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Technology provides opportunities to engage with those who are too busy, overwhelmed, or distant for face-to-face interventions, such as lay caregivers of adults with heart failure. While testing the efficacy of virtual health coaching for caregivers on stress and self-care we have encountered challenges in implementing the intervention and learned early lessons. Caregivers (n=250) enrolled into a randomized controlled trial receive a Samsung Galaxy tablet with Internet access. Half receive health information by tablet (control) and half receive 10 live virtual health coaching sessions plus health information all by tablet (intervention). Tablets are configured to allow access to preselected websites and a Vidyo conference room for the intervention group. Completing the first 6 months of enrollment, 36 caregivers have enrolled (34% black, all female, 74% spouses, mean age 56.4 years, 40% employed full-time, mean 9.3 hours spent caregiving daily), with 18 randomized to intervention. Only 2 of the 79 assessed for eligibility reported discomfort with technology. Yet, one early challenge is difficulty connecting with the health coach via Vidyo. Another is the uncertain nature of the patient’s condition, which frequently precludes the caregivers’ attendance at prescheduled sessions. Although tablets were anticipated to facilitate the intervention, in some cases, these two challenges interact to further accentuate caregiver stress. Alternatives such as FaceTime and plain old telephone contact suffice. We found that flexibility in intervention delivery is essential for such a real-world intervention. Contributing factors and implications of these challenges for future caregiving research and practice will be discussed.

Persons with dementia comprise up to 50% of hospice patients and face an increased risk of burdensome, disruptive, and costly discharge from hospice due to hospitalization. The relationship between timing, dose and site of hospice care provided, all modifiable factors, and risk of hospitalization is poorly understood. We use a retrospective cohort analysis of 2,692 electronic health records of hospice patients with dementia who received care from a large hospice agency in New York City between 2013-2017 to determine the relationship between hospice service delivery (e.g., number and timing of nurse visits, home vs. facility-based) and risk of hospitalization (vs death). We control for demographic and clinical characteristics of patients. 9.36% of patients with dementia were hospitalized. Hospice service delivery factors were significantly associated with risk of hospitalization. Each additional nurse visit was associated with a 5% decrease in risk of hospitalization (AOR: 0.95, 95% CI: 0.92-0.98). Each additional day between last nurse visit and discharge was associated with a 7% increase in risk of hospitalization (AOR: 1.07, 95% CI: 1.04-1.11). Home hospice was associated with 97% higher odds of hospitalization (AOR: 1.97, 95% CI: 1.19-2.09). Hospice patients with dementia who receive services at home, receive fewer nursing visits, and have increased time between nursing visits are at increased risk for hospitalization. Research is needed to determine if increasing the number and timing of nursing visits can reduce risk of hospitalization in this population.

Sepsis is a growing national health crisis with many sepsis survivors being discharged to home with home healthcare (HHC) services. While the long-term consequences of sepsis have become evident, little is known about the health status of those receiving HHC. The purpose of this NIH-funded study (R01NR016014) was to illustrate sepsis survivors’ clinical profiles to enhance patient-centered care. Based on Medicare data of 165,228 sepsis survivors, we describe patient characteristics by sepsis severity and examine associations between illness severity and early HHC visits using descriptive statistics, bivariate analyses, and logistic regression. Overall, the illness profile for sepsis survivors entering HHC is severe. Sepsis survivors are a vulnerable group with significant health needs, as 89.8% took > ¬five medications, 48% were cognitively impaired, 42% had frailty indicators, and 26% had a history of falls. Health status of 39% was classified as fragile, 21% reported severe pain, and 79% reported dyspnea. The majority (88.4%) were dependent in >3 activities of daily living. Despite this profile, 43% were home for two or more days before the first HHC visit. Although septic shock survivors had the most severe illness profiles, they were 14% less likely to receive prompt nursing visits than other sepsis patients, and their 30-day readmissions were higher (25% versus 19%). Given the importance of timely visits for antibiotic stewardship, medication reconciliation, and infection monitoring, there is vast potential to improve sepsis survivors’ outcomes. Highlighting profiles of sepsis survivors can inform prioritization and tailoring of HHC interventions for this vulnerable group.

Sepsis survivors transitioning from hospital-to-home are clinically complex. Family caregivers can face challenges managing patients’ care needs; however, skilled home health care (HHC) can serve as an important resource during this care transition. This study’s purpose was to describe caregiving needs among older sepsis survivors receiving post-acute HHC, and identify sources of unmet caregiving needs. We conducted a retrospective analysis of a national dataset of Medicare beneficiaries starting a new HHC episode who were after hospital discharge for sepsis between 2013 and 2014 (n=165,228). All patients received at least one HHC visit the first week after hospital discharge. Caregiving activities included seven items from the start of care Outcome and Assessment Information Set. Descriptive statistics were used to examine types of caregiving activities and needs, demographics, and clinical information. Proportions of patients with unmet caregiving needs ranged from 9%-29%, with the largest proportion of unmet needs in activities of daily living (ADL) assistance (29%), medication administration (28%), and medical procedures/treatments (25%). Unmet caregiving needs across activities were largely due to a caregiver needing training/supportive services (75%-88%), suggesting that many sepsis survivors receiving HHC have caregivers who are available to help, but who lack the knowledge and skills to manage patients’ complex care needs. Thus, HHC providers should address caregiving training and support needs, especially related to assistance with ADLs, medication administration, and medical procedures/treatments. Future research is needed to determine specific educational strategies for caregiver training and support, especially related to skills and knowledge assessment, and training delivery and monitoring.

Older adults are admitted to home health (HH) care from acute care settings with diverse needs, requiring different levels of care. However, it is unknown how nurses decide on visit patterns nor are there empirically derived clinical decision support tools to guide them. Using qualitative descriptive method, HH nurses’ decision making about the number and frequency of nursing visits when developing a visit plan was explored. Semi-structured interviews with HH nurses (N=30) employed full-time by three agencies were analyzed. Through content analysis three approaches emerged: nurses followed a systematic approach to develop visit plans and based their decisions on a central team’s recommendations, their professional evaluation, or their agency-specific guidelines. Factors considered included patient’s clinical status, learning style, and support system. Findings are contributing to a decision support tool that guides HH nurses in developing appropriate visit plans to ensure an optimal transition of older adults from hospital to home.

Older adults who experience new or worsening difficulties performing activities of daily living (ADL) after hospitalization have poorer prognoses within a year after discharge. Past research suggests racial/ethnic disparities exist in the development and progression of ADL disability. However, little research exists examining ADL disability disparities among racially/ethnically diverse older adults after hospitalization. Understanding differences in ADL disability across racial/ethnic groups may lead to targeted interventions reducing disparities and promoting ADL performance. This study’s purpose was to determine if differences exist in ADL disability trajectories among racially/ethnically diverse adults age 65 years and older receiving home care following hospitalization. We used 2013–2014 Outcome and Assessment Information Set data (n=21,473) from a large non-profit home care agency to examine overall change in ADL disability, which was measured by summing the difference of admission and discharge scores from nine individual ADL. Associations between race/ethnic groups and overall ADL change scores were examined using general linear regression models, adjusting for personal, environmental, and health-related factors from the International Classification of Functioning, Disability and Health framework. On home care admission, Asians, African-Americans, and Hispanics had poorer individual ADL scores compared to Non-Hispanic Whites (all p

Sepsis is a critical public health problem in the U.S., with heightened risk of sepsis severity shown to affect the growing population of older adults with Alzheimer’s disease and related dementia (ADRD). As part of a larger study on survivors of sepsis receiving home health care (HHC), we compared clinical and demographic profiles and health outcomes of sepsis survivors across three subgroups: patients with ADRD; patients without a known ADRD diagnosis but with cognitive symptoms identified on the HHC clinical assessment; and patients with neither of these characteristics (“reference”). Using Medicare claims and HHC assessment data on a national sample of 165,228 sepsis survivors discharged from the hospital to HHC within one year, we examined associations between ADRD/cognitive status and 6-month outcomes. Thirty-one percent had ADRD, while 11% had cognitive symptoms without an ADRD diagnosis. The ADRD group was older (42% age 85+ compared to 19% with cognitive symptoms and 16% of the reference), had a greater proportion female (60% vs. 54% and 53%, respectively), and had a greater proportion with urinary tract/kidney infection as the source of sepsis (52% vs. 38% and 34%, respectively). Compared to the reference, the ADRD group had greater odds of re-hospitalization within 6 months in multivariable regression (OR=1.32; 95% CI=[1.29, 1.36]). Both the ADRD group and cognitive symptoms group had greater odds of nursing home admission. The subgroups of sepsis survivors with ADRD and cognitive symptoms have unique profiles and risk factors that may be used to inform HHC interventions for these vulnerable patients.

Older adults with terminal illness face many end-of-life care challenges. Specifically, knowing how much time remains is essential for closure for personal and family matters. The Palliative Performance Scale (PPS) has been widely used for survival prediction among patients with cancer; however, few studies have reviewed PPS scores in heterogeneous hospice populations across multiple care settings. The purpose of this systematic literature review was to determine how the PPS tool has been used to predict survival for older adults at the end-of-life. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and electronic databases (PubMed, Embase, Cochrane Library) were searched for all published literature from 2008 to 2017. We analyzed study characteristics, the PPS score on admission, and primary outcomes, and explored differences in survival estimates by diagnosis. Seventeen studies were included in this review (9 with cancer and 8 with mixed diagnoses). The primary findings from this review were that the PPS predicted length of survival across all studies. In this review, survival estimates ranged from 1 to 3 days for older adults with PPS scores of 10% compared with a range of 5 to 36 days for those with scores of 30%. The findings confirm that the PPS has been used more frequently to estimate survival in patients with cancer and that there are opportunities to apply the tool to patients with different end-of-life diagnoses.