Health Information Technology Adoption at U.S. Home Health Care Agencies: Results from a Multi-Methods Study

Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR;(2) Benefits of EHR;(3) Benefits of other HIT;(4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR;an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.

Influenza vaccination of home health care staff and the impact on patient hospitalizations.

BACKGROUND: Influenza is associated with significant morbidity and mortality for adults aged 65 years and older. Influenza vaccination of health care workers is recommended. There is limited evidence regarding influenza vaccinations among health care workers in the home health care (HHC) setting and their impact on HHC patient outcomes. METHODS: A national survey of HHC agencies was conducted in 2018-2019 and linked with patient data from the Centers for Medicare and Medicaid Services. Adjusted logistic regression models were used to estimate the association between hospital transfers due to respiratory infection during a 60 day HHC episode and staff vaccination policies. RESULTS: Only 26.2% of HHC agencies had staff vaccination requirements and 71.2% agencies had staff vaccination rates higher than 75%. Agency policies for staff influenza vaccination were associated with reduced hospital transfers due to respiratory infection among HHC patients. DISCUSSION: Influenza vaccination rates among HHC staff were low during the 2017-2018 influenza season. Policymakers may consider vaccination mandates to improve health care worker vaccination rates and protect patient safety. CONCLUSIONS: This study sheds light on the potential impact of COVID-19 vaccination among HHC workers on patient outcomes. COVID-19 vaccination mandates could prove to be a vital tool in the fight against COVID-19 variants and infection outbreaks.

The state of infection prevention and control at home health agencies in the United States prior to COVID-19: A cross-sectional study.

BACKGROUND: Home health care is a rapidly growing healthcare sector worldwide. Home health professionals face unique challenges related to preventing and controlling infections, which are likely to amplify during an infectious disease outbreak (e.g. SARS-CoV-2). Little is known about the current state of infection prevention and control-related policies and outbreak preparedness at U.S. home health agencies. OBJECTIVES: In this study, we conducted a national survey to assess infection prevention and control-related policies, infrastructure, and procedures prior to the SARS-CoV-2 pandemic. DESIGN: Cross-sectional study. SETTING/PARTICIPANTS: Using a stratified random sample of 1506 U.S. home health agencies, we conducted a 61-item survey (paper and online) from November 9, 2018 to December 31, 2019. METHODS: Survey data were linked to publicly-available data on the quality of patient care, patient satisfaction, and other agency characteristics. Probability weights were developed to account for sample design and nonresponse; Pearson's χ2, Fisher's exact, t-tests or linear regression were used to compare the universe of agencies/respondents and urban/rural agencies. RESULTS: 35.6% of agencies responded (n = 536). Most home health personnel in charge of infection prevention and control have other responsibilities; one-third have no formal infection prevention and control training. Rural agencies are more likely to not have anyone in charge of infection prevention and control compared to those in urban areas. About 22% of agencies implement recommended guidelines when administering antibiotics. Less than a third (26.4%) report that their staff vaccination rates were higher than 95% during the last flu season. Only 48.1% of agencies accept patients requiring ventilation, and of those, 40.9% located in rural areas do not have specific infection prevention and control policies for ventilated patients, compared to 20.8% in urban areas (p < 0.001). Only 39.7% of agencies provide N95 respirators to their clinical staff; rural agencies are significantly more likely to provide those supplies than urban agencies (50.7% vs. 37.7%, p = 0.004). Lastly, agencies report their greatest challenges with infection prevention and control are collecting/reporting infection data and adherence to/monitoring of nursing bag technique. CONCLUSIONS: Prior to the SARS-CoV-2 pandemic, we found that infection prevention and control was suboptimal among U.S. home health care agencies. Consequently, most agencies have limited capacity to respond to infectious disease outbreaks. Staff and personal protective equipment shortages remain major concerns, and agencies will need to quickly adjust their existing infection prevention and control policies and potentially create new ones. In the long-term, agencies also need to improve influenza vaccination coverage among their staff. Tweetable abstract: Infection prevention and control infrastructure, policies and procedures and outbreak preparedness at U.S. home health agencies was found to be suboptimal in nationally-representative survey conducted just prior to the COVID-19 pandemic.

Home Health Staff Perspectives on Infection Prevention and Control: Implications for Coronavirus Disease 2019.

OBJECTIVES: The role of home healthcare (HHC) services in providing care to vulnerable, often frail individuals with chronic conditions is critical. Effective infection prevention and control (IPC) in HHC is essential to keeping both healthcare workers and patients safe, especially in the event of an emerging infectious disease outbreak. Prior to the coronavirus disease 2019 pandemic, we explored successes and challenges with IPC from the perspectives of HHC staff. DESIGN: Qualitative descriptive study. SETTING AND PARTICIPANTS: From May to November 2018, we conducted in-depth telephone interviews with 41 staff from 13 agencies across the nation. METHODS: Transcripts were coded by a multidisciplinary coding team, and several primary and subcategories were identified using directed content analysis. RESULTS: Four primary categories were generated including (1) uniqueness of HHC; (2) IPC as a priority; (3) importance of education; and (4) keys to success and innovation. Participants perceived that IPC plays a big part in patient safety and reducing rehospitalizations, and protection of patients and staff was a major motivator for compliance with IPC. The identified challenges included the unpredictability of the home environment, patient/family dynamics, the intermittent nature of HHC, and staffing issues. Education was seen as a tool to improve staff, patient, caregiver and families' compliance with IPC. Keys to success and innovation included a leadership focus on quality, using agency infection data to improve quality, and a coordinated approach to patient care. CONCLUSIONS AND IMPLICATIONS: This qualitative work identified barriers to effective IPC in HHC, as well as important facilitators that HHC agencies can use to implement policies and procedures to improve patient care and keep staff safe. Leadership prioritization of IPC is key to implementing appropriate IPC policies and may be especially important in midst of a crisis such as coronavirus disease 2019.

COVID-19 Preparedness in US Home Health Care Agencies.

OBJECTIVES: In the United States, home health agencies (HHAs) provide essential services for patients recovering from post-acute care and older adults who are aging in place. During the COVID-19 pandemic, HHAs may face additional challenges caring for these vulnerable patients. Our objective was to explore COVID-19 preparedness of US HHAs and compare results by urban/rural location. DESIGN: Cross-sectional study. SETTING/PARTICIPANTS: Using a stratified random sample of 978 HHAs, we conducted a 22-item online survey from April 10 to 17, 2020. METHODS: Summary statistics were computed; open-ended narrative responses were synthesized using qualitative methods. RESULTS: Similar to national data, most responding HHAs (n = 121, 12% response rate) were for-profit and located in the South. Most HHAs had infectious disease outbreaks included in their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster preparedness (84%), and had provided their staff with COVID-19 education and training (97%). More urban HHAs had cared for confirmed and recovered COVID-19 patients than rural HHAs, but urban HHAs had less capacity to test for COVID-19 than rural HHAs (9% vs 21%). Most (69%) experienced patient census declines and had a current and/or anticipated supply shortage. Rural agencies were affected less than urban agencies. HHAs have already rationed (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective equipment (PPE). Many HHAs reported accessing supplemental PPE from state/local resources, donations, and do-it-yourself efforts; more rural HHAs had accessed these additional resources compared with urban HHAs. CONCLUSIONS/IMPLICATIONS: This survey reveals challenges that HHAs are having in responding to the COVID-19 pandemic, particularly among urban agencies. Of greatest concern are the declines in patient census, which drastically affect agency revenue, and the shortages of PPE and disinfectants. Without proper protection, HHA clinicians are at risk of self-exposure and viral transmission to patients and vulnerable family members.