Timothy R. Peng

Complexity in Geriatric Home Healthcare

Abstract: The aging population and the associated rise in the prevalence of chronic conditions suggest that the home health population is increasingly complex and challenging to manage. The purpose of this study was to use national administrative data (Outcome and Assessment Information Set assessments of persons discharged in 2004 and 2005) to examine the clinical complexity of older adults admitted to home healthcare. Our descriptive analyses confirm that multiple chronic conditions and cognitive impairment are common and result in longer lengths of stay. The findings support the need for geriatric home healthcare practices that effectively address multiple morbidities and cognitive function.

Automating the medication regimen complexity index

Objective To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting. Materials and Methods In phase 1, medication data from 89 645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics. Results The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve). Discussion Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count. Conclusions An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes.

Postdischarge Communication Between Home Health Nurses and Physicians: Measurement, Quality, and Outcomes

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.

Patient Activation and Disparate Health Care Outcomes in a Racially Diverse Sample of Chronically Ill Older Adults

The Patient Activation Measure (PAM) assesses people’s ability to self-manage their health. Variations in PAM score have been linked with health behaviors, outcomes, and potential disparities. This study assessed the relative impacts of activation, socio-demographic and clinical factors on health care outcomes in a racially diverse sample of chronically ill, elderly homecare patients. Using survey and administrative data from 249 predominantly non-White patients, logistic regression was conducted to examine the effects of activation level and patient characteristics on the likelihood of subsequent hospitalization and emergency department (ED) use. Activation was not a significant predictor of hospitalization or ED use in adjusted models. Non-Whites were more likely than Whites to have a hospitalization or ED visit. Obesity was a strong predictor of both outcomes. Further research should examine potential sources of disadvantage among chronically ill homecare patients to design effective interventions to reduce health disparities in this population.

Patient Characteristics Predicting Readmission Among Individuals Hospitalized for Heart Failure

Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in hospital readmission rates. Database searches yielded 950 potential articles, of which 34 studies met inclusion criteria. Patient characteristics generally have a very modest effect on all-cause or heart failure–related readmission within 7 to 180 days of index hospital discharge. A range of cardiac diseases and other comorbidities only minimally increase readmission rates. No single patient characteristic stands out as a key contributor across multiple studies underscoring the challenge of developing successful interventions to reduce readmissions. Interventions may need to be general in design with the specific intervention depending on each patient’s unique clinical profile.

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.

Team structure and adverse events in home health care.

Objective: To identify relationships between variations in team structure and risk-adjusted adverse events across 86 teams in a large US home health care organization. Methods: Patient episode data were collected for two 6-month periods, January–June 2002 (N = 54,732 episodes) and January–June 2003 (N = 51,560 episodes). An adverse event was defined as having 1 or more events defined by the Centers for Medicare and Medicaid Services for home health care episodes. Events were risk adjusted using 2 alternative approaches—a Z-score and a Fixed Effects (FE)-score, for each team in each period. These scores (1 for each team in each period) were then regressed against objective measures of team structure. Results: The regressions based on the FE-score as the measure of quality performed better than the traditional Z-score. Based on these regressions we find that volume (number of episodes) (P = 0.03), number of weekend visits (P = 0.02), and workload distribution (P = 0.02) were negatively associated with the occurrence of adverse events, whereas higher weekend admissions (P = 0.01) were positively associated with adverse events. Conclusions: Our analysis identifies a number of key team-level organizational variables that influence adverse events in home health care services. We also have demonstrated that the FE-score is a more accurate measure of team quality, as opposed to the Z-score, given that it focuses only on “team attributable” adverse events by isolating and excluding random variation from the quality score.

A Profile of Asian/Pacific Islander Elderly in Home Health Care

Abstract This study explores the differences in patient characteristics, home health service use, and discharge outcomes between Asian/Pacific Islanders (API) (n = 408) and White elderly home health care patients (n = 2,480) with a primary diagnosis of diabetes, hypertension or cardiovascular disease. Outcomes Assessment Information Set and administrative data from a large urban home health agency located in the Northeast were used for analyses. Overall, API elders were more likely to be dually eligible for Medicare and Medicaid; entered with greater dependencies; and received more home health aide services than White elders. However, White elders reported greater anxiety and were more likely to live alone.

Can the Care Transitions Measure Predict Rehospitalization Risk or Home Health Nursing Use of Home Healthcare Patients

Abstract: The Care Transitions Measure (CTM) was designed to assess the quality of patient transitions from the hospital. Many hospitals are using the measure to inform their efforts to improve transitional care. We sought to determine if the measure would have utility for home healthcare providers by predicting newly admitted patients at heightened risk for emergency department use, rehospitalization, or increased home health nursing visits. The CTM was administered to 495 home healthcare patients shortly after hospital discharge and home healthcare admission. Follow‐up interviews were completed 30 and 60 days post hospital discharge. Interview data were supplemented with agency assessment and service use data. We did not find evidence that the CTM could predict home healthcare patients having an elevated risk for emergent care, rehospitalization, or higher home health nursing use. Because Medicare/Medicaid‐certified home healthcare providers already use a comprehensive, mandated start of care assessment, the CTM may not provide them additional crucial information. Process and outcome measurement is increasingly becoming part of usual care. Selection of measures appropriate for each service setting requires thorough site‐specific evaluation. In light of our findings, we cannot recommend the CTM as an additional measure in the home healthcare setting.

Home Health Care: Nurse–Physician Communication, Patient Severity, and Hospital Readmission

OBJECTIVE To evaluate whether communication failures between home health care nurses and physicians during an episode of home care after hospital discharge are associated with hospital readmission, stratified by patients at high and low risk of readmission. DATA SOURCE/STUDY SETTING We linked Visiting Nurse Services of New York electronic medical records for patients with congestive heart failure in 2008 and 2009 to hospitalization claims data for Medicare fee-for-service beneficiaries. STUDY DESIGN Linear regression models and a propensity score matching approach were used to assess the relationship between communication failure and 30-day readmission, separately for patients with high-risk and low-risk readmission probabilities. DATA COLLECTION/EXTRACTION METHODS Natural language processing was applied to free-text data in electronic medical records to identify failures in communication between home health nurses and physicians. PRINCIPAL FINDINGS Communication failure was associated with a statistically significant 9.7 percentage point increase in the probability of a patient readmission (32.6 percent of the mean) among high-risk patients. CONCLUSIONS Poor communication between home health nurses and physicians is associated with an increased risk of hospital readmission among high-risk patients. Efforts to reduce readmissions among this population should consider focusing attention on this factor.