Is every day at home a good day? Ankuda, Claire K.; Grabowski, David C.
Journal of the American Geriatrics Society,
September 2022, Letnik:
70, Številka:
9
Journal Article
Recenzirano
Odprti dostop
This Editorial comments on the articles by Freed et al. and Shen et al. in this issue.
IMPORTANCE: Home health care workers care for community-dwelling adults and play an important role in supporting patients with confirmed and suspected coronavirus disease 2019 (COVID-19) who remain ...at home. These workers are mostly middle-aged women and racial/ethnic minorities who typically earn low wages. Despite being integral to patient care, these workers are often neglected by the medical community and society at large; thus, developing a health care system capable of addressing the COVID-19 crisis and future pandemics requires a better understanding of the experiences of home health care workers. OBJECTIVE: To understand the experiences of home health care workers caring for patients in New York City during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: From March to April 2020, a qualitative study with 1-to-1 semistructured interviews of 33 home health care workers in New York City was conducted in partnership with the 1199SEIU Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest health care union in the US. Purposeful sampling was used to identify and recruit home health care workers. MAIN OUTCOMES AND MEASURES: Audio-recorded interviews were professionally transcribed and analyzed using grounded theory. Major themes and subthemes were identified. RESULTS: In total, 33 home health care workers employed by 24 unique home care agencies across the 5 boroughs of New York City participated. Participants had a mean (SD) age of 47.6 (14.0) years, 32 (97%) were women, 21 (64%) were Black participants, and 6 (18%) were Hispanic participants. Five major themes emerged: home health care workers (1) were on the front lines of the COVID-19 pandemic but felt invisible; (2) reported a heightened risk for virus transmission; (3) received varying amounts of information, supplies, and training from their home care agencies; (4) relied on nonagency alternatives for support, including information and supplies; and (5) were forced to make difficult trade-offs in their work and personal lives. CONCLUSIONS AND RELEVANCE: In this qualitative analysis, home health care workers reported providing frontline essential care, often at personal risk, during the COVID-19 pandemic. They experienced challenges that exacerbated the inequities they face as a marginalized workforce. Interventions and policies to better support these frontline health care professionals are urgently needed.
BACKGROUND/OBJECTIVES
Hospice care confers well‐documented benefits to patients and their families, but it is underutilized. One potential reason is inadequate family support to make end‐of‐life ...decisions and care for older adults on hospice at home. We assessed the association between amount of family support and hospice use among a population of decedents and among specific illness types.
DESIGN
Prospective cohort study using the National Health and Aging Trends Study waves 2011 to 2017, linked to Medicare claims data.
SETTING
Contiguous United States.
PARTICIPANTS
A total of 1,868 NHATS decedents.
MEASUREMENTS
Outcome variable was 1 day or longer of hospice. Family caregiving intensity was measured by self‐reported hours of care per week and number of caregivers. Covariates included probable dementia status and other demographic, clinical, and functional characteristics.
RESULTS
At the end of life, hours of family caregiving and numbers of helpers vary widely with individuals with dementia receiving the most hours of unpaid care (mean = 64.5 hours per week) and having 2.4 unpaid caregivers on average. In an adjusted analysis, older adults with cancer receiving 40 hours and more of unpaid care/week as compared with fewer than 6 hours per week were twice as likely to receive hospice care at the end of life (odds ratio = 2.0; 95% confidence interval = 1.0–4.1). This association was not seen among those with dementia or among decedents in general. No significant association was found between number of caregivers and hospice use at the end of life.
CONCLUSION
Older adults at the end of life receive a high number of hours of help at the end of life, many from more than one caregiver, which may shape hospice access. Better understanding of disparities in hospice use can facilitate timely access to care for older adults with a serious illness. J Am Geriatr Soc 68:2288–2296, 2020.
This cohort study evaluates the prevalence of homebound older adults in the US from 2011 to 2020 and assesses whether the COVID-19 pandemic was associated with a change in prevalence.
Background
Nurse practitioners (NPs) are the largest group of providers delivering home‐based primary care (HBPC) in the U.S. We examined the association of scope‐of‐practice regulations and NP‐HBPC ...rates.
Methods
Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state‐level analysis to examine the impact of scope‐of‐practice regulations on the utilization of NP‐HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341–99,345, 99,347–99,350) and domiciliary settings (99324–99,328, 99,334–99,337). We used linear regression to compare NP‐HBPC utilization rates between states of either restricted or reduced scope‐of‐practice laws to states with full scope‐of‐practice, adjusting for a number of NP‐HBPC providers, state ranking of total assisted living, the proportion of fee‐for‐service (FFS) Medicare beneficiaries and neighborhood‐level socio‐economic status and race and ethnicity.
Results
Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope‐of‐practice, states with restricted or reduced scope‐of‐practice had higher adjusted rates of NP‐HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP‐HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full‐ scope‐of‐practice laws, respectively. The rate of NP‐HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13–1.72; p = 0.023) and reduced scope‐of‐practice laws (Beta coefficient = 0.91; 95%CI 0.03–1.79; p = 0.043) compared to states with full scope‐of‐practice laws.
Conclusion
Restricted state NP scope‐of‐practice regulations were associated with higher rates of FFS Medicare NP‐HBPC care delivery compared with full or reduced scope‐of‐practice. Understanding underlying mechanisms of how scope‐of‐practice affects NP‐HBPC delivery could help to develop scope‐of‐practice regulations that improve access to HBPC for the underserved homebound population.
Background
Homebound older adults have heightened risks for isolation and negative health consequences, but it is unclear how COVID-19 has impacted them. We examine social contact and mood symptoms ...among previously homebound older adults during the COVID-19 pandemic.
Design/Setting
Cross-sectional analysis using data from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of aging in the USA.
Participants
A total of 3,112 community-dwelling older adults in 2019 who completed the COVID-19 survey in the summer/fall of 2020.
Measurements
Homebound status was defined via self-report as rarely/never leaving home or leaving the house with difficulty or help in the prior month. We measured limited social contact during COVID-19 (in-person, telephone, video or email contacts <once/week), as well as loneliness, anxiety, and depression.
Results
Among homebound older adults, 13.2% experienced limited social contact during COVID-19 vs. 6.5% of the non-homebound. Differences in social contact were greatest for contacts via email/text/social media: 54.9% of the homebound used this <once/week vs. 28.4% of the non-homebound. In adjusted analyses of those without limited social contact prior to the pandemic, the homebound had higher but not significantly different odds (OR 1.83; 95% CI 0.95–3.52) of limited social contact during COVID-19, with increased risk among the older individuals, those with dementia, and those in assisted living facilities. Of the homebound, 13.2% felt lonely every/most days during the pandemic vs. 7.7% of non-homebound older adults. Homebound and non-homebound older adults reported similar rates of increased loneliness, anxiety, or depression during COVID-19. Fewer homebound older adults learned a new technology during the pandemic (16.3%) vs. non-homebound older adults (30.4%).
Discussion
Isolation among homebound older adults increased during COVID-19, partially due to differences in technology use. We must ensure that homebound persons have the connection and care they need including new technologies for communication during and beyond COVID-19.
Abstract Objective Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of ...deficiencies in informed surgical consent and shared decision-making in preoperative patients. Methods Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings. Results 13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits. Conclusion Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process. Practice implications Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.
Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare ...measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS).
We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing.
NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% 95% confidence interval (CI) 11.5%-13.4% of the cohort received help with dressing, while in HRS this figure was 6.4% 95% CI 5.7%-7.2% and MCBS 5.3% 95% CI 4.7%-5.8%. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability.
In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.
Background
For persons with diabetes, incidence of dementia has been associated with increased hospitalization; however, little is known about healthcare use preceding and following incident ...dementia. We describe healthcare utilization in the 3 years pre‐ and post‐incident dementia among older adults with diabetes.
Methods
We used the National Health and Aging Trends Study (NHATS) linked to Medicare fee‐for‐service claims from 2011 to 2018. We included community‐dwelling adults ≥65 years who had diabetes without dementia. We matched older adults with dementia (identified with validated NHATS algorithm) at the year of incident dementia to controls using coarsened exact matching. We examined annual outpatient visits, emergency department (ED) visits, hospitalization, and post‐acute skilled nursing facility (SNF) use 3 years preceding and 3 years following dementia onset.
Results
We included 195 older adults with diabetes with incident dementia and 1107 controls. Groups had a similar age (81.6 vs 81.7 years) and were 56.4% female. Persons with dementia were more likely to be of minority racial and ethnic groups (26.7% vs 21.3% Black, non‐Hispanic, 15.3% vs 6.7% other race or Hispanic). We observed a larger decrease in outpatient visits among persons with dementia, primarily due to decreasing specialty visits (mean outpatient visits: 3 years pre‐dementia/matching 6.8 (SD 2.6) dementia vs 6.4 (SD 2.6) controls, p < 0.01 to 3 years post‐dementia/matching 4.6 (SD 2.3) dementia vs 5.5 (SD 2.7) controls, p < 0.01). Hospitalization, ED visits, and post‐acute SNF use were higher for persons with dementia and rose in both groups (e.g., ED visits 3 years pre‐dementia/matching 3.9 (SD 5.4) dementia vs 2.2 (SD 4.8) controls, p < 0.001; 3 years post‐dementia/matching 4.5 (SD 4.7) dementia vs 3.5 (SD 6.1) controls, p = 0.04).
Conclusions
Older adults with diabetes with incident dementia have higher rates of acute and post‐acute care use, but decreasing outpatient use over time, primarily due to a decrease in specialty visits.
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