Barriers and facilitators to family caregiver training during home health care: A multisite qualitative analysis.

BACKGROUND: During Medicare home health care (HHC), family caregiver assistance is often integral to implementing the care plan and avoiding readmission. Family caregiver training delivered by HHC clinicians (nurses and physical therapists [PTs]) helps ensure caregivers' ability to safely assist when HHC staff are not present. Yet, family caregiver training needs often go unmet during HHC, increasing the risk of adverse patient outcomes. There is a critical knowledge gap regarding challenges HHC clinicians face in providing necessary family caregiver training. METHODS: Multisite qualitative study using semi-structured, in-depth key informant interviews with Registered Nurses (n = 11) and PTs (n = 8) employed by four HHC agencies. Participating agencies were diverse in rurality, scale, ownership, and geographic region. Key informant interviews were audio-recorded, transcribed, and analyzed using directed content analysis to identify existing facilitators and barriers to family caregiver training during HHC. RESULTS: Clinicians had an average of 9.3 years (range = 1.5-23 years) experience in HHC, an average age of 45.1 years (range = 28-63 years), and 95% were female. Clinicians identified facilitators and barriers to providing family caregiver training at the individual, interpersonal, and structural levels. The most salient factors included clinician-caregiver communication and rapport, accuracy of hospital discharge information, and access to resources such as additional visits and social work consultation. Clinicians noted the COVID-19 pandemic introduced additional challenges to providing family caregiver training, including caregivers' reduced access to hospital staff prior to discharge. CONCLUSIONS: HHC clinicians identified a range of barriers and facilitators to delivering family caregiver training during HHC; particularly highlighting the role of clinician-caregiver communication. To support caregiver training in this setting, there is a need for updated reimbursement structures supporting greater visit flexibility, improved discharge communication between hospital and HHC, and structured communication aids to facilitate caregiver engagement and assessment.

Shared Access to Patient Portals for Older Adults: Implications for Privacy and Digital Health Equity.

Growing reliance on the patient portal as a mainstream modality in health system interactions necessitates prioritizing digital health equity through systems-level strategies that acknowledge and support all persons. Older adults with physical, cognitive, sensory, and socioeconomic vulnerabilities often rely on the involvement of family and friends in managing their health, but the role of these care partners in health information technology is largely undefined and poorly understood. This viewpoint article discusses challenges and opportunities of systematic engagement of care partners through shared access to the patient portal that have been amplified in the context of the COVID-19 outbreak and recent implementation of federal information blocking rules to promote information transparency alongside broader shifts toward care delivery innovation and population aging. We describe implementation considerations and the promise of granular, role-based privacy controls in addressing the nuanced and dynamic nature of individual information sharing preferences and fostering person- and family-centered care delivery.

Neighborhood Broadband and Use of Telehealth Among Older Adults: Cross-sectional Study of National Survey Data Linked With Census Data.

BACKGROUND: The COVID-19 pandemic has amplified the role of telehealth in health care delivery. Regional variation in internet access and telehealth use are well-documented, but the effect of neighborhood factors, including the pervasiveness of broadband internet, on older adults' telehealth usage in the context of internet access is not known. OBJECTIVE: This study aimed to investigate how individual and neighborhood characteristics, including the pervasiveness of neighborhood broadband internet subscription, are associated with engagement in telehealth among older adults with internet access. METHODS: In this cross-sectional study, we included 5117 community-living older adults aged ≥65 years, who participated in the 2017 National Health and Aging Trends Study with census tract-level data for participants' places of residence from the American Community Survey. RESULTS: Of an estimated 35.3 million community-living older adults, 21.1 million (59.7%) were internet users, and of this group, more than one-third (35.8%) engaged in telehealth. In a multivariable regression model adjusted for individual- and neighborhood-level factors, age, education, income, and the pervasiveness of neighborhood broadband internet subscription were associated with engagement in telehealth, while race, health, county metropolitan status, and neighborhood social deprivation were not. Among internet users, living in a neighborhood at the lowest (versus highest) tertile of broadband internet subscription was associated with being 40% less likely to engage in telehealth (adjusted odds ratio 0.61, 95% CI 0.42-0.87), all else equal. CONCLUSIONS: Neighborhood broadband internet stands out as a mutable characteristic that is consequential to engagement in telehealth.

Impact of Neighborhood Social and Environmental Resources on Medicaid Spending.

INTRODUCTION: In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. Research linking medical spending to variation in neighborhood resources is critical to building the case for increased funding for social conditions. However, few studies link neighborhood factors to medical spending. This study assesses the relationship between neighborhood social and environmental resources and medical spending across the spending distribution. METHODS: Individual-level health outcomes were drawn from a sample of Medicaid enrollees living in Baltimore, Maryland during 2016. A multidimensional index of neighborhood social and environmental resources was created and stratified by tertile (high, medium, and low). Differences were examined in individual-level medical spending associated with living in high-, medium-, or low-resource neighborhoods in unadjusted and adjusted 2-part models and quantile regression models. Analyses were conducted in 2019. RESULTS: Enrollees who live in neighborhoods with low social and environmental resources incur significantly higher spending at the mean and across the distribution of medical spending even after controlling for age, race, sex, and morbidity than those who live in neighborhoods with high social and environmental resources. On average, this spending difference between individuals in low- and those in high-resource neighborhoods is estimated to be $523.60 per person per year. CONCLUSIONS: Living in neighborhoods with low (versus those with high) resources is associated with higher individual-level medical spending across the distribution of medical spending. Findings suggest potential benefits from efforts to address the social and environmental context of neighborhoods in addition to the traditional orientation to addressing individual behavior and risk.