Background/Objectives
Older adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication ...management and may miss key components. The objective of this study is to examine the current scope of hospital‐to‐home transitional care interventions that impact health‐related outcomes and to examine other key components including engagement by older adults and their caregivers.
Design
Scoping review.
Methods
Eligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results.
Results
Five hundred sixty‐seven records were identified by title. Forty‐four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self‐management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality.
Conclusion
To improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver‐reported needs and their well‐being.
During Medicare home health care (HHC), family caregiver assistance is often integral to implementing the care plan and avoiding readmission. Family caregiver training delivered by HHC clinicians ...(nurses and physical therapists PTs) helps ensure caregivers' ability to safely assist when HHC staff are not present. Yet, family caregiver training needs often go unmet during HHC, increasing the risk of adverse patient outcomes. There is a critical knowledge gap regarding challenges HHC clinicians face in providing necessary family caregiver training.
Multisite qualitative study using semi-structured, in-depth key informant interviews with Registered Nurses (n = 11) and PTs (n = 8) employed by four HHC agencies. Participating agencies were diverse in rurality, scale, ownership, and geographic region. Key informant interviews were audio-recorded, transcribed, and analyzed using directed content analysis to identify existing facilitators and barriers to family caregiver training during HHC.
Clinicians had an average of 9.3 years (range = 1.5-23 years) experience in HHC, an average age of 45.1 years (range = 28-63 years), and 95% were female. Clinicians identified facilitators and barriers to providing family caregiver training at the individual, interpersonal, and structural levels. The most salient factors included clinician-caregiver communication and rapport, accuracy of hospital discharge information, and access to resources such as additional visits and social work consultation. Clinicians noted the COVID-19 pandemic introduced additional challenges to providing family caregiver training, including caregivers' reduced access to hospital staff prior to discharge.
HHC clinicians identified a range of barriers and facilitators to delivering family caregiver training during HHC; particularly highlighting the role of clinician-caregiver communication. To support caregiver training in this setting, there is a need for updated reimbursement structures supporting greater visit flexibility, improved discharge communication between hospital and HHC, and structured communication aids to facilitate caregiver engagement and assessment.
Medicare home health providers are now required to deliver family caregiver training, but potential consequences for service intensity are unknown.
The objective of this study was to assess how ...family caregiver training needs affect the number and type of home health visits received.
Observational study using linked National Health and Aging Trends Study (NHATS), Outcomes and Assessment Information Set (OASIS), and Medicare claims data. Propensity score adjusted, multivariable logistic, and negative binomial regressions model the relationship between caregivers' training needs and number/type of home health visits.
A total of 1217 (weighted n=5,870,905) National Health and Aging Trends Study participants receiving Medicare-funded home health between 2011 and 2016.
Number and type of home health visits, from Medicare claims. Family caregivers' training needs, from home health clinician reports.
Receipt of nursing visits was more likely when family caregivers had medication management adjusted odds ratio (aOR): 3.03; 95% confidence interval (CI): 1.06, 8.68 or household chore training needs (aOR: 3.38; 95% CI: 1.33, 8.59). Receipt of therapy visits was more likely when caregivers had self-care training needs (aOR: 1.70; 95% CI: 1.01, 2.86). Receipt of aide visits was more likely when caregivers had household chore (aOR: 3.54; 95% CI: 1.82, 6.92) or self-care training needs (aOR: 2.12; 95% CI: 1.11, 4.05). Medication management training needs were associated with receiving an additional 1.06 (95% CI: 0.11, 2.01) nursing visits, and household chores training needs were associated with an additional 3.24 total (95% CI: 0.21, 6.28) and 1.32 aide visits (95% CI: 0.36, 2.27).
Family caregivers' activity-specific training needs may affect home health visit utilization.
Home health clinicians report a need for family caregiver assistance during the majority of skilled home health care episodes. Since 2018, the Medicare Conditions of Participation has required home ...health agencies to provide training to family caregivers. However, little is known regarding current practices of family caregiver assessment and training during home health care.
Qualitative research relying on semistructured key informant interviews with registered nurses and physical therapists (n = 19), hereafter "clinicians," from four home health agencies. Interviews were recorded and transcribed, then analyzed using directed content analysis to identify relevant themes and concepts.
Three agencies were not-for-profit and one was for-profit; three were urban and one was rural; two operated on a local scale, one on a regional scale, and one on a national scale. Key informants had an average of 9.3 years of experience in home health care and an average age of 45.0 years. Clinicians described a cyclic process of family caregiver training including four major phases: initial assessment, education, reassessment, and adjustment. Initial assessment was informal and holistic; education was delivered via demonstration and teach-back; reassessment was used to evaluate caregiver progress and inform adjustments to the care plan. Clinicians noted that their perceptions regarding the success of family caregiver training efforts influenced decisions relating to clinical practice, including the number of visits provided and whether to discharge the patient.
Caregiver training is currently integrated into clinician workflows in home health care and helps determine visit intensity and discharge timing, but clinicians face a lack of structured assessment instruments or training materials. Efforts by policymakers and home health agencies to facilitate clinicians' training efforts could positively affect the cost and quality of Medicare-funded home health care.
Background/Objectives
Medicare‐certified home health agencies are required to offer family caregiver training, but little is known regarding the potential impact of this training on outcomes during ...home health care. We estimate the proportion of family caregivers assisting Medicare home health patients who have unmet training needs and examine whether these unmet training needs are associated with older adults' risk of acute care utilization during home health care.
Design
Observational, nationally representative cohort study.
Setting
Linked National Health and Aging Trends Study, Outcome and Assessment Information Set (OASIS), Medicare Provider of Services file, and Medicare claims data from 2011 to 2016.
Participants
Thousand two hundred seventeen (weighted n = 5,870,905) community‐living Medicare beneficiaries who received home health care between 2011 and 2016.
Measurements
Family caregivers' unmet training needs measured from OASIS and Medicare claims; home health patients' acute care utilization (including emergency department use and hospitalization) measured from OASIS.
Results
Rates of unmet need for training varied by activity, from 8.2% of family caregivers assisting with household chores to 16.0% assisting with self‐care tasks. After controlling for older adult and home health provider characteristics, older adults whose family caregivers had an unmet need for training with any caregiving activity were twice as likely to incur acute care utilization during their home health episode (adjusted odds ratio aOR: 2.01, 95% confidence interval CI: 1.20–3.38). This relationship held across specific caregiving activities including household chores (aOR: 1.98; 95% CI: 1.13–3.46), medication management (aOR: 2.50; 95% CI: 1.46–4.26), patient supervision (aOR: 2.92; 95% CI: 1.36–6.24), and self‐care tasks (aOR: 3.11; 95% CI: 1.62–6.00).
Conclusions and Relevance
Unmet training needs among family caregivers are associated with greater likelihood of acute care utilization among Medicare beneficiaries receiving home health care. Identifying and addressing family caregivers' training needs may reduce older adults' risk of acute care utilization during home health care.
Purpose: This study attempts to determine the associations between postdischarge environmental (PDE) and socioeconomic (SES) factors and early readmission to hospitals. Design and Methods: This study ...was a cohort study using the 2001 Medicare Current Beneficiary Survey and Medicare claims for the period from 2001 to 2002. The participants were community-dwelling Medicare beneficiaries admitted to hospitals, discharged home, and surviving at least 1 year after discharge (n = 1,351). The study measurements were early readmission (within 60 days), PDE factors, and SES factors. PDE factors consisted of having a usual source of care, requiring assistance to see the usual source of care, marital status, living alone, lacking self-management skills, having unmet functional need, having no helpers with activities of daily living, number of living children, and number of levels in the home. SES factors consisted of education, income, and Medicaid enrollment. Results: Of the 1,351 beneficiaries, 202 (15.0%) experienced an early readmission. After adjustment for demographics, health, and functional status, the odds of early readmission were increased by living alone (odds ratio or OR = 1.50, 95% confidence interval or CI = 1.01–2.24), having unmet functional need (OR = 1.48, 95% CI = 1.04–2.10), lacking self-management skills (OR = 1.44, 95% CI = 1.03–2.02), and having limited education (OR = 1.42, 95% CI = 1.01–2.02). Implications: These findings suggest that PDE and SES factors are associated with early readmission. Considering these findings may enhance the targeting of pre-discharge and postdischarge interventions to avert early readmission. Such interventions may include home health services, patient activation, and comprehensive discharge planning.
Objectives
To review studies investigating cochlear implant (CI) outcomes in older adults, and to develop a conceptual framework demonstrating important interactions between characteristics of ...hearing disability, aging, and the CI intervention.
Design
Review of English literature with titles containing the words “cochlear implant” and generic term referring to older adults or numerical value for age greater than 65.
Results
Hearing loss is a prevalent consequence of aging and poses special challenges for older adults. Particularly when superimposed on other age‐related conditions, presbycusis (age‐related hearing loss) places older adults at risk for social isolation and associated psychological and general health sequelae. The increasing cognitive demand of verbal communication and the diminished sense of social and physical connectedness can contribute to a feeling of vulnerability and poor health that worsens with advancing presbycusis. This cascade of downstream effects of hearing loss has implications for the self‐assessment of health‐related quality of life (HRQoL) and resulting estimates of associated costs. There is accumulating evidence of a potential role for CI in older adults with poor word understanding despite conventional hearing aid use. This review of the literature provides strong evidence of the benefits of restoring communication capacity in the deaf and hard‐of‐hearing geriatric population. There is, however, a lack of attention to communication performance in the real world and HRQoL outcomes, and significant gaps in knowledge regarding how CI rehabilitation interacts with changing psychosocial and functional status with aging.
Conclusion
A broader conceptual framework than is currently available for the role of CI rehabilitation in the management of severe‐to‐profound hearing loss in older adults is proposed. It is posited that the use of such a model in future investigations is needed to guide multidisciplinary investigations into the unique challenges of hearing loss in older adults and may open new opportunities for innovation.
Background
Hospital at home (HaH) is a model of care that provides acute‐level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. ...Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully.
Objectives
This study examined facilitators and barriers to implementation of an HaH program.
Design
A HaH program that included a 30‐day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators.
Setting
Large urban academic health system.
Participants
Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation).
Results
To facilitate successful development and implementation of a high‐quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work‐arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors.
Conclusion
Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships. J Am Geriatr Soc 67:588–595, 2019.
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