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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.

Activity-limiting pain is common among older home care patients and pain management is complicated by the high prevalence of physical frailty and multimorbidity in the home care population. A comparative effectiveness study was undertaken at a large urban home care agency to examine an evidence-based pain self-management program delivered by physical therapists (PTs). This article focuses on PT training, methods implemented to reinforce content after training and to encourage uptake of the program with appropriate patients, and therapists' fidelity to the program. Seventeen physical therapy teams were included in the cluster randomized controlled trial, with 8 teams (155 PTs) assigned to a control and 9 teams (165 PTs) assigned to a treatment arm. Treatment therapists received interactive training over two sessions, with a follow-up session 6 months later. Additional support was provided via emails, e-learning materials including videos, and a therapist manual. Program fidelity was assessed by examining PT pain documentation in the agency's electronic health record. PT feedback on the program was obtained via semistructured surveys. There were no between-group differences in the number of PTs documenting program elements with the exception of instruction in the use of imagery, which was documented by a higher percentage of intervention therapists (p = 0.002). PTs felt comfortable teaching the program elements, but cited time as the biggest barrier to implementing the protocol. Possible explanations for study results suggesting limited adherence to the program protocol by intervention-group PTs include the top-down implementation strategy, competing organizational priorities, program complexity, competing patient priorities, and inadequate patient buy-in. Implications for the implementation of complex new programs in the home healthcare setting are discussed.

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.

Diabetes mellitus (DM) increases the risk of developing infectious complications, including sepsis. Little is known about sepsis survivors with DM. Overall, there are limited and conflicting information regarding outcomes of patients with diabetes after a hospitalization for sepsis. The purpose of this study was to profile the characteristics and outcomes for sepsis survivors with (n = 80,312) and without DM (n = 84,916). The sample included Medicare beneficiaries discharged from the hospital to home health care (HHC) after a sepsis admission between July 1, 2013 and June 30, 2014. We utilized Medicare administrative claims and the Outcome and Assessment Information Set Version C start of care assessments. The incidence of older adults with DM and sepsis in HHC was 48.6%; a much higher rate than the 20-30% reported in the general hospitalized population. Those with DM and sepsis had a higher proportion of 30-day rehospitalization (24.3% verse 20.8%, p < .001) and were more likely to have a prior sepsis admission (9.28% verse 3.35%, p < .001) than sepsis patients without DM. They had more comorbid conditions (5.19 versus 3.8, p Disclosure C.R. Whitehouse: None. L. Jordan: None. K. Bowles: None. C.M. Murtaugh: None. Funding National Institute of Nursing Research (R01NR016014); Visiting Nurse Service of New York; Ruth L. Kirschstein National Research Service Award; University of Pennsylvania School of Nursing

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.

Patients who are discharged to home health care (HHC) after a hospitalization for sepsis may experience high rates of readmission, functional decline, and mortality. The presence of one or more geriatric syndromes (GS) may exacerbate these negative outcomes. This purpose of this retrospective study was to identify the prevalence of GSs and describe their cumulative effects associated with healthcare utilization (rehospitalization, skilled nursing facility or sub-acute rehabilitation placement) and death in sepsis survivors recently discharged to HHC. Utilizing the Medicare administrative, Outcome and Assessment Information Set, and claims data from the Chronic Condition Warehouse for beneficiaries receiving HHC, six GSs (frailty, incontinence, falls, depression, pressure ulcers and functional decline) were identified. Overall, 91.6% of patients had one or more GSs. At 30 days post hospitalization, sepsis survivors with incontinence or pressure ulcers had a higher rate of rehospitalization and death than patients without these GSs. At seven days after discharge the rate of death was more than double for patients with a pressure ulcer (24.8%) when compared to those without (8.46%). However, risk of 30-day rehospitalization did not increase with increased number of GSs. Improvements in the assessment and identification of GSs in HHC are needed. Prompt and proper identification of GS can lead to early identification of at-risk older adults and timely, focused interventions to improve health outcomes.

Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in hospital readmission rates. Database searches yielded 950 potential articles, of which 34 studies met inclusion criteria. Patient characteristics generally have a very modest effect on all-cause or heart failure–related readmission within 7 to 180 days of index hospital discharge. A range of cardiac diseases and other comorbidities only minimally increase readmission rates. No single patient characteristic stands out as a key contributor across multiple studies underscoring the challenge of developing successful interventions to reduce readmissions. Interventions may need to be general in design with the specific intervention depending on each patient’s unique clinical profile.

Objectives To determine the effectiveness of a cognitive–behavioral pain self-management (CBPSM) protocol delivered by physical therapists (PTs) for use by older adults with activity-limiting pain receiving home care. Design A randomized pragmatic trial comparing delivery of the intervention plus usual care with usual care alone. Setting Community. Participants Individuals aged 55 and older admitted with orders for physical therapy who endorsed activity-limiting pain and reported pain scores of 3 or greater on a scale from 0 to 10 (N = 588). Intervention A CBPSM protocol delivered by PTs. Measurements Primary outcomes were assessed at 60 days using validated measures of pain-related disability, pain intensity, gait speed, and number of activity of daily living (ADL) deficits. Results Of 588 participants, 285 received care from a PT randomized to the intervention and 303 from a PT randomized to the usual care group. Both groups had significant reductions in pain-related disability, pain intensity, and ADL limitations and improved gait speed. No significant treatment differences were identified. There were no consistent treatment differences when interactions and subgroups were examined. Conclusion This real-world pragmatic trial found no effect of implementation of a pain self-management intervention in a home care setting. Despite the lack of positive findings, future studies are indicated to determine how similar protocols that have been found to be effective in efficacy studies can be successfully implemented in routine clinical care.

Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home health patients. Upon review of the frontloading evidence, visit intensity emerged as being closely related. This state of the science presents a critique and synthesis of the published empirical evidence related to frontloading and visit intensity. OVID/Medline, PubMed, and Scopus were searched. Seven studies were eligible for inclusion. Further research is required to define frontloading and visit intensity, identify patients most likely to benefit, and to provide a better understanding of how home health agencies can best implement these strategies.

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.

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.

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.

The aging population and the associated rise in the prevalence of chronic conditions suggest that the home health population is increasingly complex and challenging to manage. The purpose of this study was to use national administrative data (Outcome and Assessment Information Set assessments of persons discharged in 2004 and 2005) to examine the clinical complexity of older adults admitted to home healthcare. Our descriptive analyses confirm that multiple chronic conditions and cognitive impairment are common and result in longer lengths of stay. The findings support the need for geriatric home healthcare practices that effectively address multiple morbidities and cognitive function.

Appropriate and efficient provision of services at home requires more than skilled personnel; effective communication between the primary care provider and the agency is an often overlooked but essential tool for maintaining the patient's health in the community. A method was developed to create home care orders (the “e-485”) that guides the physician through the order writing process, uploads data from the electronic medical record, and creates a legible, complete order set that can be faxed quickly to the agency. This paper describes this tool and the challenges and rewards of its implementation in an academic medical center.

Transition points are the weak links in communication between providers. As an example, the discharge home often is a hurried “handoff” from inpatient physician to home care agency, whose visiting nurse admits the patient for a period of observation, medication management, rehabilitation, and teaching. The primary means of communication between physician and home health agency is the CMS 485, a form that contains the orders and that physicians frequently sign well after patients begin receiving services. This paper describes the first phase of a project that restructured and automated the CMS 485 using an existing electronic health record. The principles guiding the restructuring are described along with early reaction to and revision of the form to address operational issues. The paper also discusses evaluation plans and a web-based system of communication that will be developed in the second phase of the project.

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.

Translating research into health care practice is a complex, challenging process aimed ultimately at yielding improvements in patient outcomes. Most of the literature in the field has focused on efforts to increase the use of clinical guidelines in hospitals and by physicians (Davis et al. 1995; Bero et al. 1998; Hunt et al. 1998; Grimshaw et al. 2001; 2004). Although such guidelines usually incorporate practices shown in clinical trials and/or judged by experts to produce clinically meaningful benefits for patients, relatively few “translation” studies have attempted to trace the impact of changes in practitioner behavior to actual improvements in patients' self-management of chronic conditions or to patient outcomes (Worrall, Chaulk, and Freake 1997). This study moves out of the hospital setting and beyond physician practice changes to describe the impact and relative cost-effectiveness of a basic and an augmented e-mail reminder intervention designed to help home health nurses improve the self-management skills and outcomes of their heart failure (HF) patients. The interventions, described in a companion article by Murtaugh et al. (2005), delivered evidence-based, condition-specific information to nurses each time they began to care for a new HF patient—“just-in-time” to incorporate the recommended assessment and instruction practices into each patient's individualized plan of care. The interventions, selected for their reported effectiveness in other settings (Oxman et al. 1995; Bero et al. 1998; Grimshaw et al. 2001), were grounded in the “dual task theory of human performance.” This theory suggests that busy, information-overloaded clinicians will be more likely to perform “secondary” management tasks in conjunction with hands-on care when they receive well organized, cogent information for the right patient at the right time (Litzelman et al. 1993). HF—a debilitating chronic condition characterized by symptoms such as severe shortness of breath, edema, and fatigue—is a high frequency, high cost disease that imposes a significant burden on older adults and their families. The leading cause of hospitalization among elders, HF accounted for nearly one million discharges in 1999 (Rich 2003). HF is also one of the major conditions for which older persons receive home health services. In 1999 it accounted for approximately 8.6 percent of Medicare home health discharges, 226,000 cases, and payments of $646 million (HCFA 2001). HF care has benefited over the past 20 years from the completion of several large-scale, randomized clinical trials and the development of authoritative evidence-based guidelines for clinical evaluation and treatment (Konstam, Dracup, and Baker 1994; Hunt et al. 2001; Rich 2003). Yet HF management among older adults has been suboptimal—marked by under use of effective therapies and lack of patient adherence to diet and medication regimens (Rich 2003). To improve HF care and reduce hospital readmission, experts have recommended early discharge planning (Naylor et al. 1999; Phillips et al. 2004) and disease management approaches that entail post hospital follow-up, close monitoring of patient symptoms, and education regarding diet, medication, and exercise (Rich et al. 1995; Naylor et al. 1999; 2004; Stewart, Marley, and Horowitz 1999; Quaglietti et al. 2000; McAlister et al. 2001; Harrison et al. 2002; Weingarten et al. 2002; Rich 2003; Phillips et al. 2004). In theory, if not in practice, the role of a home health nurse encompasses the close patient follow-up that is a key element of disease management programs. Over the course of an HF home care episode—51 days on average (Centers for Disease Control and Prevention 2004)—home health nurses are routinely responsible for ongoing patient assessment, individualized care planning in consultation with the patient's physician, patient instruction in self-care management, monitoring of patient symptoms and support of patient adherence to medications and diet. Thus rather than mounting a new care management program, this study focused on the use of just-in-time, condition-specific information to improve the evidence-based knowledge and practices of home care staff already serving in the community. The interventions capitalized on existing intranet communication channels, so no significant organizational systems changes needed to be made. As an inexpensive and convenient mechanism, e-mail reminders were hypothesized to be an effective new medium for home care agencies and other decentralized health care practices to upgrade and standardize service provision and improve patient self-management and outcomes. The results reported here describe the comparative impact and cost-effectiveness of two variations of the information-based interventions.

The difficulty of translating research findings into sustainable improvements in care practices and clinical outcomes is well documented (Grimshaw and Russell 1993; Woolf et al. 1999; AHRQ 2001; Grimshaw et al. 2001; Grol 2001; Gross et al. 2001). A growing number of studies show that passive approaches, such as unsolicited distribution of consensus recommendations or guidelines, and traditional didactic lectures and seminars, generally are ineffective in changing clinical practice (Davis et al. 1995; Oxman et al. 1995; Bero et al. 1998). Strategies having more influence on provider behavior are audit and feedback by peers or opinion leaders, reminder systems, and multi-faceted interventions (Davis and Taylor-Vaisey 1997; Grimshaw et al. 2001; Wagner et al. 2001). Physicians generally have been the focus of studies examining practice change strategies, with the interventions targeting specific behaviors such as preventive care, prescribing practices, and test ordering. The study reported here expands the literature on translating research into practice by testing the effectiveness of two computer-based interventions designed to promote evidence-based practice among home care nurses. We describe the effect of these interventions on the adoption of evidence-based care practices for the treatment of heart failure (HF) patients. Three relatively recent phenomena fuel interest in evidence-based practice among home care agencies. On the market front, rapid enrollment of Medicare beneficiaries in managed care organizations during the mid-to-late 1990s led to agency competition for managed care contracts and to the adoption of various disease management programs thought to be attractive to, and sometimes required by, managed care customers. On the regulatory front, the development and dissemination of the uniform home health assessment (i.e., the Outcome and Assessment Information Set, or OASIS) now mandated by the Centers for Medicare and Medicaid Services, has made outcomes-based reporting and regulation a reality for most home health agencies. Finally, on the payment front, the Balanced Budget Act of 1997 replaced cost-based reimbursement with a prospective payment system for Medicare home health that pays agencies a fixed dollar amount per episode of care and puts a premium on more efficient and effective use of clinical resources. HF patients frequently are admitted to home care following a hospital stay with the objective of improving patient and family management of the disease. Referrals to home care, whether from a hospital or community-based physician, will include a preliminary set of medical orders that form the basis of the plan of care to be implemented by the home care nurse. At the first visit the nurse will perform an initial assessment of the patient and the home environment, seek verbal orders for necessary changes in the plan of care (e.g., updating an incomplete list of medications) and send the revised plan of care to the physician for signature. During subsequent visits nurses are responsible for ongoing assessment of the patient's condition, monitoring medications (and infrequently for HF patients, medication administration), instructing the patient about HF management, and implementing all medical orders. Home care nurses usually are generalists who vary in educational background and experience. All nurses, however, receive HF management training at the agency orientation. The interventions tested were a basic intervention consisting of a single just-in-time e-mail reminder to nurses, and an augmented intervention in which the e-mail reminder was supplemented by additional provider prompts and patient education materials. Reminders trigger the action of the informed person without a preceding specific request, as compared with passive systems that require an individual to recognize when advice would be helpful and make an active effort to retrieve information. Litzelman and colleagues (1993) postulate that reminders work in the realm of prevention because they are consistent with the dual task theory of human performance. This theory suggests that performance of “secondary” preventive tasks in conjunction with hands-on medical care can be improved by organizing and presenting cogent information at critical times to reduce clinician overload and direct clinicians to tasks needing their attention. Chueh and Barnett (1997) describe the use of “just-in-time” reminders to identify patients who are candidates for a particular guideline and to send that guideline to the clinician at the right time and place. Employing a “system driven, ‘push’ approach,” software programs can be used to trigger just-in-time e-mails to push out information to the clinician. Electronic patient-specific clinical reminders were selected for study because of their efficacy in other settings and because they enabled us to address some of the unique challenges that the home care environment poses for quality improvement initiatives. Nurses in this setting usually care for a very diverse group of patients; the nurse workforce is largely decentralized; communication is impeded by the dispersion of patients and referring physicians; and few evidence-based practice recommendations have been adapted or developed for home health care (Brannon and Dansky 2001; Peterson 2004). We hypothesized that nurses receiving care recommendations at the time they are assigned a HF patient would be more likely than others to provide evidence-based care.

187 This paper describes the methodology used in selecting and reweighting discharge level data from the 1985 National Nursing Home Survey so that it represents a sample of decedents who used nursing homes sometime during their lives. Such a strategy allows for the analysis of lifetime nursing home use and financing with a level of information that previously was not available. Adjustments to the existing weight included those for unit nonresponse, multiple probabilities of selection, and differential follow-up periods, as well as a ratio adjustment to bring the distribution of nursing home users with and without use in the last year of life in line with an external distribution from the 1986 National Mortality Followback Survey. A comparison of weighted estimates is made between the reweighted Nursing Home Survey data and the Mortality Followback data.

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.

This paper assesses the effect of changes in the minimum number of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations, type of help, and duration of disability required on the size of the population potentially eligible for home care benefits. Only 411,000 elders meet very restrictive disability criteria, whereas over 4 million would be eligible under expansive criteria. The selection of disability criteria has important implications not only for the size of the eligible population but also for which groups qualify for benefits and which are excluded.

Risk adjustment is a critical tool in public reporting of quality measures. Its aim is to level the playing field so that providers serving different patients can be meaningfully compared. We used a theory and evidence-based approach to develop risk-adjustment models for the 10 publicly reported home health quality measures and compared their performance with current models developed using a data-driven stepwise approach. Overall, the quality ratings for most agencies were similar regardless of approach. Theory and evidence-based models have the potential to simplify risk adjustment, and thereby improve provider and consumer understanding and confidence in public reporting.

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.

The authors consider an integrated income and disability annuity as an alternative framework for long-term care financing, show that pooling disability and mortality risks can reduce the need for medical underwriting, and discuss private and public implications. Data from the National Mortality Followback Survey of 1986 were used to simulate current underwriting and minimal underwriting, excluding only those already eligible for benefits. Remaining disability, life expectancy, and premiums are compared under both underwriting assumptions. Under minimal underwriting, 98% of persons age 65 would be eligible to purchase disability protection through an integrated annuity, versus 77% under current underwriting. Premiums for both the income and disability components were lower with minimal underwriting. Combining income and disability protection may be able to expand private markets for long-term care financing beyond what appears possible in the long-term care insurance market. Public policy should avoid the distortion of choices created by focusing exclusively on an insurance model.

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.

Little national data have been available to guide the design of programs aimed at reducing the hospitalization of nursing home residents. This article uses the 1987 National Medical Expenditure Survey to identify elderly nursing home residents with an elevated risk of hospitalization and the reasons for and outcomes of residents' hospital stays. Study findings include an elevated risk of hospitalization for residents with one of several different primary diagnoses and a rise in risk as ADL dependence increases. An infection was the main medical reason for roughly 27% of hospital stays. The results suggest possible target groups for two types of programs aimed at reducing hospitalization.

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.

This article examines the implications of the positive correlation of mortality and disability for the benefits of combining an immediate income annuity with long-term care disability coverage at retirement ages. It also investigates the value of such a combined benefit to various subgroups of prospective purchasers and the implications of possible errors and moral hazard in the reporting of disability status and making claims. (The Journal of Risk and Insurance, 2001, Vol. 68, No. 2, 225-254)

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