Melissa O'Connor

Clinical effectiveness, access to, and satisfaction with care using a telehomecare substitution intervention: a randomized controlled trial

Background. Hospitalization accounts for 70% of heart failure (HF) costs; readmission rates at 30 days are 24% and rise to 50% by 90 days. Agencies anticipate that telehomecare will provide the close monitoring necessary to prevent HF readmissions. Methods and Results. Randomized controlled trial to compare a telehomecare intervention for patients 55 and older following hospital discharge for HF to usual skilled home care. Primary endpoints were 30- and 60-day all-cause and HF readmission, hospital days, and time to readmission or death. Secondary outcomes were access to care, emergency department (ED) use, and satisfaction with care. All-cause readmissions at 30 days (16% versus 19%) and over six months (46% versus 52%) were lower in the telehomecare group but were not statistically significant. Access to care and satisfaction were significantly higher for the telehomecare patients, including the number of in-person visits and days in home care. Conclusions. Patient acceptance of the technology and current home care policies and processes of care were barriers to gaining clinical effectiveness and efficiency.

The Outcome and Assessment Information Set (OASIS): A Review of Validity and Reliability

The Outcome and Assessment Information Set (OASIS) is the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality. Since its inception in 1999, there has been debate over the reliability and validity of the OASIS as a research tool and outcome measure. A systematic literature review of English-language articles identified 12 studies published in the last 10 years examining the validity and reliability of the OASIS. Empirical findings indicate the validity and reliability of the OASIS range from low to moderate but vary depending on the item studied. Limitations in the existing research include: nonrepresentative samples; inconsistencies in methods used, items tested, measurement, and statistical procedures; and the changes to the OASIS itself over time. The inconsistencies suggest that these results are tentative at best; additional research is needed to confirm the value of the OASIS for measuring patient outcomes, research, and quality improvement.

Information Deficits in Home Care: A Barrier to Evidence-Based Disease Management

A disease management study conducted in home care with 303 patients with diabetes, heart failure, or both revealed information deficits that make disease and quality management difficult. Nurses used a guideline checklist to indicate the amount and type of information available to them on admission and by the end of the episode of care. Nurses reported having data on 7% to 94% of the data elements. Whether a lipid profile had been done, the HbA1C (glycosolated hemoglobin test, also called a hemoglobin A1C) levels, or ejection fractions were known for 7%, 17%, and 18%, respectively. When nurses reported information related to ACE-I use (N = 183), they reported that 76% of patients were on ACE-I (angiotensin-converting enzyme inhibitor) or acceptable alternative for heart failure. But no information was reported on ACE-I use for 12% of the patients (N = 24). Potential solutions to these deficits in information and quality include increased use of guidelines in home care, guideline checklists, information transfer forms, nurse activism to request information, and the adoption of the electronic health record.

The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature

Objective: To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting. Methods: Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed. Results: Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence (n=33) and lacking robust measurement (n=37). The designation of index or principal condition was equally heterogeneous with approximately half (n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed. Discussion: The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.

Impact of frontloading of skilled nursing visits on the incidence of 30-day hospital readmission

Hospitalization among older adults receiving skilled home health services continues to be prevalent. Frontloading of skilled nursing visits, defined as providing 60% of the planned skilled nursing visits within the first two weeks of home health episode, is one way home health agencies have attempted to reduce the need for readmission among this chronically ill population. This was a retrospective observational study using data from five Medicare-owned, national assessment and claim databases from 2009. An independent randomized sample of 4500 Medicare-reimbursed home health beneficiaries was included in the analyses. Propensity score analysis was used to reduce known confounding among covariates prior to the application of logistic analysis. Although whether skilled nursing visits were frontloaded or not was not a significant predictor of 30-day hospital readmission (p = 0.977), additional research is needed to refine frontloading and determine the type of patients who are most likely to benefit from it.

The impact of home health length of stay and number of skilled nursing visits on hospitalization among medicare-reimbursed skilled home health beneficiaries

The implementation of the Home Health Prospective Payment System in 2000 led to a dramatic reduction in home health length of stay and number of skilled nursing visits among Medicare beneficiaries. While policy leaders have focused on the rising costs of home health care, its potential underutilization, and the relationship between service use and patient outcomes including hospitalization rates have not been rigorously examined. A secondary analysis of five Medicare-owned assessment and claims data sets for the year 2009 was conducted among two independently randomly selected samples of Medicare-reimbursed home health recipients (each n = 31,485) to examine the relationship between home health length of stay or number of skilled nursing visits and hospitalization rates within 90 days of discharge from home health. Patients who had a home health length of stay of at least 22 days or received at least four skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits. Additional study is needed to clarify the best way to structure home health services and determine readiness for discharge to reduce hospitalization among this chronically ill population. In the mean time, the findings of this study suggest that home health providers should consider the benefits of at least four SNV and/or a home health LOS of 22 days or longer.

Identifying Critical Factors in Determining Discharge Readiness from Skilled Home Health: An Interprofessional Perspective

A lack of readiness for discharge from skilled home health can result in adverse events among older adults. The purpose of the current study was to explore interprofessional home health clinician perceptions of the factors they consider important to determine readiness for discharge among skilled home health recipients. A qualitative descriptive study was conducted using four focus groups among 32 interprofessional clinicians from one large skilled home health agency and two telephone interviews with home visiting physicians. A semi-structured interview guide was followed. Qualitative content analysis was used for manifest coding and then thematic analysis. Five themes emerged: (a) patient safety, (b) long-term plan is in place, (c) reached maximum self-care potential, (d) presence of a willing and able caregiver, and (e) patient attributes. The goal of this line of inquiry is to develop an evidence-based home health discharge decision support tool to provide a standardized approach in determining readiness for discharge from skilled home health services. [Res Gerontol Nurs. 2016; 9(6):269-277.].

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults

ABSTRACT Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community‐dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong‐Lo‐Mendell‐Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community‐dwelling older adults. HIGHLIGHTSThe Vuong‐Lo‐Mendell‐Rubin Likelihood Ratio Test demonstrated three risk profiles.The three risk profiles identified were High, Medium and Low.The High Risk profile had shorter time to hospitalization, ED visit, and death.

Hartford Gerontological Nursing Leaders: From Funding Initiative to National Organization

In 2000, the John A. Hartford Foundation established the Building Academic Geriatric Nursing Capacity Program initiative, acknowledging nursings key role in the care of the growing population of older adults. This program has supported 249 nurse scientists with pre- and postdoctoral awards. As a result of the programs success, several Building Academic Geriatric Nursing Capacity Program awardees formed an alumni organization to continue to advance the quality care of older adults. This group of Building Academic Geriatric Nursing Capacity Program awardees joined others receiving support from the John A. Hartford Foundation nursing initiatives to grow a formal organization, the Hartford Gerontological Nursing Leaders (HGNL). The purpose of this article is to present the development, accomplishments, and challenges of the HGNL, informing other professional nursing organizations that are experiencing similar accomplishments and challenges. This article also demonstrates the power of a funding initiative to grow an organization dedicated to impact gerontological health and health care through research, practice, education, and policy.