Robert J. Rosati

Risk factors for repeated hospitalizations among home healthcare recipients.

One indicator of quality home healthcare is the prevention of rehospitalization. This study explored factors that place patients at risk for repeat hospitalizations after home healthcare admission. One year of outcomes assessment information data from a large home health agency was used to identify 7,393 patients who had at least one episode of rehospitalization. Results revealed that after the data had been adjusted for age and gender, a number of demographic, clinical, and functional factors predicted repeat hospitalizations. Home health agencies that focus on these risk factors may improve the effectiveness and efficiency of their efforts to prevent rehospitalization.

Continuity in home health care: is consistency in nursing personnel associated with better patient outcomes?

Abstract: A growing body of evidence suggests that patients who receive coordinated and uninterrupted health care services have better outcomes, more efficient resource utilization, and lower costs of health care. However, limited research has considered whether attributes of continuity in home health care service delivery are associated with improved patient outcomes. The present study examines the relationship between one dimension of continuity of care, consistency in nursing personnel, and three patient outcomes: hospitalization, emergent care, and improvement in activities of daily living. Analyses of data from a large population of home health patients (N=59,854) suggest that greater consistency in nursing personnel decreases the probability of hospitalization and emergent care, and increases the likelihood of improved functioning in activities of daily living between admission and discharge from home health care. These results provide preliminary evidence that efforts to decrease dispersion of nursing personnel across a series of home visits to patients may lead to improved outcomes. The implications of these findings for clinical practice and further research are discussed in the paper.

Assessment of OASIS Reliability and Validity Using Several Methodological Approaches

ABSTRACT The Outcome Assessment and Information Set (OASIS) plays an essential role in home healthcare. To date, few researchers have investigated the psychometric properties of the OASIS in actual clinical practice. This study used several methodologies to estimate reliability and validity of OASIS when clinicians were conducting assessments as part of the routine care process. Analyses from a delayed assessment approach (n = 259), a simultaneous assessment approach (n = 105) and an assessment of consistency between OASIS and the Centers for Medicare and Medicaid Services (CMS) 485 (n = 141) provided insights into OASIS reliability and validity. Reliability for many items was considerably lower than prior studies and there were notable inconsistencies between several domains of OASIS and the CMS 485. Based on these findings it was also unclear whether prior reliability findings could be generalized to practice because the previous research did not account for the stresses and unpredictability of the home healthcare setting. Further, the inconsistencies between the OASIS and CMS 485 suggested that the OASIS might not truly reflect the patients condition. Implications for improving the use of the instrument in practice settings are discussed.

The History of Quality Measurement in Home Health Care

Quality improvement is as central to home health care as to any other field of health care. With the mandated addition in 2000 of Outcome Assessment and Information Set (OASIS) and outcome-based quality improvement (OBQI), Medicare home health agencies entered a new era of documenting, tracking, and systematically improving quality. OBQI is augmented by the Medicare Quality Improvement Organization (QIO) program, which is now entering the ninth in a series of work assignments, with the tenth scope in the planning stages. Evidence has shown that applied quality improvement methods can drive better outcomes using important metrics, such as acute care hospitalization. This article reviews key findings from the past 2 decades of home care quality improvement research and public policy advances, describes specific examples of local and regional programmatic approaches to quality improvement, and forecasts near-future trends in this vital arena of home health care.

Implementing a transitional care program for high-risk heart failure patients: findings from a community-based partnership between a certified home healthcare agency and regional hospital.

Abstract: Provisions within the recently passed health reform law provide support for new approaches to reducing the high cost of care for clinically complex patients. This article describes the characteristics of a recent transitional care pilot initiative that aims to reduce hospital readmissions among high‐risk heart failure patients. The program was designed and implemented through a joint collaboration between a Certified Home Healthcare Agency and regional hospital. As a preliminary assessment of the impact of this program on patient outcomes, we compare the odds of rehospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Analyses indicated that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group. Although preliminary, our findings suggest that providing transitional care services to high‐risk heart failure patients can be an effective deterrent against patterns of rehospitalization. The opportunities and challenges associated with implementing this pilot program are discussed.

Using technology to enhance the quality of home health care: three case studies of health information technology initiatives at the visiting nurse service of New York.

&NA; There is a growing recognition among health services researchers and policy makers that Health Information Technology (HIT) has the potential to address challenging issues that face patients and providers of healthcare. The Visiting Nurse Service of New York (VNSNY), a large not‐for‐profit home healthcare agency, has integrated technology applications into the service delivery model of several programs. Case studies, including the development and implementation, of three informatics initiatives at VNSNY are presented on: (1) Quality Scorecards that utilize process, outcomes, cost, and satisfaction measures to assess performance among clinical staff and programs; (2) a tool to identify patients at risk of being hospitalized, and (3) a predictive model that identifies patients who are eligible for physical rehabilitation services. Following a description of these initiatives, we discuss their impact on quality and process indicators, as well as the opportunities and challenges to implementation.

The Future of Home Health Care: A Strategic Framework for Optimizing Value

The Future of Home Health project sought to support transformation of home health and home-based care to meet the needs of patients in the evolving U.S. health care system. Interviews with key thought leaders and stakeholders resulted in key themes about the future of home health care. By synthesizing this qualitative research, a literature review, case studies, and the themes from a 2014 Institute of Medicine and National Research Council workshop on “The Future of Home Health Care,” the authors articulate a vision for home-based care and recommend a bold framework for the Medicare-certified home health agency of the future. The authors also identify challenges and recommendations for achievement of this framework.

Continuity in the Provider of Home-Based Physical Therapy Services and Its Implications for Outcomes of Patients

Background A growing body of research suggests that greater continuity of health care is positively associated with improved outcomes of patients. However, few studies have examined this issue in the context of physical therapy. Objective The purpose of this study was to evaluate whether the level of continuity in the provider (provider continuity) of physical therapy services was related to outcomes in a population of patients receiving home health care. Design This was a retrospective observational study. Methods Clinical and administrative records were retrieved for a population of adult patients receiving physical therapy services from a large, urban, not-for-profit certified home health care agency in 2009. Descriptive and multivariable analyses were used to examine how the level of provider continuity, calculated by use of a formula that models dispersion in contact between the patient and the providers of physical therapy services, varied across characteristics and outcomes of patients. Results Logistic regression analyses indicated that patients with lower levels of provider continuity had significantly higher odds of hospitalization (odds ratio [OR]=2.06, 95% confidence interval [CI]=1.90–2.23) and lower odds of improvements in the number of activity limitations (OR=0.85, 95% CI=0.80–0.92) and in the severity of activity limitations (OR=0.85, 95% CI=0.78–0.93) between the beginning and the end of the home health care episode. Limitations Baseline clinical characteristics associated with continuity of care suggest some level of indication bias. Outcome measures for activities of daily living were limited to patients who were not hospitalized during their home health stay. Conclusions These findings build upon research suggesting that continuity in the patient-provider relationship is an important determinant of outcomes of patients.

Improving Communication at the Transition to Home Health Care: Use of an Electronic Referral System

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

Continuity in the Provider of Home Health Aide Services and the Likelihood of Patient Improvement in Activities of Daily Living

Receiving care from the same provider over time is an important dimension of continuity in home healthcare. In the present study, we examine whether continuity in the provider of home health aide services is associated with the likelihood of improvement in Activities of Daily Living (ADLs). To address this research question, we retrieved clinical and administrative records from a population of cases receiving home health aide services at a large, urban, not-for-profit Medicare-certified home healthcare agency (N =16,541). Results revealed that cases which had high levels of continuity in the provider of home health aide services had a significantly greater likelihood of improvement in ADLs compared to cases with the lowest level of continuity.