Abstracts to Inform Home Health Best Practices

S TO INFORM HOME HEALTH BEST PRACTICES These abstracts are current articles examining hot topics in home health care, with a focus on topics reported on Home Health Compare. The abstracts are intended to assist home health agencies to identify strategies supported by evidence that may improve outcomes for patients receiving home health services. This is not a comprehensive review of literature on every topic area addressed in the VNAA Blueprint for Excellence – 5-Star Best Practices. The abstracts are loosely organized by topic area, but the reader may benefit from browsing the abstracts for topics of interest. Compiled December, 2015 HH and HOSPITALIZATION Esslinger EE, Schade CP, Sun CK, Sun YH, Manna J, Hall BK, Wright S, Hannah KL, Lynch JR. Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients. J Eval Clin Pract. 2014 Oct;20(5):664-70. Abstract RATIONALE, AIMS AND OBJECTIVES: To determine whether US home health agencies that intensively engaged with the 2010 Home HealthQuality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies.RATIONALE, AIMS AND OBJECTIVES: To determine whether US home health agencies that intensively engaged with the 2010 Home HealthQuality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. METHOD: We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for preand postintervention periods (March-November 2009 and 2010, respectively). RESULTS: Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. CONCLUSION: We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures. Jarrín O, Flynn L, Lake ET, Aiken LH. Home health agency work environments and hospitalizations. Med Care. 2014 Oct;52(10):877-83. Abstract BACKGROUND: An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasingcare costs.BACKGROUND: An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasingcare costs. OBJECTIVES: To determine the relationship between home health agency work environments and agencylevel rates of acute hospitalization and discharges to community living. METHODS AND DESIGN: Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge. RESULTS: Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments. CONCLUSION: Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care. O'Connor M, Bowles KH, Feldman PH, St Pierre M, Jarrín O, Shah S, Murtaugh CM. Frontloading and intensity of skilled home health visits: a state of the science. Home Health Care Serv Q. 2014;33(3):159-75. Author information Abstract Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home healthpatients. 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. Sanford DE, Olsen MA, Bommarito KM, Shah M, Fields RC, Hawkins WG, Jaques DP, Linehan DC. Association of discharge home with home health care and 30day readmission after pancreatectomy. J Am Coll Surg. 2014 Nov;219(5):875-86. BACKGROUND: We sought to determine if discharge home with home health care (HHC) is an independent predictor of increased readmission after pancreatectomy. STUDY DESIGN: We examined 30-day readmissions in patients undergoing pancreatectomy using the Healthcare Cost and Utilization Project State Inpatient Database for California from 2009 to 2011. Readmissions were categorized as severe or nonsevere using the Modified Accordion Severity Grading System. Multivariable logistic regression models were used to examine the association of discharge home with HHC and 30-dayreadmission using discharge home without HHC as the reference group. Propensity score matching was used as an additional analysis to compare the rate of 30-day readmission between patients discharged home with HHC with patients discharged home without HHC. RESULTS: Of 3,573 patients who underwent pancreatectomy, 752 (21.0%) were readmitted within 30 days of discharge. In a multivariable logistic regression model, discharge home with HHC was an independent predictor of increased 30-day readmission (odds ratio = 1.37; 95% CI, 1.11-1.69; p = 0.004). Using propensity score matching, patients who received HHC had a significantly increased rate of 30-day readmission compared with patients discharged home without HHC (24.3% vs 19.8%; p < 0.001). Patients discharged home with HHC had a significantly increased rate of non severe readmission compared with those discharged home without HHC, by univariate comparison (19.2% vs 13.9%; p < 0.001), but not severe readmission (6.4% vs 4.7%; p = 0.08). In multivariable logistic regression models, excluding patients discharged to facilities, discharge home with HHC was an independent predictor of increased non severe readmissions (odds ratio = 1.41; 95% CI, 1.11-1.79; p = 0.005), but not severe readmissions (odds ratio = 1.31; 95% CI, 0.88-1.93; p = 0.18). CONCLUSIONS: Discharge home with HHC after pancreatectomy is an independent predictor of increased 30day readmission; specifically, these services are associated with increased non severe readmissions, but not severe readmissions. Fortinsky RH, Madigan EA, Sheehan TJ, Tullai-McGuinness S, Kleppinger A. Risk factors for hospitalization in a national sample of Medicare home health care patients. J Appl Gerontol. 2014 Jun;33(4):474-93. Acute care hospitalization during or immediately following a Medicare home health care (HHC) episode is a major adverse outcome, but little has been published about HHC patient-level risk factors for hospitalization. The authors determined risk factors at HHC admission associated with subsequent acute care hospitalization in a nationally representative Medicare patient sample (N = 374,123). Hospitalization was measured using Medicare claims data; risk factors were measured using Outcome Assessment and Information Set data. Seventeen percent of sample members were hospitalized. Multivariate logistic regression analysis found that the most influential risk factors (all p < .001) were skin wound as primary HHC diagnosis, clinicianjudged guarded rehabilitation prognosis, congestive heart failure as primary HHC diagnosis, presence of depressive symptoms, dyspnea severity, and Black, compared to White. HHC initiatives that minimize chronic condition exacerbations and actively treat depressive symptoms might help reduce Medicare patient hospitalizations. Unmeasured reasons for higher hospitalization rates among Black HHC patients deserve further investigation. Linertová R, García-Pérez L, Vázquez-Díaz JR, Lorenzo-Riera A, Sarría-Santamera A. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. J Eval Clin Pract. 2011 Dec;17(6):1167-75. RATIONALE, AIMS AND OBJECTIVES: Unplanned hospital readmissions of elderly people represent an increasing burden on health care systems. This burden could theoretically be reduced by adequate preventive interventions, although there is uncertainty about the effectiveness of different types of interventions. The objective of this systematic review was to identify interventions that effectively reduce the risk of hospital readmissions in patients of 75 years and older, and to assess the role of home follow-up. METHODS: We searched studies in MEDLINE, CINAHL, CENTRAL and seven other electronic databases up to October 2007, and we updated the MEDLINE search in October 2009. Clinical trials (randomized or controlled) evaluating the effectiveness of an intervention aimed at reducing readmissions in elderly patients were selected. Quality was assessed using the SIGN tool and the information extracted is presented in text and tables. RESULTS: Thirty-two clinical trials were included and they were divided into two groups: in-hospital interventions (17 studies) and interventions withhome follow-up (15 studies). A positive effect of the intervention evaluated on the readmission outcome was found in three studies from the first group and in seven from the second group. CONCLUSIONS: Most of the interventions evaluated did not have any effect on the readmission of elderly patients. However, those interventions that included home care components seem to be more likely to reduce readmissions in the elderly. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999 Feb 17;281(7):613-20. CONTEXT: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. OBJECTIVE: To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions. DESIGN: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. SETTING: Two urban, academically affiliated hospitals in Philadelphia, Pa. PARTICIPANTS: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission. INTERVENTION: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses. MAIN OUTCOME MEASURES: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. RESULTS: A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in postdischarge acute care visits, functional status, depression, or patient satisfaction. CONCLUSIONS: An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs. REVIEWS OF READMISSION PREVENTION STRATEGIES (INCLUDING HH) Kansagara D, Chiovaro JC, Kagen D, Jencks S, Rhyne K, O'Neil M, Kondo K, Relevo R, Motu'apuaka M, Freeman M, Englander H. So many options, where do we start? An overview of the care transitions literature. J Hosp Med. 2015 Nov 9. BACKGROUND: Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply. PURPOSE: To summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. DATA SOURCES: PubMed and Cochrane Database of Systematic Reviews (January 1950-May 2014), reference lists, and technical advisors. STUDY SELECTION: Systematic reviews of transitional care interventions that reported hospital readmission as an outcome. DATA EXTRACTION: We extracted transitional care procedures, patient populations, settings, readmissions, and health outcomes. We identified commonalities and compiled a narrative synthesis of emerging themes. DATA SYNTHESIS: Among 10 reviews of mixed patient populations, there was consistent evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. Among 7 reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations. In general, interventions that reduced readmission addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs. There was insufficient evidence on how caregiver involvement, transition to sites other than home, staffing, patient selection practices, or care settings modified intervention effects. CONCLUSIONS: Successful interventions are comprehensive, extend beyond hospital stay, and have the flexibility to respond to individual patient needs. The strength of evidence should be considered low because of heterogeneity in the interventions studied, patient populations, clinical settings, and implementation strategies. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine. Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0078978/pdf/PubMedHealth_PMH0078978. pdf Summary of findings: We examined 17 systematic reviews across different patient populations and representing a variety of intervention types in order to provide a broad overview of the care transitions literature. While there have been numerous examples of interventions that reduced readmission rates, there were no patient population or intervention type categories within which transitional care interventions were uniformly successful. It is not surprising that there are many sources of heterogeneity in a field as broadly defined as transitional care. Variation in populations studied, intervention characteristics, personnel, outcomes measured, and settings make it difficult to identify definitive recommendations for a specific intervention that should be broadly applied. Nevertheless, we were able to draw several generalizations from the literature. 1. Interventions that address more components of the care transition are probably better than those that address fewer. 2. Successful interventions tended to include the means to assess and respond to individual peri-discharge needs. 3. There is very little data supporting the effectiveness of interventions isolated to either the preor post-discharge settings. Successful interventions which were largely implemented in one setting often included components (such as home visits, a single point of contact, and/or telephone calls) that bridged settings. On the other hand, in select populations such as patients with CHF, there is some evidence supporting postdischarge interventions such as structured telephone support and multidisciplinary CHF clinics. 4. It is not clear to what extent and for whom post-discharge home visits are a necessary component of care transitions. 5. The vast majority of the care transitions literature has been hospital-focused, with very little literature examining the role of primary care teams during the transitions of care. There is a growing literature examining the effects of medical home interventions, most of which include cross-site care coordination activities; however, the characteristics of successful care transitions within the medical home context have not been well explored. 6. Many interventions that have demonstrated a reduction in readmission rates have included patients at high risk for readmission because of underlying comorbidities such as CHF and/or because of additional factors such as prior utilization. 7. Interventions designed to address the needs of patients with complex, chronic medical illness have been the best studied. It is unclear whether the success of some interventions studied in these patient populations reflects the content expertise that intervention personnel might develop in working with specific patient populations, higher baseline risk of poor outcomes among these patients, or sensitivity of chronic medical illness to transitional care improvements. However, there are many notable exceptions even among patients with chronic medical illness – for example, we found little evidence of benefit in COPD populations, though many transitional care components were absent in these studies. There is little good-quality transitional care literature in mental health or surgical populations. 8. Reviews that examined effects by year of publication suggest that many of the interventions demonstrating benefit were conducted more than a decade ago. 9. In order to allow for better collation of results from trials, development of a standard taxonomy is needed. This taxonomy should include both population descriptors as well as intervention descriptors. Policy implications: In the main report, we present several policy implications along with a brief discussion and rationale for each. There are likely many steps of the care transition that, if missed, could hinder the quality of the care transition. We recommend each institution use a standardized approach to diagnose transitional care gaps. We have included a transitional care “map” that could be used for such assessments. We do not suggest that each step is necessary for every patient. We also suggest that the VHA could harness existing infrastructures such as PACT and home-based primary care to accomplish pieces of the care transition that had previously been accomplished in the intervention literature by additional transitional care nurses. Because some transitional care intervention activities can be resource intensive, we provide some discussion about the potential merits and pitfalls of risk assessment to identify high-risk patients for intervention. Finally, we suggest the VHA critically examine the current broad-based implementation of post-discharge telephone calls. Murkofsky RL, Alston K. The past, present, and future of skilled home health agency care. Clin Geriatr Med. 2009 Feb;25(1):1-17, Abstract This article reviews the past history of home health agency care from its beginnings to the present day, evidence regarding the effect of recent changes in financing on these services, the state of skilled home health care in 2008, and a discussion of future directions. Home health care serves several million patients per year, many of whom are recuperating from acute illness episodes. Due to illness burden and Medicare funding, a large proportion of care that home health agencies deliver is geriatric care. However, home health care plays an important role for patients of all ages with significant acute and chronic illnesses. Medicare home health care suffered a significant downturn following the 1997 Balanced Budget Act and is recovering under Prospective Payment. Like most sectors of care, home health care has often operated in a "silo" but there is increasing recognition of the need to bridge care settings and provide care continuity for sick, chronically ill individuals. This is an important challenge for the future. Agencies that have strong information technology infrastructure and chronic care management systems along with a seasoned clinical workforce will be well positioned for key roles in home health care in decades to come. Home health care serves several million patients each year, many of whom are recuperating from acute illness episodes. Due to the burden of illness and Medicare funding, a large proportion of care that home health agencies deliver is geriatric care. However, home health care plays an important role for patients of all ages with significant acute and chronic illnesses. Medicare home health care suffered a significant downturn following the 1997 Balanced Budget Act (BBA) and is recovering under prospective payment. Like most sectors of care, home health care has often operated in a "silo," but there is increasing recognition of the need to bridge care settings and provide care continuity for sick, chronically ill individuals. This is an important challenge for the future. Agencies that have strong information technology infrastructure and chronic care management systems along with a seasoned clinical workforce will be well positioned for key roles in home health care in the decades to come.This article reviews the past history of home health agency care from its beginnings to the present day, evidence regarding the effect of recent changes in financing on these services, the state of skilled home health care in 2008, and a discussion of future directions. Home health care serves several million patients per year, many of whom are recuperating from acute illness episodes. Due to illness burden and Medicare funding, a large proportion of care that home health agencies deliver is geriatric care. However, home health care plays an important role for patients of all ages with significant acute and chronic illnesses. Medicare home health care suffered a significant downturn following the 1997 Balanced Budget Act and is recovering under Prospective Payment. Like most sectors of care, home health care has often operated in a "silo" but there is increasing recognition of the need to bridge care settings and provide care continuity for sick, chronically ill individuals. This is an important challenge for the future. Agencies that have strong information technology infrastructure and chronic care management systems along with a seasoned clinical workforce will be well positioned for key roles in home health care in decades to come. Home health care serves several million patients each year, many of whom are recuperating from acute illness episodes. Due to the burden of illness and Medicare funding, a large proportion of care that home health agencies deliver is geriatric care. However, home health care plays an important role for patients of all ages with significant acute and chronic illnesses. Medicare home health care suffered a significant downturn following the 1997 Balanced Budget Act (BBA) and is recovering under prospective payment. Like most sectors of care, home health care has often operated in a "silo," but there is increasing recognition of the need to bridge care settings and provide care continuity for sick, chronically ill individuals. This is an important challenge for the future. Agencies that have strong information technology infrastructure and chronic care management systems along with a seasoned clinical workforce will be well positioned for key roles in home health care in the decades to come. Baier RR, Wysocki A, Gravenstein S, Cooper E, Mor V, Clark M. A qualitative study of choosing home health care after hospitalization: the unintended consequences of 'patient choice' requirements. J Gen Intern Med. 2015 May;30(5):634-40. BACKGROUND: Although hospitals are increasingly held accountable for patients' post-discharge outcomes, giving them incentive to help patients choose high-performing home health agencies, little is known about how quality reports inform decision making. OBJECTIVE: We aimed to learn how quality reports are used when choosing home care in one northeast state (Rhode Island) . DESIGN: The study consisted of focus groups with home health consumers and structured interviews with hospital case managers. PARTICIPANTS: Thirteen consumers and 28 case managers from five hospitals participated in the study. APPROACH: We identified key themes and illustrative quotes by audiotaping each session, and then three independent reviewers conducted repeated examination and content analysis. KEY RESULTS: No participants were aware of existing state or Medicare home health agency public reports. Case managers provided agency lists to consumers, who routinely asked case managers to tell them which agencies to choose or which were best; but case managers felt unable to directly respond to consumers' requests for help in making the choice, because they did not have additional information to provide and because they feared violating federal laws requiring freedom of patient choice. Case managers also felt that there was little difference in agency quality, although they acknowledged they might not be aware of problems related to post-hospital care. CONCLUSIONS: Home health consumers and hospital case managers were unaware of public reports about home health quality, which limited consumers' ability to make informed decisions and case managers' ability to assist them in that decision-making process. Case managers were otherwise prohibited from recommending specific providers to patients and viewed the 'patient choice' laws as restricting their ability to respond to patients' requests for help in choosing home health agencies. Public reports can be marketed as tools that case managers can use to help patients differentiate among providers, while supporting patient autonomy. Jung K, Polsky D. Competition and quality in home health care markets. Health Econ. 2014 Mar;23(3):298-313. Market-based solutions are often proposed to improve health care quality; yet evidence on the role of competition in quality in non-hospital settings is sparse. We examine the relationship between competition and quality in home health care. This market is different from other markets in that service delivery takes place in patients' homes, which implies low costs of market entry and exit for agencies. We use 6 years of panel data for Medicare beneficiaries during the early 2000s. We identify the competition effect from within-market variation in competition over time. We analyze three quality measures: functional improvements, the number of home health visits, and discharges without hospitalization. We find that the relationship between competition and home health quality is nonlinear and its pattern differs by quality measure. Competition has positive effects on functional improvements and the number of visits in most ranges, but in the most competitive markets, functional outcomes and the number of visits slightly drop. Competition has a negative effect on discharges without hospitalization that is strongest in the most competitive markets. This finding is different from prior research on hospital markets and suggests that market-specific environments should be considered in developing polices to promote competition. Press MJ, Gerber LM, Peng TR, Pesko MF, Feldman PH, Ouchida K, Sridharan S, Bao Y, Barron Y, Casalino LP. Postdischarge Communication Between Home Health Nurses and Physicians: Measurement, Quality, and Outcomes. J Am Geriatr Soc. 2015 Jul;63(7):1299-305. Abstract OBJECTIVES: To use natural language processing (NLP) of text from electronic medical records (EMRs) to identify failed communication attempts between home health nurses and physicians, to identify predictors of communication failure, and to assess the association between communication failure and hospital readmission.OBJECTIVES: To use natural language processing (NLP) of text from electronic medical records (EMRs) to identify failed communication attempts between home health nurses and physicians, to identify predictors of communication failure, and to assess the association between communication failure and hospital readmission. DESIGN: Retrospective cohort study. SETTING: Visiting Nurse Service of New York (VNSNY), the nation's largest freestanding home health agency. PARTICIPANTS: Medicare beneficiaries with congestive heart failure who received home health care from VNSNY after hospital discharge in 2008-09 (N = 5,698). MEASUREMENTS: Patient-level measures of communication failure and risk-adjusted 30-day allcause readmission. RESULTS: Identification of failed communication attempts using NLP had high external validity (kappa = 0.850, P < .001). A mean of 8% of communication attempts failed per episode of home care; failure rates were higher for black patients and lower for patients from higher median income ZIP codes. The association between communication failure and readmission was not significant with adjustment for patient, nurse, physician, and hospital factors. CONCLUSION: NLP of EMRs can be used to identify failed communication attempts between home health nurses and physicians, but other variables mostly explained the association between communication failure and readmission. Communication failures may contribute to readmissions in more-serious clinical situations, an association that this study may have been underpowered to detect. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.