Joan K. Davitt

Outcomes of a Telehealth Intervention for Homebound Older Adults With Heart or Chronic Respiratory Failure: A Randomized Controlled Trial

PURPOSE  Telehealth care is emerging as a viable intervention model to treat complex chronic conditions, such as heart failure (HF) and chronic obstructive pulmonary disease (COPD), and to engage older adults in self-care disease management.  DESIGN AND METHODS  We report on a randomized controlled trial examining the impact of a multifaceted telehealth intervention on health, mental health, and service utilization outcomes among homebound medically ill older adults diagnosed with HF or COPD. Random effects regression modeling was used, and we hypothesized that older adults in the telehealth intervention (n = 51) would receive significantly better quality of care resulting in improved scores in health-related quality of life, mental health, and satisfaction with care at 3 months follow-up as compared with controls (n = 51) and service utilization outcomes at 12 months follow-up.  RESULTS  At follow-up, the telehealth intervention group reported greater increases in general health and social functioning, and improved in depression symptom scores as compared with usual care plus education group. The control group had significantly more visits to the emergency department than the telehealth group. There was an observed trend toward fewer hospital days for telehealth participants, but it did not reach significance at 12 months.  IMPLICATIONS  Telehealth may be an efficient and effective method of systematically delivering integrated care in the home health sector. The use of telehealth technology may benefit homebound older adults who have difficulty accessing care due to disability, transportation, or isolation.

It Takes a Village: Community Practice, Social Work, and Aging-in-Place

The US population of older adults will increase significantly in the coming decades. Most of these individuals prefer to age in their homes/communities. However, most communities are not prepared to handle the long-term care needs of an aging population. This article examines one model that communities are using to help older adults age-in-place, the Village. A conceptual lens based in community practice and empowerment theory is offered to explicate this model and critically evaluate social works role in it. It also presents challenges to social work roles in facilitation and evaluation of the model.

Does the Village Model Help to Foster Age-Friendly Communities?

This article explores the potential role of the Village model, a social initiative that emphasizes member involvement and service access, in helping communities to become more age-friendly. A survey of 86.3% of operational Villages examined activities designed to help members access a variety of supports and services consistent with the World Health Organizations (WHO) Global Network of Age-Friendly Cities and Communities program model, as well as other potential contributions to community age friendliness. Analysis revealed that 85.5% of Villages provided assistance with at least six of the eight WHO domains, but only 10.1% implemented features of all eight; more than one-third were engaged in direct or indirect efforts to improve community physical or social infrastructures or improve community attitudes toward older persons. These findings suggest that Villages and other social organizations may have untapped potential for enhancing their members’ ability to age in place consistent with the goals of age-friendly initiatives while also promoting constructive changes in the overall community.

Integrating Mental Health Parity for Homebound Older Adults Under the Medicare Home Health Care Benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.

Racial/ethnic disparities in access to medicare home health care: the disparate impact of policy.

The Balanced Budget Act of 1997 dramatically decreased reimbursements for traditional Medicare home health patients. A multivariate analysis of Medicare Current Beneficiary Survey data showed that African American and “other” users experienced greater decreases in home care between 1996 and 1998 than did White users. These results suggest (a) race/ethnicity is an independent factor in determining service use post-BBA and (b) health policy has a disparate impact on minority older adults. Capitated payment systems must be pursued cautiously to avoid negative effects on vulnerable populations. The potential for current and future Medicare policy changes to negatively affect vulnerable populations is also discussed.

Policy Changes in Medicare Home Health Care: Challenges to Providing Family-Centered, Community-Based Care for Older Adults

The Balanced Budget Act of 1997 (BBA) established new reimbursement systems in the Medicare home health fee-for-service benefit. Reimbursements were reduced to 1993 levels and per-beneficiary capitated limits were introduced for the first time. This article analyzes the impact of these changes on chronically ill older adults and their families. The study combined a secondary analysis of the Provider of Service file (1996, 1999, 2002, and the Medicare Current Beneficiary Survey (1996, 1998) with qualitative interviews of home health agency directors. The greatest decreases in staff and visits were for medical social work and home health aide services. Patients with caregivers saw greater decreases in visits and reimbursements for all visits, skilled nursing, medical social work, and home health aide visits. Agency directors reported that they increased caregiver education, training, and involvement in care in order to discharge patients sooner. Additional research is needed to understand the long-term, adverse impact of these policy changes on chronically ill patients and their families.

The impact of policy on nursing and allied health services. Lessons from the Medicare Home Health Benefit.

This article analyzes changes in Medicare home health staffing and service delivery patterns across three different reimbursement methods: cost based (1996), interim payment system (IPS) (1999), and the prospective payment system (PPS) (2002). This study combined secondary analysis of existing data (Provider of Services File and Statistical Supplement) with qualitative interviews of 22 home health agency directors to understand agency responses to policy changes created under the Balanced Budget Act of 1997. Cuts in staff and visits were greater under the IPS than they were under the PPS. Agencies cut staff and visits more dramatically for nonskilled services across both time periods. As a proportion of total services and visits, nursing and therapy services increased the most. Directors used various strategies to sustain the agency financially during these dramatic cuts in reimbursements, including eliminating staff, shifting staff roles, training staff on reimbursement methods, increasing use of telephone monitoring, increasing patient and family education and self-care, and cutting services to patients. Directors expressed concerns about staff stress related to the changes and the need to increase productivity without increasing staff. However, directors also believed the agencys position would improve under the PPS. Additional research is needed to determine whether increased staff stress, work demands, and fewer resources for patients will affect the quality of care delivered and, thus, patient outcomes under the PPS.

Racial/Ethnic Disparities in Home Health Care: Charting a Course for Future Research

Racial/ethnic disparities in health have been well-documented. However, we know little about the existence of or mechanisms that contribute to disparities in home health care. This article proposes a conceptual framework, based on a comprehensive review of the literature, to guide research to understand whether and how disparities emerge in home health care. The framework outlines the patient, agency, practice, and system factors that have been shown to or theoretically could contribute to disparities. Enhanced parity in home health care will impact society by reducing health costs due to morbidity, while directly benefiting minority patients.

Variations on the Village Model: An Emerging Typology of a Consumer-Driven Community-Based Initiative for Older Adults.

Villages, which are community-based initiatives designed to help older adults age in place through a combination of services, participant engagement, and peer support, have expanded rapidly since their initial development in the early 2000s. Using a sample of Villages in the United States, we examined variations from characteristics of the Village model as portrayed by media and organizational leaders. Results indicate there is no uniform Village model that can be implemented and evaluated by policy makers, funders, service providers, and researchers. Based on the extent of member involvement, methods of service provision, and funding sources, we developed a conceptually and empirically informed typology of Villages that reflects the model’s focus on consumer involvement. Descriptive analyses indicate potential differences in member, community, and organizational characteristics. This emerging typology has implications for understanding the implementation and sustainability of Villages, including whether specific Village types are best suited to certain community contexts.

Understanding Inequities in Home Health Care Outcomes: Staff Views on Agency and System Factors

Results regarding staff perspectives on contributing factors to racial/ethnic disparities in home health care outcomes are discussed. Focus group interviews were conducted with home health care staff (N = 23) who represented various agencies from three Northeastern states. Participants identified agency and system factors that contribute to disparities, including: (a) administrative staff bias/discretion, (b) communication challenges, (c) patient/staff cultural discordance, (d) cost control, and (e) poor access to community resources. Participants reported that bias can influence staff at all levels and is expressed via poor coverage of predominantly minority service areas, resulting in reduced intensity and continuity of service for minority patients.