Strategies to support HCBS.

States are spending more money on home- and community- based services (HCBS) and are spending a greater proportion of their long-term care (LTC) dollars on these services rather than on institutional care. Some states have been more successful than others in supporting HCBS. This brief reviews strategies states have used to promote HCBS and summarizes existing research on the effectiveness of these strategies in increasing access, expanding revenues, and moderating institutional bed supply. Research shows that increased use of Medicaid waivers and Medicare home health services are important predictors of increased access to HCBS. Using regulation to constrain the number of institutional beds (and redirect resources to HCBS) shows mixed results. Research on the effectiveness of capitating LTC to increase access to HCBS has not been conclusive, though initial findings are promising and appear to be worth pursuing

The impact of Medicare home health policy changes on Medicare beneficiaries: part II.

This brief presents the results of a follow-up study (Murtaugh et al., 2003) on the effects of the Balanced Budget Act of 1997 on Medicare home health service use and beneficiary outcomes.[The results of the initial study (McCall et al., 2001) were discussed in a Spring 2003 policy brief and fact sheet.] The 2003 study found that the new payment systems have had a significant impact on the Medicare home health benefit: utilization declined, aggregate payments and payments per visit decreased (and then increased), the mix of services shifted, and the types of patients served appears to have changed. These results show that policy goals-in this case attempting to limit the use of the Medicare home health benefit while shifting services towards skilled care-can be instituted through changes in the payment system, though it is important to examine the impact of changes for possible unintended effects. Further study on the sustained impact of the current payment system-particularly on quality of care-is still needed.

Managed care and long-term care: a potential solution?

This brief summarizes research by Sparer (2003) and Hughes (2002) on managed care issues for people with long-term care needs. Managed care has been proposed as a solution to the difficult problem of managing the health of this complex population. Sparer's research examines the reasons behind the failure of states' attempts to encourage commercial managed care plans to take on this task. He argues that understanding these reasons can yield important lessons for the mostly provider-sponsored plans that currently serve the long-term care population, as well as for states, that aim to save money and better serve this population. Hughes' evaluation of a small, provider-sponsored organization found that when the organization became a managed care provider, it faced significant organizational challenges that forced it to become more efficient. Importantly, it showed that the use of capitation reimbursed the plan more effectively than fee for service, increased the range of services provided to clients, and maintained client satisfaction; however, capitation did not affect the rate of nursing home admission.

The need for evidence-based guidelines in home care.

There is a lack of condition-specific evidence-based guidelines in the home care field. A recent article by Peterson (2004) suggests that the home care industry must now address this on several fronts, including: 1. adopting guidelines for specific conditions from other settings, 2. implementing selected "best practices" developed by within home care agencies (that are usually consensus-based), and 3. collecting outcomes data with the purpose of creating a home care specific evidence base.This column summarizes Peterson's (2004) recent work on the importance of creating an evidence base for the home care field.

Examining "operational failures" to reduce home care errors.

The majority of health care errors that impact patient safety can be linked not to caregivers' lack of skills or knowledge, but to faulty work design (Perrow 1984; Reason 1990). Yet little is known about operational failures in home health care that lead to adverse events. This article summarizes the findings of a recent case study (Tucker 2004) that identifies 23 operational failures that took place during seven home care visits over the course of one day. The majority of these failures were linked to either the patient/family or the home health agency servicing the family rather than to the individual nurse treating the patient. Findings suggest that to understand and reduce errors in home health care, further examination of the structure of the work environment is necessary to create an atmosphere that can promote better patient care.

Towards creating an informatics infrastructure in home health care.

Although information technology is utilized successfully in many industries, its use in health care-and home health care in particular--continues to lag. This column summarizes a recent article by Bakken and Hripcsak (2004) examining the potential for informatics to improve patient care quality in home health care by supporting evidence-based practices and patient safety. The authors provide definitions of the basic components of an informatics infrastructure e.g., data mining, digital sources of evidence, etc.--and recommend how to make an informatics infrastructure for the home health care industry a reality. Suggestions include: (1) integrating informatics into education and training; (2) creating public/private partnerships among government agencies, vendors, and industry associations; and (3) performing cost-effective analyses to determine the optimal uses of specific technologies.

The positive impact of hospice care on the surviving spouse.

The study discussed here examined the possible indirect benefits of hospice care for older adults whose terminally ill spouses received hospice care. Surviving spouses whose husband/wife received hospice care had lower mortality rates 18 months after the spouse's death compared to older adults whose spouse had not received hospice care. The impact was larger for bereaved wives and the effect was statistically significant. The results illustrate that hospice care benefits patients and their spouses thereby mediating the effects of caregiver burden and the widow/er effect.

Long-term care: an overview.

This brief provides an overview of long-term care (LTC), a term that refers to a broad range of health and supportive services delivered in a variety of service settings, including people's own homes and nursing homes. People of all ages and with many different health conditions may need LTC. Although the demand for these services is increasing, funding sources for LTC remain unstable. Moreover, lack of societal agreement about the goals of LTC makes it difficult to establish an effective LTC policy for the future. This brief discusses these issues and reviews the key challenges that must be confronted in order to build a strong infrastructure for LTC.

Public funding for long-term care services for older people in residential care settings.

Provision of long-term care (LTC) services to older adults in group settings that are less institutional than nursing homes may be more economical than providing services in individual homes. This brief addresses a number of questions about how states can provide access to residential care through Medicaid.

Italian study concludes "home hospitalization" benefits stroke patients.

A randomized study in Italy recently found that uncomplicated ischemic stroke patients who were provided intensive, specialized home care services ("home hospitalization") were less depressed, more likely to remain at home post-discharge, less likely to need additional rehabilitation services, and had lower admission rates to long-term care facilities than did patients who received inpatient care in a general hospital ward. Home hospitalization was found to be at least as effective as inpatient hospital care when measured in terms of mortality and residual neurological deficits and functioning. This study illustrates the benefits of an intensive model of home care over inpatient care; its results could be applied to additional stroke patients who lack complications as well as to other differently diagnosed individuals who may achieve more positive outcomes at home. It is important to note that this study compared the effectiveness of an established home hospitalization program specializing in stroke care to the inpatient care provided on general hospital medical wards (rather than inpatient care provided by specialized stroke units).

A model for home care clinician and home health aide collaboration: diabetes care by nurse case managers and community health workers.

Researchers at Johns Hopkins University conducted a randomized clinical trial to test the effect of nurse case management and community health worker interventions on diabetes control among inner city African Americans. The results demonstrated that the greatest improvement occurred when nurse case managers and community health workers worked together. This study has implications for how nurse/home health aide collaboration can enhance diabetes management in home care.

Bringing managed care home to the long-term care population.

Managed care has been proposed as a solution to the problems facing long-term care: its high costs, bias towards nursing homes, lack of coordination with acute and primary care, and inflexible service delivery. Kodner and Kyriacou (2003) argue that home care agencies may have considerable advantages in creating managed care systems for this population over traditional managed care organizations because of the experience home care organizations have in caring for older adults as well as people with disabilities. Although home care agencies are likely to better understand the needs of the long-term care population, they may lack the expertise and organizational resources to develop successful managed care organizations. Addressing these deficiencies will be key in order for home care organizations to successfully operate as managed care providers.

The importance of screening for depression in home care patients.

The home care population is especially vulnerable to depression, yet a recent study showed that home care nurses are not well equipped to identify the signs and symptoms of depression (Brown et al., 2003). Probable causes include lack of training and support for home care nurses combined with passivity and embarrassment about depression among elderly patients. Depression is treatable; however, when left undiagnosed it causes patient suffering, increased likelihood of adverse events, and higher medical costs. Home care agencies can support their nurses to better recognize the signs and symptoms of depression through education and increased awareness of the prevalence and complexity of depression in the home care population. Furthermore, with the aid of screening questions already included in the Outcome and Assessment Information Set (OASIS), agencies can identify patients at risk of depression and refer them to necessary and beneficial mental health services.

Combatting medication errors in home health.

Home care patients are vulnerable to medication errors. Until recently, however, little was done to find out how many or what types of errors were occurring. A 2001 study shows that nearly one out of three elderly home care patients has a potential medication error. The good news is that a simple intervention can be implemented by home care agencies to reduce this daunting statistic.

Giving care & comfort in the aftermath of tragedy. New York's finest nurses show their true colors.

VNSNY is proud of how our employees and all of New York City coped with the events of September 11. As we continue to support our employees and patients in the aftermath, VNSNY is working to be even better prepared in the future.

Preventing medication errors in home care.

This practice brief highlights the results of two home health care studies on medication errors. The first study determined how often medication errors occur in home health care. The second study tested a strategy to reduce these errors. Although nearly one third of home care patients are at risk for potential medication errors, adding a simple, practical program can reduce the potential for errors. These results should encourage home care agencies to be more vigilant in monitoring medication errors and to institute programs that help prevent errors from occurring.