OBJECTIVES
Little population‐level evidence exists to guide the development of interventions for people with dementia in non–nursing home settings. We hypothesized people living at home with ...moderately severe dementia would differ in social, functional, and medical characteristics from those in either residential care or nursing home settings.
DESIGN
Retrospective cohort study using pooled data from the National Health and Aging Trends Study, an annual survey of a nationally representative sample of Medicare beneficiaries.
SETTING
US national sample.
PARTICIPANTS
Respondents newly meeting criteria for incident moderately severe dementia, defined as probable dementia with functional impairment: 728 older adults met our definition between 2012 and 2016.
MEASUREMENTS
Social characteristics examined included age, sex, race/ethnicity, country of origin, income, educational attainment, partnership status, and household size. Functional characteristics included help with daily activities, falls, mobility device use, and limitation to home or bed. Medical characteristics included comorbid conditions, self‐rated health, hospital stay, symptoms, and dementia behaviors.
RESULTS
Extrapolated to the population, an estimated 3.3 million older adults developed incident moderately severe dementia between 2012 and 2016. Within this cohort, 64% received care at home, 19% in residential care, and 17% in a nursing facility. social, functional, and medical characteristics differed across care settings. Older adults living at home were 2 to 5 times more likely to be members of disadvantaged populations and had more medical needs: 71% reported bothersome pain compared with 60% in residential care or 59% in nursing homes.
CONCLUSION
Over a 5‐year period, 2.1 million people lived at home with incident moderately severe dementia. People living at home had a higher prevalence of demographic characteristics associated with systematic patterns of disadvantage, more social support, less functional impairment, worse health, and more symptoms compared with people living in residential care or nursing facilities. This novel study provides insight into setting‐specific differences among people with dementia. J Am Geriatr Soc 67:1907–1912, 2019
See related editorial by Joanne Lynn.
There is an increase in the number of individuals who receive care at home. A significant proportion of these patients acquire infections during their care episode. Whilst there has been significant ...focus on strategies for infection prevention and control in acute care environments, there is a lack of research into infection prevention in a home care setting.
To understand (1) if and how home care nurses identify patients at high risk of infection and (2) the strategies they use to mitigate that risk.
A qualitative descriptive study, using semi-structured interviews.
A large not for profit home care agency located in the New York region of the United States.
Fifty nurses with a range of experience in home care nursing.
Purposive and snowball sampling was used to recruit nurses from across the home care agency with varied years of work experience. Interviews were audio recorded and transcribed. The interviews explored how home care nurses evaluate their patients’ risk of developing an infection and if/how they modify the plan of care based on that risk. Data were analysed using thematic analysis.
Three themes were derived from the data; assessing a patient's risk of infection, the risk assessment process, and strategies for mitigating infection risk. Factors identified by nurses as putting a patient at higher risk of infection included being older, having diabetes, inadequate nutrition; along with inadequate clinical information available at start of care. The patient's knowledge and understanding of infection prevention, and the availability and knowledge of caregivers were also important, as was the cleanliness of the home environment. Given the context of home care, where nurses have little control over the environment and care processes in-between visits, the main strategy for infection prevention was patient and caregiver education. Nurses also discussed the importance of their own infection prevention behaviours, and the ability to adjust a patient's plan of care according to their infection risk.
The study highlights the complexity of the risk assessment process in relation to infection. Existing guidelines for infection prevention and control do not adequately cover the home care environment and more research needs to determine which interventions (such as patient/caregiver education) would be most effective to prevent infections in the home care setting.
Objective
Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to ...determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30‐day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable.
Data Sources
Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services.
Study Design
Retrospective cohort design.
Data Extraction
The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File.
Principal Findings
The 30‐day rehospitalization rate was 26 percent with 42 percent of patients having cardiac‐related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable.
Conclusions
The persistently high rates of rehospitalization have been difficult to address. There are health care‐specific actions and policy implications that are worth examining to improve rehospitalization rates.
IMPORTANCE: Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these ...tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care. OBJECTIVE: To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary’s home zip code and the closest home health agency and the closest skilled nursing facility as an instrument. EXPOSURES: Receipt of postacute care at home vs in a skilled nursing facility. MAIN OUTCOMES AND MEASURES: Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode. RESULTS: A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean SD age, 80.5 7.9 years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (−2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (−1.9 percentage points; 95% CI, –12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (−$5384; 95% CI, –$6932 to –$3837; P < .001), as was total Medicare payment within the first 60 days after admission (−$4514; 95% CI, –$6932 to –$3837; P < .001). CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.
The housing we live in shapes individual access to jobs, health, well being and communities. There are also substantial differences between generations regarding the type of housing they aspire to ...live in, their attitudes to housing costs, the nature of their households and their attitudes to different tenures. This important contribution to the literature draws upon research from the UK, Australia and the USA to show how lifetime attitudes to housing have changed, with new population dynamics driving the market and a greater emphasis on consumption. It also considers how the global financial crisis has differentially affected housing markets across the globe, with variable impacts on the long term housing transitions of different populations.
In this paper, we explore a popular flexible work arrangement (FWA), home-based telework, in the Indian IT industry. We show how IT managers used the dominant meanings of telework to portray telework ...as an employee benefit that outweighed the attendant cost—intensified work. While using their discretion to grant telework, the managers drew on this portrayal to orchestrate a negotiated exchange with their subordinates. Consequently, the employees consented to accomplish the intensified work at home in exchange of telework despite their opposition to the intensified work in the office. Thus, whereas the extant studies consider work intensification as an unanticipated outcome of using FWAs, we show how firms may use FWAs strategically to get office-based intensified work accomplished at home. While the dominant argument is that employees reciprocate the opportunity to telework with intensified work, we show a discursively orchestrated negotiation that favors management. A corrective policy measure is to frame telework as an employee right.
The study addresses staffing and workforce issues for home‐ and community‐based long‐term care in Germany. It is based on a study aimed at developing staffing recommendations for home‐care provider ...organisations. The study was commissioned within the regulation of the German long‐term care act. Following an exploratory literature search on staffing issues in home‐ and community‐based care qualitative interviews with 30 experts in home care were conducted. In addition, time needed for different interventions in homes of people in need of care (n = 129) was measured. Ethical approval for the study was obtained. The literature on the topic is limited. In Germany, no fixed staff‐to‐client ratio exists, but staffing is determined primarily by reimbursement policies, not by care recipients’ needs. The results of the interviews indicated that staffing ratios are not the main concern of home‐care providers. Experts stressed that general availability of staff with different qualification levels and the problems of existing regulation on services and their reimbursement are of higher concern. The measurement of time needed for selected interventions reveals the huge heterogeneity of home‐care service delivery and the difficulty of using a task‐based approach to determine staffing levels. Overall, the study shows that currently demand for home‐care exceeds supply. Staff shortage puts a risk to home care in Germany. Existing approaches of reimbursement‐driven determination of staffing levels have not been sufficient. A new balance between staffing, needs and reimbursement policies needs to be developed.
OBJECTIVES
To determine the effect of home‐based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long‐term institutionalization (LTI).
...DESIGN
Case‐cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks.
SETTING
Three IAH‐participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC.
PARTICIPANTS
HBPC integrated with long‐term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home‐qualified (IAH‐Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC.
INTERVENTION
HBPC integrated with LTSS under IAH demonstration incentives.
MEASUREMENTS
Measurements include LTI rate and mortality rates, community survival, and LTSS costs.
RESULTS
The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH‐Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home‐ and community‐based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed‐to‐expected ratio = .88 .68‐1.09). LTI‐free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH‐q participants in NHATS.
CONCLUSION
HBPC integrated with long‐term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.
See related editorial by Leff et al.
Objectives
To describe the characteristics of home‐based primary care practices: staffing, administrative, population served, care practices, and quality of care challenges.
Design
Survey of ...home‐based primary care practices.
Setting
Home‐based primary care practices in the United States.
Participants
Members of the American Academy of Home Care Medicine and nonmember providers identified by surveyed members.
Measurements
A 58‐item questionnaire that assessed practice characteristics, care provided by the practice, and how the quality of care that the practice provided was assessed.
Results
Survey response rate was 47.9%, representing 272 medical house calls practices. Mean average daily census was 457 patients (median 100 patients, range 1–30,972 patients). Eighty‐eight percent of practices offered around‐the‐clock coverage for urgent concerns, 60% held regularly scheduled team meetings, 89% used an electronic medical record, and one‐third used a defined quality improvement process. The following factors were associated with practices that used a defined quality improvement process: practice holds regularly scheduled team meetings to discuss specific patients (odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.02–4.21), practice conducts surveys of patients (OR = 8.53, 95% CI = 4.07–17.88), and practice is involved in National Committee for Quality Assurance patient‐centered medical home (OR = 3.27, 95% CI = 1.18–9.07). Ninety percent of practices would or might participate in quality improvement activities that would provide them timely feedback on patient and setting‐appropriate quality indicators.
Conclusions
There is a substantial heterogeneity of home‐based primary care practice types. Most practices perform activities that lend themselves to robust quality improvement efforts, and nearly all indicated interest in a national registry to inform quality improvement.
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