Inverse Dose-Response Relationship Between Home Health Care Services and Rehospitalization in Older Adults.

OBJECTIVES: (1) To examine the impact of specific services [skilled nursing (SN), physical therapy (PT), occupational therapy (OT), and home health aide (HA)] in Medicare-certified home health care (HHC) on subsequent rehospitalization among older patients during a 60-day HHC episode and (2) to test the moderating effect of functional limitation on these services. DESIGN: Secondary analysis of data from the Outcome and Assessment Information Set (OASIS) and HHC administrative records of a statewide not-for-profit HHC agency from January 1, 2016, to December 31, 2016. SETTING AND PARTICIPANTS: Participants were ≥65 years old and were admitted to HHC within 48 hours of hospital discharge. MEASURES: Outcome was time to rehospitalization during the 60-day HHC episode (ie, number of days). Independent variables were visit intensity (number of visits/week) of SN, PT, OT, and HA, respectively. Functional limitation was measured by a composite score generated from 9 OASIS items on physical function. Multivariate Cox Proportional hazard analyses were conducted. Subgroup analysis (high vs low functional limitation) was conducted to examine the moderating effect of functional limitation on specific HHC services. Ad hoc analysis was conducted to examine potential interaction between specific HHC services that were significantly related to rehospitalization. RESULTS: The sample included 1377 participants, among whom 11.5% were rehospitalized during the 60-day HHC episode. At the threshold dose of 1 PT or 2 SN visits/week, higher visit intensity significantly reduced the hazard of rehospitalization in these patients by up to 82% for PT (2.30 visits/week; hazard ratio [HR] = 0.18, P value < .001) and 48% for SN visits (2.51 visits/week; HR = 0.52, P value < .05). The effect of PT on reducing the risk of rehospitalization was more pronounced in patients with low versus high functional limitation (2.30 visits/week, HR = 0.08 vs 0.24, both P < .001). SN was only effective in reducing the hazard of rehospitalization in the low functional limitation group (1.70 visits/week, HR = 0.41, P < .05; 2.51 visits/week, HR = 0.29, P < .05), but not in the high functional limitation group (P > .05 at all intensity levels). Visit intensity of HA or OT was not significantly related to rehospitalization. CONCLUSIONS/RELEVANCE: At a threshold of 1 PT visit or 2 SN visits/week, HHC lowered the risk of rehospitalization in older patients by up to 82% and 48%, respectively. Both PT and SN were more effective in avoiding rehospitalization in patients with low functional limitation than in those with high functional limitation. Older patients should receive enough HHC services (especially PT and SN) to avoid rehospitalizations with consideration of their functional limitation.

Somali Older Adults' and Their Families' Perceptions of Adult Home Health Services.

Many studies have identified the vulnerability of ethnic elders, and there is promising evidence indicating home health care (HHC) services can improve the health outcomes of Somali older adults. This study used a community-engaged qualitative descriptive approach with the participation of non-profit organization Refugees Helping Refugees. The purpose of this study was to explore and describe Somali older adults' and their families' perceptions of and experiences with HHC services in order to improve its use and access. Data collection included home visits (n = 15), semi-structured interviews (n = 17) and debriefing sessions (n = 16) with 19 individuals from 14 Somali families. Somali families recognized HHC services were needed and believed having services in the home facilitated learning but HHC agencies should work more with the Somali community. HHC agencies need to work with community organizations to facilitate cultural and health understanding, and better health care for Somali older adults.

Using a Clinical Outreach Project to Foster a Community-Engaged Research Partnership With Somali Families.

BACKGROUND: Community-engaged research partnerships build the capacity of community and educational organizations to work together toward addressing important health issues and disparities for vulnerable populations, such as refugees or immigrants. A critical step for building a community-engaged research partnership is the Thrst contact or entrée into the community. PURPOSE: The purpose of this paper is to describe how a successful home health community-engaged partnership became the entrée and foundation for a community-engaged research partnership to explore the home health needs of Somali older adults and their families. METHODS: A number of strategies were used to engage the Somali community, initially in a clinical home health project and subsequently in an academic research study. LESSONS LEARNED: Valuable lessons were learned on delivering home health care (HHC) services to Somali older adults and their families as well as conducting research with this population. The most important lesson was that none of the work could be done without the involvement of the Somali community. The partnership described is one of the Thrst to address the home health needs and experiences of Somali older adults and their families. The project illustrates a mutually beneThcial relationship that can occur when a community-engaged clinical project expanded to address an issue of importance to the community through research. CONCLUSIONS: This foundation served to create an opportunity for more comprehensive community-academic partnerships with the potential to improve the delivery of HHC to Somali older adults, as well as open avenues for research in other areas that are relevant to the Somali, medical, and academic communities.

Home health care nurse interactions with homebound geriatric patients with depression and disability.

Building therapeutic nurse-patient relationships is pivotal to the provision of optimum nurse care management for geriatric home health care (HHC) patients. However, little is known about which strategies most effectively treat older adult HHC patients with concomitant depression and disability. This qualitative descriptive study was conducted in two parts to explore the issue further. The first part involved interviews regarding HHC nurse perceptions of geriatric depression and disability care management. The second part, which is the focus of the current analysis, describes HHC nurses' use of care management and therapeutic during home visits. Observation of nurse-patient interactions involved 25 nurses home visits to HHC patients 60 and older who had depression and disability. Drawing on clinical knowledge and interpersonal skills, nurses built relationships and fostered trust. However, despite their disabilities to make these connections, multiple missed opportunities occurred for nurses to engage in more productive interactions. Four training components to support improvement of nurse-patient therapeutic relationships are described and recommended.

Evaluation of geriatric home healthcare depression assessment and care management: are OASIS-C depression requirements enough?

OBJECTIVE: Research is scarce on how depression is identified and treated among Medicare home healthcare (HHC) patients age 65+ with disability. The Centers for Medicare & Medicaid Services (CMS) recently incorporated depression screening into the OASIS-C HHC assessment. Our study objectives were to evaluate and characterize depression care management (DCM) in an HHC agency after CMS increased its depression requirements and to determine if there was an association of DCM with disability (activities of daily living [ADLs]) outcomes. METHODS: The authors conducted a retrospective chart review of 100 new Medicare HHC admissions patients age 65+ (mean age: 81.7) who screened positive for depression and had disability and multimorbidity. Clinical and administrative records were examined and descriptive analyses used. Multivariate regression analyses investigated the association of six DCM components with ADLs improvement. RESULTS: Depression was recognized in care plans of 60% of patients. Documentation of only one nurse care management activity, antidepressant use, indicated the use of evidence-based standards of depression assessment and DCM. Depression measures were not administered at discharge, recertification, or transfer. Forty percent of patients had a formal depression diagnosis by the referring physician in the chart, and 65% were receiving an antidepressant. Having a depression care plan and depression medication were significantly associated with a large ADLs improvement. CONCLUSION: Despite the association of depression care plans with patient disability improvement, inadequate compliance to evidence-based DCM was found. Medicare and HHC agencies must ensure compliance to DCM, including follow-up depression assessment for patients with positive screens.

Longitudinal prevalence and correlates of elder mistreatment among older adults receiving home visiting nursing.

The objectives of this study were to identify elder mistreatment (EM) prevalence among a cohort of older adults receiving visiting nurse care in their homes, determine EM subtypes, and identify factors associated with EM. EM data were collected by nurses during monthly home visits for up to 24 months. It took the nurses a mean of 10.5 visits to discern EM. Fifty-four (7.4%) of 724 patients were identified as mistreated, of which 33 had enough information to subtype the EM. Of these 33, 27 were victims of neglect, 16 of psychological abuse, and 10 of financial exploitation, and 17 suffered more than one type. Among the entire sample, 11 variables were positively correlated with EM presence. Nurses visiting older adults in their homes should be aware that their patients are, as a group, vulnerable to EM, and that the factors identified here may be specific markers of greater risk.

Effects of a home visiting nurse intervention versus care as usual on individual activities of daily living: a secondary analysis of a randomized controlled trial.

BACKGROUND: Home visiting nurses (HVNs) have long been part of home and community-based care interventions designed to meet the needs of functionally declining older adults. However, only one of the studies including HVNs that have demonstrated successful impacts on Activities of Daily Living (ADL) has reported how those interventions affected individual ADLs such as bathing, instead reporting the effect on means of various ADL indices and scales. Reporting impacts on means is insufficient since the same mean can consist of many different combinations of individual ADL impairments. The purpose of our study was to identify which individual ADLs were affected by a specific HVN intervention. METHODS: This is a secondary analysis comparing two arms of a randomized controlled study that enrolled Medicare patients (mean age = 76.8 years; 70% female) with considerable ADL impairment. At baseline difficulty with individual ADLs ranged from a low of 16.0% with eating to a high of 78.0% with walking. Through monthly home visits, the HVN focused on empowering patients and using behavior change approaches to facilitate chronic disease self-management. Three categories of analyses were used to compare difficulty with and dependence in 6 individual ADLs between the HVN (n = 237) and care as usual (n = 262) groups (total N = 499) at 22 months after study entry: (1) unadjusted analyses that strictly depend on random assignment, (2) multinomial logistic regression analyses adjusting for baseline risk factors, and (3) multinomial regression analyses that include variables reporting post-randomization healthcare use as well as the baseline risk factors. RESULTS: Compared to care as usual, patients receiving the HVN intervention had less difficulty performing bathing at 22 months. However, there were no effects for difficulty performing the other 5 ADLs. While no effects were found for lower levels of dependence for any ADLs, impacts were detected for the most dependent levels of 4 ADLs: patients experienced less dependence in walking and transferring, a substitution effect for toileting, and more dependence in eating. CONCLUSIONS: Future research is needed to confirm these findings and determine how HVN interventions affect individual ADLs of older adults with multiple ADLs.

Which components of a primary care affiliated home visiting nurse program are associated with disability maintenance/improvement?

A process evaluation of a primary care affiliated home visiting nurse intervention was performed to determine which intervention components were associated with disability maintenance/improvement. This secondary analysis (N = 238) used data recorded in intervention databases and patient interviews among community-dwelling elders with disability. Intervention components were examined in descriptive, correlational, bivariate, and logistic regression analyses. Results demonstrated that two structure components--physician-patient-family-nurse conference visits and intervention (education) materials--and three process components--disease management activities, goal setting, and medication management activities--were linked to maintaining/improving activities of daily living disability status. Confirmation of these findings may help home care nurses to delay disability worsening.

Barriers and facilitators to optimize function and prevent disability worsening: a content analysis of a nurse home visit intervention.

AIMS: This paper is a report of an analysis of how to better understand the results of the nurse home visit intervention in the Medicare Primary and Consumer-Directed Care Demonstration in terms of facilitators and barriers to disability improvement/maintenance as compared with disability worsening. BACKGROUND: There is a lack of literature describing how nurse home visit interventions are able to maintain/improve disability among older persons with disability. The present study is one of only six reporting beneficial disability outcomes. METHODS: Cases were purposefully sampled to represent change in the disability construct leading to selection of ten cases each of disability maintenance/improvement (no change or decrease in total Activities of Daily Living score from baseline) and worsening (an increase in total Activities of Daily Living score from baseline). Data from nurses' progress notes and case studies (collected in March 1998-June 2002) were analysed using qualitative descriptive analysis (May 2009). These results remain relevant because the present study is one of the few studies to identify select nurse activities instrumental in postponing/minimizing disability worsening. RESULTS/FINDINGS: Three primary themes captured the facilitators and barriers to effective disability maintenance/improvement: (1) building and maintaining patient-centred working relationships, (2) negotiating delivery of intervention components and (3) establishing balance between patients' acute and chronic care needs. Sub-themes illustrate nurse, patient and system factors associated with effective disability maintenance/improvement (e.g. nurse caring, communicating, facilitating interdisciplinary communication) and barriers associated with disability worsening (e.g. dementia, depression and recurring acute illnesses). CONCLUSION: This study provides new insights about the facilitators and barriers to effective disability maintenance/improvement experienced by patients receiving home visits. Potential opportunities exist to integrate these insights into best-practice models of nurse home visiting.

Patient satisfaction, empowerment, and health and disability status effects of a disease management-health promotion nurse intervention among Medicare beneficiaries with disabilities.

PURPOSE: To report the impact on patient and informal caregiver satisfaction, patient empowerment, and health and disability status of a primary care-affiliated disease self-management-health promotion nurse intervention for Medicare beneficiaries with disabilities and recent significant health services use. DESIGN AND METHODS: The Medicare Primary and Consumer-Directed Care Demonstration was a 24-month randomized controlled trial that included a nurse intervention. The present study (N = 766) compares the nurse (n = 382) and control (n = 384) groups. Generalized linear models for repeated measures, linear regression, and ordered logit regression were used. RESULTS: The patients whose activities of daily living (ADL) were reported by the same respondent at baseline and 22 months following baseline had significantly fewer dependencies at 22 months than did the control group (p = .038). This constituted the vast majority of respondents. In addition, patient satisfaction significantly improved for 6 of 7 domains, whereas caregiver satisfaction improved for 2 of 8 domains. However, the intervention had no effect on empowerment, self-rated health, the SF-36 physical and mental health summary scores, and the number of dependencies in instrumental ADL. IMPLICATION: If confirmed in other studies, this intervention holds the potential to reduce the rate of functional decline and improve satisfaction for Medicare beneficiaries with ADL dependence.

Review of nurse home visiting interventions for community-dwelling older persons with existing disability.

Despite there being a considerable number of meta-analyses and reviews synthesizing the nurse in-home visiting literature, there have been no reviews examining nurse in-home visiting for patients who are already disabled. This article presents a literature review and synthesis of 10 trials targeted on older adults with disability. The review is organized into structure and process components related to the outcome variable disability based on the classic Donabedian model. The review suggests that the components of in-home visiting associated with favorable disability outcomes include multiple home visits, geriatric training and experience, health provider collaboration, multidimensional assessment, and theory use. In contrast, lack of process measures, physician collaboration, training, and specific intervention components targeting disability are associated with ineffective interventions. This review helps provide insight into variables that influence disability outcomes as well as the development of best-practice models of in-home visiting to older adults with existing disability.