring nurse follow-up. Adequate follow-up was significantly lower for the former. The relationship between inappropriate alerts and poorer follow-up reinforces the need for more specific alert systems to focus clinicians' attention on clinically important alerts.

Developing community indicators to promote the health and well-being of older people.

As the US population ages and the number of older people who are "aging in place" increases, communities will face new opportunities and challenges in responding to this population's desires and needs. Qualitative research was conducted to inform the development of a model of an "elder-friendly community" and a set of indicators to measure and help improve community capacity to promote the health and well-being of older residents. Focus groups were conducted in four US cities with younger and older adults and community leaders who identified attributes that make a community a good place in which to grow old. The group interactions were videotaped, transcribed, and analyzed to identify common themes. Results were remarkably similar across sites. Participants said that a community could be considered elder-friendly if it helped older residents continue active participation in the community, sustain their independence, and reduce the risk of isolation. A model of an elder-friendly community, along with corresponding indicators, was created on the basis of focus group results. These tools are being tested in 10 pilot communities to determine their usefulness for measuring older people's health and well-being, prioritizing aging issues, and stimulating and informing action strategies to improve community "elder-friendliness."

Conducting translation research in the home care setting: lessons from a just-in-time reminder study.

BACKGROUND: Home care organizations are relatively isolated from academic health centers, university-based schools of nursing, and centers of health services research that have advanced the knowledge base for quality improvement. Thus limited information exists about how best to promote evidence-based practice in this setting. AIMS: This article examines research and translation issues posed by the decentralized home care setting and considers how these issues compare to issues in other settings. METHODS: A case study approach is used to frame a discussion of the contextual and practical factors that can influence the design and future acceptance of different translation strategies in the home care setting. Use of a recently concluded randomized trial that tested the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses has been made to inform this discussion. DISCUSSION: Effective translation interventions in home health care need to address the unique nature of this setting including the dispersed, generalist workforce that serves a diverse patient population and lacks strong peer contact or on-site support and supervision. Proactive push translation strategies such as reminders that have been effective in other settings show promise in this service area but had a differential effect across conditions. Significantly, the cost-effectiveness analysis of this intervention showed that net patient care costs actually increased for one condition. IMPLICATIONS: The study described in this article demonstrates that rigorous translation research can be conducted in highly decentralized practice settings. It also points to the value of assessing different levels of intensity of interventions in a single study, looking at process measures and patient outcomes, and conducting a cost-effectiveness analysis. To encourage broader adoption of translation strategies, additional incentives from purchasing or regulatory agencies may be needed.