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Infection prevention is a high priority for home healthcare (HHC) but tools are lacking to identify patients at highest risk for developing infections. The purpose of this study was to develop and test a predictive risk model to identify HHC patients at risk of an infection-related hospitalization or emergency department visit. A non-experimental study using secondary data was conducted. The Outcome and Assessment Information Set linked with relevant clinical data from 112,788 HHC admissions in 2014 were used for model development (70% of data) and testing (30%). A total of 1,908 patients (1.69%) were hospitalized or received emergency care associated with infection. Stepwise logistic regression models discriminated between individuals with and without infections. Our final model, when classified by highest risk of infection, identified a high portion of those who were hospitalized or received emergent care for an infection while also correctly categorizing 90.5% of patients without infection. The risk model can be used by clinicians to inform care planning. This is the first study to develop a tool for predicting infection risk that can be used to inform how to direct additional infection control intervention resources on high-risk patients, potentially reducing infection related hospitalizations, emergency department visits, and costs.

The purpose of the study was to obtain exploratory, descriptive information that would provide insights into the barriers to and facilitators of the implementation of fall prevention programs in home care settings. The study employed a qualitative approach through a series of focus groups with home care providers who work with patients with diabetes (N = 29). The study identified teamwork, resistance to change, and patient's readiness as major factors in fall prevention practice at home care. Understanding health-care providers' experiences with fall prevention in home care settings has the potential to facilitate better translation of evidence to practice for community-dwelling older adults.

Pain is a common problem for patients receiving home care, often limiting mobility and contributing to functional decline. Pharmacological pain management is common, but all drugs bring some risk of side effects and adverse reactions. The opioid epidemic has brought into question analgesic prescribing patterns across all care settings. This study, which used data collected between 2012 and 2014, examines the pain medications used by older adults with activity-limiting pain receiving home care physical therapy in a large metropolitan home care agency. Eighty-five percent of subjects took at least one analgesic medication on admission to home care, and of these, 51.3% were using an opioid, 33.1% used acetaminophen, and 23.2% used nonsteroidal anti-inflammatory drugs (NSAIDs). At the 60-day follow-up, the most common medication classes taken by participants included acetaminophen (38%), opioids (35.9%), and NSAIDs (31.6%). We found racial/ethnic differences in analgesic use at baseline but not at follow-up. At baseline, analgesic use differed by pain type, but there were no differences at follow-up. The high use of medications to control pain by patients receiving home care, particularly opioid use, underscores the importance of providers being alert to potential adverse drug reactions.

This cohort study examines the risk factors for long-term mortality and the patterns of end-of-life care among a national population of adult sepsis survivors who are Medicare fee-for-service beneficiaries and have been discharged to home health care., Key Points Question What are the risk factors for long-term mortality and patterns of end-of-life care among sepsis survivors who are Medicare beneficiaries and have been discharged to home health care? Findings In this cohort study of 87 581 adult sepsis survivors who are Medicare fee-for-service beneficiaries and have been discharged to home health care, 1 in 4 survivors died within 1 year, and among the decedents, hospitalization and intensive care unit use in the last 30 days of life and in-hospital death were common. Several factors were found to be associated with an increased risk of mortality. Meaning The findings of this study suggest that home health assessments may provide an opportunity to identify high-risk sepsis survivors and target efforts to improve their end-of-life care., Importance Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. Objective To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. Design, Setting, and Participants This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. Exposures Sepsis hospital discharge and 1 or more home health assessments within 1 week. Main Outcomes and Measures Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. Results Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P

This study sought to: 1) identify the predictors of hospice enrollment for patients with heart failure (HF); and 2) determine the impact of hospice enrollment on health care use.Patients with HF rarely enroll in hospice. Little is known about how hospice affects this group's health care use.Using a propensity score-matched sample of Medicare decedents with ≥2 HF discharges within 6 months, an Outcome and Assessment Information Set (OASIS) assessment, and subsequent death, we used Medicare administrative, claims, and patient assessment data to compare hospitalizations, intensive care unit stays, and emergency department visits for those beneficiaries who enrolled in hospice and those who did not.The propensity score-matched sample included 3,067 beneficiaries in each group with a mean age of 82 years; 53% were female, and 15% were Black, Asian, or Hispanic. For objective 1, there were no differences in the characteristics, symptom burden, or functional status between groups that were associated with hospice enrollment. For objective 2, in the 6 months after the second HF discharge, the hospice group had significantly fewer emergency department visits (2.64 vs. 2.82; p = 0.04), hospital days (3.90 vs. 4.67; p 0.001), and intensive care unit stays (1.25 vs. 1.51; p 0.001); they were less likely to die in the hospital (3% vs. 56%; p 0.001), and they had longer median survival (80 days vs. 71 days; log-rank test p = 0.004).Beneficiaries' characteristics, including symptom burden and functional status, do not predict hospice enrollment. Those patients who enrolled in hospice used less health care, survived longer, and were less likely to die in the hospital. A tailored hospice model may be needed to increase enrollment and offer benefits to patients with HF.

To describe racial/ethnic group differences in pain presentation and the prevalence of psychosocial factors among patients admitted to home health care, and to determine the extent of racial/ethnic group differences in the association of psychosocial factors with pain intensity and pain-related disability. We analyzed cross-sectional data on 588 patients with activity-limiting pain admitted to home care for physical therapy. Three psychosocial factors were assessed: depressive symptoms, pain self-efficacy, and health literacy. Statistical methods included estimation of general linear models of pain intensity and pain-related disability. Hispanics and non-Hispanic blacks report a greater number of pain sites, worse pain intensity, and higher levels of pain-related disability than non-Hispanic whites and others. Racial/ethnic minority group patients also have a higher prevalence of adverse psychosocial factors than others, with evidence that race/ethnicity interacts with pain self-efficacy and depressive symptoms in their association with mean pain intensity and pain-related disability, respectively. The substantial racial/ethnic difference in the psychosocial profiles of older adults with activity-limiting pain highlights the importance of screening for these modifiable risk factors and tailoring interventions accordingly. Direct attention to the psychosocial needs of patients could help to address racial/ethnic disparities in pain outcomes.

There is little evidence to guide the care of over a million sepsis survivors following hospital discharge despite high rates of hospital readmission.We examined whether early home health nursing (first visit within 2 days of hospital discharge and at least 1 additional visit in the first posthospital week) and early physician follow-up (an outpatient visit in the first posthospital week) reduce 30-day readmissions among Medicare sepsis survivors.A pragmatic, comparative effectiveness analysis of Medicare data from 2013 to 2014 using nonlinear instrumental variable analysis.Medicare beneficiaries in the 50 states and District of Columbia discharged alive after a sepsis hospitalization and received home health care.The outcomes, protocol parameters, and control variables were from Medicare administrative and claim files and the home health Outcome and Assessment Information Set (OASIS). The primary outcome was 30-day all-cause hospital readmission.Our sample consisted of 170,571 mostly non-Hispanic white (82.3%), female (57.5%), older adults (mean age, 76 y) with severe sepsis (86.9%) and a multitude of comorbid conditions and functional limitations. Among them, 44.7% received only the nursing protocol, 11.0% only the medical doctor protocol, 28.1% both protocols, and 16.2% neither. Although neither protocol by itself had a statistically significant effect on readmission, both together reduced the probability of 30-day all-cause readmission by 7 percentage points (P=0.006; 95% confidence interval=2, 12).Our findings suggest that, together, early postdischarge care by home health and medical providers can reduce hospital readmissions for sepsis survivors.

Background/objectives New or worsened disabilities in functional, cognitive, or mental health following an intensive care unit (ICU) stay are referred to as post-intensive care syndrome (PICS). PICS has not been described in older adults receiving home care. Our aim was to examine the relationship between length of ICU stay and PICS among older adults receiving home care. We expected that patients in the ICU for 3 days or longer would demonstrate significantly more disability in all three domains on follow-up than those not in the ICU. A secondary aim was to identify patient characteristics increasing the odds of disability. Design Retrospective cohort study. Setting Hospitalization for sepsis in the United States. Participants A total of 21 520 Medicare patients receiving home care and reassessed a median of 1 day (interquartile range 1-2 d) after hospital discharge. Measurements PICS was defined as a decline or worsening in one or more of 16 indicators tested before and after hospitalization using OASIS (Home Health Outcome and Assessment Information Set) and Medicare claims data. Results The sample was predominantly female and white. All had sepsis, and most (81.8%) had severe sepsis. In adjusted models, an ICU stay of 3 days or longer, compared with no ICU stay, increased the odds of physical disability. Overall, the declines were modest and found in specific activities of daily living (16% for feeding and lower body dressing to 26% for oral medicine management). No changes were identified in cognition or mental health. Significant determinants of new or worsened physical disabilities were sepsis severity, older age, depression, frailty, and dementia. Conclusion Older adults receiving home care who develop sepsis and are in an ICU for 3 days or longer are likely to develop new or worsened physical disabilities. Whether these disabilities remain after the early postdischarge phase requires further study. J Am Geriatr Soc 67:520-526, 2019.

Objective To compare the effectiveness of two “treatments”—early, intensive home health nursing and physician follow-up within a week—versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care. Data Sources National Medicare administrative, claims, and patient assessment data. Study Design Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week. Data Extraction Methods All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files. Principal Findings Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p

Objective To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. Design Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. Setting and Participants National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N = 165,228). Methods We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. Results The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. Conclusions and Implications Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.

Objective: To estimate risk and duration of chronic conditions and disability for all older Americans and demographic subgroups. Method: Analysis of National Mortality Followback Survey data for survivors to age 65 to project lifetime risk and duration of selected conditions and examine their relationship with life expectancy and disability. Results: For women, Blacks, and non-Blacks, arthritis is most common and has the longest average duration, followed by diabetes and COPD. Among men, diabetes duration is longest, followed by COPD. Disability risk is elevated for all conditions studied, except heart attack. Those very overweight most of life and persons with dementia have the greatest disability risk and relatively long disability durations. Among women, those very overweight most of life can expect to die 3.1 years sooner and have above average disability duration. Discussion: Findings provide new information about the relative burden of common chronic diseases among all older Americans and major subgroups.

Computerized drug utilization review (DUR) can potentially reduce adverse drug events. We examined automated DUR for home healthcare patients with diabetes or hypertension. Sixty-eight percent of diabetes patients and 50.7% of hypertension patients triggered severe, moderate, or duplicative alerts. Among diabetes patients, 74.3% of duplicative alerts were trivial or inappropriate, compared with 3.9% among hypertension patients. Experts judged that 40.5% of high-risk diabetes patients and 53.6% of hypertension patients had alerts requiring nurse follow-up. Adequate follow-up was significantly lower for the former. The relationship between inappropriate alerts and poorer follow-up reinforces the need for more specific alert systems to focus clinicians' attention on clinically important alerts.

Purpose: The prevalence of pain in older adults receiving home health care is high, yet safety concerns for analgesic therapy point to a need for nonpharmacologic approaches to pain management in this population. The purpose of this study was to determine the feasibility and acceptability to physical therapists (PTs) and patients of a cognitive-behavioral pain self-management (CBPSM) program. Methods: Thirty-one PTs volunteered to participate, completed two 4-hour training sessions, and recruited 21 patients with activity-limited pain who consented to participate in the study. Physical therapists completed pre- and posttest assessments of CBPSM knowledge at the first training session, provided structured survey feedback after the second training session, and responded to a phone survey 3 months after training. Patients provided feedback during weekly phone interviews, while receiving the CBPSM program. Treatment sessions were audiotaped during delivery of the self-management pain protocol. Audiotapes were evaluated by independent raters for program fidelity. Results: Participating PTs were experienced in physical therapy (average 16.5 years) and in home health care (average 11.0 years). Analysis of pre- and posttest data showed that PTs' CBPSM knowledge increased from a pretest mean of 60.9% to a posttest mean of 85.9%. Audiotape analysis indicated 77.7% therapist adherence to the protocol. At 3-month follow-up, 24.0% of therapists continued to use the entire protocol with their patients presenting with activity-limiting pain. Patient data show high rates of patient recall of being taught protocol components, trying components at least once (ranging from 84.4% to 100.0%) and daily use of protocol components (ranging from 47.3% to 68.4%). The percentage of patients finding a technique helpful for pain management ranged from 71.4% to 81.2%. Conclusion: This study offers preliminary data on the use of nonpharmacologic pain self-management strategies by PTs in home health setting. Positive feedback from PTs and patients suggests that the translated protocol is both feasible and acceptable.

Research on African American and white attitudes, perceptions, and knowledge of hospice care has focused predominantly on patients and providers in institutions and community-based care settings. Little is known about patients receiving home health services, despite growing trends toward noninstitutional care in the United States. This study of home health clients who are eligible for hospice, but not currently receiving it, found few differences between racial groups with regard to attitudes about end-of-life care. An alarming proportion of African American and white home health clients held erroneous ideas about hospice care and had not discussed this option with their providers. These findings suggest that increased referrals to home-based hospice care among home health clients depend on the availability and professional dissemination of accurate, spiritually sensitive information.

To assess the impact and cost-effectiveness of two information-based provider reminder interventions designed to improve self-care management and outcomes of heart failure (HF) patients.Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF.Patients were treated by nurses randomly assigned to usual care or one of two intervention groups. The basic intervention was an e-mail to the patient's nurse highlighting six HF-specific clinical recommendations. The augmented intervention supplemented the initial nurse reminder with additional clinician and patient resources.Patient interviews were conducted 45 days post admission to measure self-management behaviors, HF-specific outcomes (Kansas City Cardiomyopathy Questionnaire-KCCQ), health-related quality of life (EuroQoL), and service use.Both interventions improved the mean KCCQ summary score (15.3 and 12.9 percent, respectively) relative to usual care (por =.05). The basic intervention also yielded a higher EuroQoL score relative to usual care (por =.05). In addition, the interventions had a positive impact on medication knowledge, diet, and weight monitoring. The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes.This study demonstrates the positive impact of targeting evidence-based computer reminders to home health nurses to improve patient self-care behaviors, knowledge, and clinical outcomes. It also advances the field's limited understanding of the cost-effectiveness of selected strategies for translating research into practice.

The purpose of this randomized, controlled, home care intervention was to test the effectiveness of two nurse-targeted, e-mail-based interventions to increase home care nurses' adherence to pain assessment and management guidelines, and to improve patient outcomes. Nurses from a large urban non-profit home care organization were assigned to usual care or one of two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcomes measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized nursing workforce with limited recent exposure to state-of-the-art pain management practices.

This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses' support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home healthcare agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses'teaching and support skills. Outcome measures included home care,physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p.05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur.

The Balanced Budget Act of 1997 mandated a major overhaul in Medicare payment for home health care with an interim payment system (IPS) preceding a prospective payment system (PPS). This study extends an earlier analysis of the impact of the IPS to determine whether home health use and spendingtrends changed after the introduction of the PPS. The rapid decline in the incidence of use and visits per user under the IPS slowed in its final year and then picked up again in the first year of the PPS. In addition, average payment per visit increased sharply under the PPS. Little is known about the impact of continued large reductions in home health services since 1999.

Objectives. Despite the large number of elders using postacute and long-term care services, there is little information about transitions through different settings or the impact of transitions on elders’ health. This gap in knowledge is addressed by analyzing the use of postacute and long-term care settings during a 2-year interval by a nationally representative cohort of elders. Methods. A 2-year longitudinal record of the use of short-stay hospitals and postacute and long-term care settings was constructed for all respondents to the 1994 National Long Term Care Survey age 65 or older in 1992. Indicators of potential transition problems include emergency room visits, potentially avoidable hospital stays, and return to an institutional setting following discharge to the community. Results. Almost 18% of elders, 4.9 million persons, were admitted to or discharged from a study setting between 1992 and 1994. A sizable number of these elders (22.4%) had subsequent health care use, suggesting a possible transition problem. Transitions from acute care hospitals to paid home care represent 20.8% of all transitions and are followed by relatively high rates of potential problems. Conclusions. This study provides new information on patterns of postacute and long-term care use and the types of transitions most likely to be followed by potential problems. The results suggest three broad strategies for improving the outcome of transitions through postacute and long-term care settings.

Despite the growth in the number of Americans in nursing homes, there are only limited data on the total amount of time that people spend in such facilities. We estimate the amount of time the average person spends in nursing homes over his or her lifetime (lifetime nursing home use), using data from the National Mortality Followback Survey of the next of kin of a sample of persons 25 years of age or older who died in 1986. On the basis of these data, we estimated the likelihood that Americans will use nursing home care during the course of their lifetimes and the total duration of such care. Current data on life expectancy were then used to reweight the sample to project lifetime nursing home use for those who became 65 years old in 1990.Of those who died in 1986 at 25 years of age or older, 29 percent had at some time been residents in a nursing home, and almost half of those who entered a nursing home spent a cumulative total of at least one year there. The probability of nursing home use increased sharply with age at death: 17 percent for age 65 to 74, 36 percent for age 75 to 84, and 60 percent for age 85 to 94. For persons who turned 65 in 1990, we project that 43 percent will enter a nursing home at some time before they die. Of those who enter nursing homes, 55 percent will have total lifetime use of at least one year, and 21 percent will have total lifetime use of five years or more. We also project that more women than men will enter nursing homes (52 percent vs. 33 percent), and among them, more women than men will have total lifetime nursing home use of five years or more (25 percent vs. 13 percent).Our projections indicate that over a lifetime, the risk of entering a nursing home and spending a long time there is substantial. With the elderly population growing, this has important implications for both medical practice and the financing of long-term care.