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Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs. [ABSTRACT FROM AUTHOR]

Background: There is limited evidence regarding the challenges of providing hospice care to those dying at home during the COVID-19 pandemic. Objective: To describe the challenges of home hospice care and the specific types of disruptions in care processes experienced by patients and families. Design: Qualitative study of the electronic medical record notes of a large New York City (NYC) home-based primary care program. Setting/Subjects: Subjects were 58 patients referred to hospice who died during the initial NYC COVID-19 surge from March to June 2020. Results: We identified six domains of disruptions in home hospice care: delayed hospice enrollment, inability to conduct home visits, lack of needed supplies, communication failures, strained caregivers, and limitations of telehealth. Conclusions: This study provides a critical first analysis of disruptions in home hospice care that can feasibly be addressed and must be prioritized by hospices throughout the ongoing pandemic and in advance of future emergencies. [ABSTRACT FROM AUTHOR]

COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care. [ABSTRACT FROM AUTHOR]

Objective: To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19. Study setting: Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020. Study design: Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward. Data collection: We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles. Principal findings: CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place. Conclusions: Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention. [ABSTRACT FROM AUTHOR]

Background: Access to health care has traditionally been conceptualized as a function of patient socio-demographic characteristics (i.e., age, race/ethnicity, education, health insurance status, etc.) and/or the system itself (i.e., payment structures, facility locations, etc.). However, these frameworks typically do not take into account the broader, dynamic context in which individuals live and in which health care systems function. Purpose: The growth in market-driven health care in the U.S. alongside policies aimed at improving health care delivery and quality have spurred health system mergers and consolidations, a shift toward outpatient care, an increase in for-profit care, and the closure of less profitable facilities. These shifts in the type, location and delivery of health care services may provide increased access for some urban residents while excluding others, a phenomenon we term "health care gentrification." In this commentary, we frame access to health care in the United States in the context of neighborhood gentrification and a concurrent process of changes to the health care system itself. Conclusions: We describe the concept of health care gentrification, and the complex ways in which both neighborhood gentrification and health care gentrification may lead to inequitable access to health care. We then present a framework for understanding health care gentrification as a function of dynamic and multi-level systems, and propose ways to build on existing models of health care access and social determinants of health to more effectively measure and address this phenomenon. Finally, we describe potential strategies applied researchers might investigate that could prevent or remediate the effects of health care gentrification in the United States. [ABSTRACT FROM AUTHOR]

Background: Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care. Objective: To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks. Design: Semi-structured interviews. Participants: Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center. Approach: Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives. Key Results: Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work. Conclusions: Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans. [ABSTRACT FROM AUTHOR]

Death and dying are woven throughout the work of home care aides, and yet the care they provide at the end of life (EOL) remains poorly understood. This is due in part to the multiple circumstances under which aides provide EOL care. In this paper, we elucidate the EOL care experiences of aides working in home care agencies in New York City. We conducted in-depth interviews with 29 home care aides, and we analyzed these data using inductive, team-based methods. Our findings show that aides may not be aware of or accept a client's EOL status, and they may avoid EOL care. These conditions shape EOL care, and we detail the committed forms of care aides provide when they are aware and accepting. We recommend improved training, support systems, and policy change to enhance aides' contributions to EOL care, while protecting aides' health and well-being. [ABSTRACT FROM AUTHOR]

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers. [ABSTRACT FROM AUTHOR]

Background/Objectives: COVID‐19 required rapid innovation throughout the healthcare system. Home‐based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands‐on, model of care to accommodate restrictions on in‐person contact. Our aim was to determine strategies used by New York City (NYC)‐area HBPC practices to provide patient care during the first wave of the COVID‐19 pandemic with the goal of informing planning and preparation for home‐based practices nationwide. Design: Cross‐sectional qualitative design using semi‐structured interviews. Setting: HBPC practices in the NYC metro area during spring 2020. Participants: HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC‐area practices. Measurements: Semi‐structured interviews explored HBPC practices' COVID‐19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end‐of‐life care, telehealth, community‐based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. Results: Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID‐19, such as patient outreach and telehealth. HBPC‐specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in‐person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long‐standing patients. Conclusion: NYC‐area HBPC providers adapted care delivery and operations rapidly during the height of the COVID‐19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges. [ABSTRACT FROM AUTHOR]

While there is a growing literature on home care workers, less is known about how home care companies market their services. Through a content analysis of the 19 largest U.S. home care and home health providers' websites, we examined how companies describe services, desired outcomes of care, and job responsibilities and qualifications. Companies actively market family-like relationships as central to "good care". However, companies' emphasis on unmeasurable skills such as compassion and warmth may also create exploitative work environments. Supporting "good care" requires improved data collection, industry oversight, and policy change to recognize socio-emotional care and protect a marginalized workforce. [ABSTRACT FROM AUTHOR]

Background and Objectives Interventions to strengthen the home care workforce focus on workers' economic and physical well-being, without acknowledging the caring labor affecting emotional well-being. Our study examined workers' perceptions of the emotional effects of caring work, coping mechanisms, and desired support. Research Design and Methods We conducted 4 worker focus groups (n = 27). Moderators cross-checked codes and themes, and aides provided input through report-backs. Results Building close, trusting relationships with clients was central to aides' emotional well-being. Well-being was also influenced by relationships with client families and agency supervisors, work–life balance, and the level to which aides felt their work was valued. Aides were largely alone in managing job stressors and desired more communication, connection, and support from supervisors and peers. Discussion and Implications Recognizing and supporting the emotional demands of caring work is crucial to strengthening the workforce. Policy makers and agencies must realign reimbursement systems, job descriptions, and care plans to include measures of emotional labor, improve communication between workers and supervisors, and provide training, mental health benefits, and peer support. [ABSTRACT FROM AUTHOR]

While many types of health care workers experience patient death, home care workers do so under vastly different social and economic circumstances. When a client dies, home care workers often lose both a close relationship and a job. Though research suggests that health care workers' grief may frequently be disenfranchised, there is no in-depth study of the mechanisms that disenfranchise home care workers' grief specifically. To address this gap, our study used focus groups and peer interviews between home care workers in New York City. We describe four interrelated grief strategies they employ to navigate social and employer-based "grieving rules." Our findings suggest that home care workers' grief is disenfranchised via employer and societal underestimations of their relationships with clients and their losses when clients die, particularly job loss. Building on our findings, we suggest alterations to agency practices and home care systems to improve support for workers. [ABSTRACT FROM AUTHOR]

This article describes a novel approach to reciprocal peer interviewing in which participants interview one another sequentially, allowing each the space of a full interview to articulate her experiences and reflections. This structure of data collection offers a new conceptualization of the way that elicitation functions; not just as a process inside of an interview, but one that is also shaped by factors preceding and outside of the individual interview, a process we call "meta-elicitation." We argue that this form of reciprocal peer interviewing offers a view of the emic that is both participant-led and uniquely balanced between collective and individual perspectives. However, we also argue that shared authority and rapport are actively, and not always successfully, negotiated in such interviews. To prepare participants for peer interviewing, we hosted a 1-day workshop involving interview training, planning, and the recording of interviews. To maximize quality of such projects, we recommend that external researchers consider carefully (1) the balance of structure and flexibility in designing the workshop and interviews, (2) thorough preparation of participants, and (3) the role of meta-elicitation dynamics during analysis. [ABSTRACT FROM AUTHOR]

1. Characterize patients in a home-based primary and palliative care (HBMC) practice who died during the spring 2020 COVID-19 surge in New York City 2. Identify multiple levels of disruption that occurred during the COVID-19 surge 3. Describe three ways that home-based medical and palliative care practices are positioned to support end-of-life care for homebound older adults during emergencies COVID-19 end-of-life research has focused primarily on patients who died in hospitals and nursing homes. Less is known about homebound patients receiving home-based primary and palliative care (HBMC) in the community. To describe characteristics and end-of-life care experiences of patients in an HBMC practice who died during New York City's initial 2020 COVID-19 surge. Mixed-methods, retrospective quantitative and narrative analysis of demographic, clinical, and end-of-life data from unstructured electronic medical record notes for all patients who died between March 1 and June 30, 2020. 112 (9%) of the practice's 1,300 patients died during this period, with the average monthly mortality rate doubling in April 2020, the peak of the NYC surge. Thirty-four (30.4%) had confirmed or probable COVID-19. 58 (52%) were referred to hospice, and 50 enrolled. Eighty-two patients (73%) died at home. Our qualitative analysis found that COVID-19 disrupted regular caregiving routines, often requiring new or inexperienced caregivers to step in; rapidly evolving COVID-19 knowledge and protocols complicated access to services (e.g., requiring patients to present a negative COVID-19 test to begin hospice despite testing shortages); avoiding hospitals and emergency departments became an urgent concern due to visitor restrictions and families' fears of loved ones dying alone; and COVID-19 complicated ongoing care for complex conditions (e.g., continuing dialysis for COVID+ patients). Throughout the surge, the HBMC team drew on their collaborative practice and longstanding relationships with patients, families, and hospice and home care providers to navigate service disruptions and provide comfort and emotional support. Overall, COVID-19 created severe disruptions and barriers to necessary care, further complicating care for this very high-risk, high-needs population. HBMC played an integral role in supporting patients and their families through the pandemic surge. As a model focused on interdisciplinary, whole-person care for medically complex patients, HBMC may be uniquely positioned to support homebound patients at the end of life, both during emergencies and beyond. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Advancing urban health equity in the United States in an age of health care gentrifcation: a framework and research agenda."

1. Characterize patients in a home-based medical care (HBMC) practice who died during the spring 2020 COVID-19 surge in New York City 2. Identify health service and caregiving disruptions that occurred during the COVID-19 surge 3. Identify home-based primary and palliative care practice adaptations to maintain care for homebound patients during the COVID-19 surge Much COVID-19 research focuses on care in institutional settings, but less is known about the care experiences of homebound patients receiving home-based primary and palliative care in the community. Before COVID-19, these patients faced high symptom burden, multiple comorbidities, and high mortality. To describe characteristics and care experiences of patients in a home-based medical care (HBMC) practice who died during New York City's (NYC) spring COVID-19 surge through a mixed-methods, retrospective electronic medical record (EMR) review. We analyzed EMRs for all HBMC patients who died in the initial COVID-19 wave in NYC (March 1-June 30, 2020). We developed an abstraction tool to collect service-related measures (eg, phone calls, televisits), household and clinical characteristics (eg, dementia status), and clinical notes on key disruptions including those related to family caregiving, paid caregiving, medical supplies, and hospice. During the study period 112 patients died, twice the practice's usual monthly deaths. Thirty percent died from confirmed or suspected COVID-19, 73% died at home, and 46% were enrolled in hospice. Medical and service disruptions included medication shortages, delayed hospice enrollment, and suspension of nursing and hospice visits due to personal protective equipment and staff shortages. Caregivers experienced difficulties with long-distance care and frustration over service disruptions. HBMC providers adapted by conducting outreach via phone and telehealth and leveraging relationships with partners such as hospice and medical equipment vendors. Hospital restrictions and fear of infection increased caregivers' and providers' commitment to keeping patients at home at the end of life. Disruptions in family caregiving and health services such as hospice during COVID-19 complicated the dying experience. HBMC providers were an important bridge between caregivers and supportive community and medical resources. The COVID-19 pandemic exemplified how home-based primary and palliative care can be an important resource at the end of life. Targeted resources are needed to support families in managing end-of-life care. [ABSTRACT FROM AUTHOR]

Background: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID‐19 pandemic. The AHCaH waived the 24/7 on‐site nursing requirement and enabled hospitals to obtain full hospital‐level diagnosis‐related group (DRG) reimbursement for providing Hospital‐at‐Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. Methods: We conducted semi‐structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. Principal Findings: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre‐existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. Conclusions: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery. See related Editorial by Brody et al. in this issue. [ABSTRACT FROM AUTHOR]

Background/Objectives: To identify major barriers to video‐based telehealth use among homebound older adults. Design Cross‐sectional survey. Setting: A large home‐based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community. Participants: Sixteen primary care physicians. Measurements An 11‐item assessment of provider perceptions of patients' experience with and barriers to telehealth. Results: According to physicians in the HBPC program, more than one‐third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first‐time video‐based telehealth encounters between April and June 2020 during the first COVID‐19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) "unable to interact over video" for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video‐capable device access. Conclusion: The COVID‐19 pandemic resulted in a large and dramatic shift to video‐based telehealth use in home‐based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video‐based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video‐based telehealth use. [ABSTRACT FROM AUTHOR]

Background: Home care workers (HCWs)—including home health aides, personal care aides, and other direct care workers—provide functional and other essential support that allows older, disabled, and seriously ill people to live at home. As a growing number of patients are aging and dying at home, HCWs are increasingly providing care at the end of life (EOL). Although prior qualitative studies have shown that patient death is an impactful and challenging experience for HCWs, the majority of HCWs receive almost no training on EOL issues. Objective: The goal of this scoping review is to identify intervention studies describing training of HCWs in EOL issues to map types of training and to assess the degree to which existing efforts address HCW health and well-being. Design: Our scoping review covered three databases and focused on articles published in English since 2000. Results: Of the 393 articles screened, 26 underwent full-text review and 6 met inclusion criteria. Only one article discussed training designed for and implemented with HCWs exclusively. Other trainings simultaneously targeted multiple kinds of workers. Supporting HCWs in reducing their stress and improving their coping skills was substantially addressed in only one article, although HCWs' emotional needs were addressed less centrally in several others. Conclusion: Our findings suggest that there is a paucity of EOL training interventions tailored specifically to the experiences and positioning of HCWs. We recommend that future intervention studies address the multiple facets of HCWs' stress related to patient death to improve EOL care in the home. [ABSTRACT FROM AUTHOR]

Demands for home-based care have surged alongside population aging, preferences for aging in place, policy-driven reforms incentivizing lower hospital utilization, and public concerns around coronavirus disease 2019 transmissions in institutional care settings. However, at both macro and micro levels, sociopolitical, and infrastructural contexts are not aligned with the operational needs of home health care organizations, presenting obstacles to home health care equity. We integrate the social-ecological model and organizational theory to highlight contextual forces shaping the delivery of home-based care services between 2010 and 2020. Placing home-based health care organizations at the center of observation, we discuss patterns and trends of service delivery as systematic organizational behaviors reflecting the organizations' adaptations and responses to their surrounding forces. In this light, we consider the implications of provision and access to home care services for health equity, discuss topics that are understudied, and provide recommendations for home-based health care organizations to advance home health care equity. The article represents a synthesis of recent literature and our research and industry experiences. [ABSTRACT FROM AUTHOR]

Outcomes: 1. Summarize and discuss the primary factors driving palliative care program viability in the context of a global pandemic 2. Identify strategies and methods that can empower and support palliative care leaders to sustain and strengthen the programs they lead During the pandemic, US palliative care teams have provided direct care to patients with COVID-19; support for caregivers and families; peer support; and guidance to other clinicians in communication skills, symptom management, and coping with loss. However, the authors were concerned about a potential national trend around palliative care program viability given workforce reallocation, the financial strain on healthcare systems due to the pandemic, and historic operational challenges documented for palliative care teams. Two national Field Surveys were developed and distributed to 1,430 palliative care leaders across the country in May 2020 and January 2021 to ask whether leaders were concerned about the future viability of the programs they lead. The 440 responses were pooled, and the data were analyzed using directed content analysis to identify codes and synthesize emergent themes. Seventy-two percent of responding palliative care leaders indicated that they were not concerned for the future viability of their program or service. Instead, these leaders cited strong leadership buy-in; their highly valued provision of support to colleagues; and the pandemic's positive impact on their services' visibility, perceived value, and utilization. Among the 27.7% of respondents concerned about viability, lack of organizational support, lack of understanding about palliative care services, negative financial consequences of the pandemic, and significant staff burnout were key themes. Both groups reported concerns about staffing. These COVID Field Surveys provide insights about factors driving palliative care program viability from the perspective of program leaders during a global pandemic. Resources and technical assistance designed to empower and support palliative care team leaders are necessary to sustain and strengthen programs, including organizational relationship-building; rejuvenation of the value case to reinforce the impact of specialty palliative care services on patients, families, referring clinicians, and health care organizations; and attention to critical workforce investments through national and local policy. [ABSTRACT FROM AUTHOR]

1. Summarize current practices in messaging palliative care services to online readers. Like the general public, people with serious illness increasingly rely on the Internet for health information. Therefore, it is important for palliative care teams to consider carefully the information and messaging they include on their team websites and how they contribute to the brand of palliative care. To identify common themes in how palliative care teams describe themselves to the public and potential referring providers online. We conducted a qualitative study using thematic analysis to identify frequent themes. A purposive sampling approach—criterion and quota sampling—were used to generate a sample of palliative care team websites operated by hospitals, hospice organizations, and other community organizations (eg, home health agencies). Website text was coded using Atlas.ti and analyzed to produce thematic statements. The thematic analysis generated three themes describing how palliative care teams explain their services online: underscoring palliative care's similarities to hospice, highlighting the patient as an individual, and emphasizing the interdisciplinary nature of palliative care. Teams highlighted key aspects of palliative care as well as its resemblance to hospice. By comparing palliative care to hospice, websites may inadvertently encourage misperceptions of palliative care and its target population. Future research should expand to include pediatric palliative care websites and other forms of communication in order to refine messaging practices further. [ABSTRACT FROM AUTHOR]

Introduction: Seriously ill people with dementia living at home may be particularly vulnerable to disruptions in their care during times of crisis. The study sought to describe care experiences of those receiving home‐based primary care in New York City during the COVID‐19 pandemic and compare the experiences of people with and without dementia. Methods: We conducted a retrospective review of all electronic medical record notes between March 1, 2020 and December 30, 2020 among a sample of home‐based primary care recipients (n = 228), including all deaths that occurred in the spring of 2020. Drawing from administrative records and using an abstraction tool that included both structured (e.g., documented COVID‐19 exposure) and unstructured (e.g., text passage describing caregiver burden) data, we identified salient COVID‐19 related care experiences and identified and categorized major disruptions in care. Results: Both people with and without dementia experienced significant disruptions of paid caregiving, family caregiving, and home‐based services during the COVID‐19 pandemic. While the paid caregivers of people with dementia reported more burden to the home‐based primary care team as compared to people without dementia, we found little evidence of differences in quantity or type of COVID‐19 related disruptions relative to dementia status. Discussion: While those with dementia have distinct care needs, our findings emphasize the way that dementia may be one piece of a larger clinical picture of serious illness. In order to support all patients with high care needs in crisis, we need to understand the interdependence of clinical care, long‐term care, and family caregiving support for older adults and view dementia within the larger context of serious illness and care need. [ABSTRACT FROM AUTHOR]

Background: Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems.Objective: To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone.Design: Cluster-randomized controlled trial with group assignment by primary care team.Patients: Veterans 65 or older who received primary care at 2 VA facilities who consented to HIE and had a non-VA hospital admission or emergency department visit between 2016 and 2019.Interventions: For all subjects, real-time HIE notification of the non-VA acute care encounter was sent to the VA primary care provider. Subjects assigned to HIE plus CTI received home visits and telephone calls from a VA social worker for 30 days after arrival home, focused on patient activation, medication and condition knowledge, patient-centered record-keeping, and follow-up.Measures: Primary outcome: 90-day hospital admission or readmission.Secondary Outcomes: emergency department visits, timely VA primary care team telephone and in-person follow-up, patients' understanding of their condition(s) and medication(s) using the Care Transitions Measure, and high-risk medication discrepancies.Key Results: A total of 347 non-VA acute care encounters were included and assigned: 159 to HIE plus CTI and 188 to HIE alone. Veterans were 76.9 years old on average, 98.5% male, 67.8% White, 17.1% Black, and 15.1% other (including Hispanic). There was no difference in 90-day hospital admission or readmission between the HIE-plus-CTI and HIE-alone groups (25.8% vs. 20.2%, respectively; risk diff 5.6%; 95% CI - 3.3 to 14.5%, p = .25). There was also no difference in secondary outcomes.Conclusions: A care transitions intervention did not improve outcomes for veterans after a non-VA acute care encounter, as compared with HIE notification alone. Additional research is warranted to identify transitions services across systems that are implementable and could improve outcomes. [ABSTRACT FROM AUTHOR]

Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes. [ABSTRACT FROM AUTHOR]

Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. Mixed-methods national survey. HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

1. Illustrate the role of home care workers (HCWs) in caring for homebound older adults during COVID-19 2. Characterize disruptions in HCW services in the setting of COVID-19 and how these impacted the ability of patients to stay safely at home 3. Identify the impact of HCW services on patients and their family and other unpaid caregivers The devastating impact of the COVID-19 pandemic has made the need for quality home-based care for homebound older adults with serious illness clear. Home care workers (HCWs) played a critical role in keeping homebound older adults safely at home during COVID-19, yet their essential work is often undervalued and understudied. To illustrate the roles of HCWs during COVID-19 and how HCW service disruptions impacted patients and their caregivers. We collected demographic and clinical data and performed a thematic analysis of medical records from 53 patients with HCWs in a home-based primary and palliative care practice in New York City. We abstracted unstructured clinical notes between 12/1/2019 and 12/31/2020 into a priori and emergent categories and identified core themes via discussion in team meetings. Of the 53 patients, 24.5% died during the initial COVID surge, 34% lived alone, and 41.5% had 24-hour HCWs. The following five themes emerged: Changes to HCW roles included taking on new medical tasks and increased intensity of existing tasks (e.g., managing progressing dementia behaviors); delays in staffing contributed to changes in HCW hours and continuity, including unexpected loss of services; disruptions in HCW services put patients at risk of hospitalization and nursing home placement due to safety concerns; payment structure and patient preferences made it challenging to get sufficient hours of paid care; and lack of adequate and high-quality HCW services created additional caregiver responsibilities and caregiver burden. During COVID-19, HCWs were essential to keeping homebound older adults safely at home. Inadequate HCW services, including unstable schedules and inadequate hours of paid care, became particularly disruptive, leading to risk of hospitalization and prolonged length of stay. This analysis can inform policies encouraging better integration of HCWs on medical teams and addressing workforce shortages to expand access to adequate HCW services for homebound older adults and their caregivers to manage serious illness and end-of-life care. [ABSTRACT FROM AUTHOR]