National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Access to Care (2)
- Caregiving (4)
- Chronic Conditions (4)
- Community-Acquired Infections (2)
- Dementia (1)
- Diabetes (2)
- Diagnostic Safety and Quality (1)
- Disparities (1)
- Elderly (9)
- Electronic Health Records (EHRs) (3)
- Falls (1)
- Guidelines (1)
- Healthcare-Associated Infections (HAIs) (2)
- Healthcare Costs (1)
- Healthcare Delivery (1)
- Healthcare Utilization (3)
- Health Information Technology (HIT) (3)
- (-) Home Healthcare (24)
- Hospital Discharge (1)
- Hospitalization (2)
- Hospital Readmissions (3)
- Infectious Diseases (1)
- Injuries and Wounds (1)
- Long-Term Care (3)
- Medicare (5)
- Medication (1)
- Medication: Safety (1)
- Neurological Disorders (1)
- Nursing (2)
- Nursing Homes (2)
- Outcomes (1)
- Patient Adherence/Compliance (1)
- Patient Safety (2)
- Patient Self-Management (1)
- Prevention (3)
- Provider (4)
- Provider: Nurse (4)
- Racial and Ethnic Minorities (2)
- Rehabilitation (1)
- Risk (3)
- Training (2)
- Transitions of Care (3)
- Urinary Tract Infection (UTI) (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 24 of 24 Research Studies DisplayedMa C, McDonald MV, Feldman PH
Continuity of nursing care in home health: impact on rehospitalization among older adults with dementia.
The objective of this retrospective cohort study was to examine the association between continuity of nursing care in home health care (HHC) and rehospitalization among persons with dementia (PWD). Multiple years of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency was used. Findings showed that wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.
AHRQ-funded; HS023593.
Citation: Ma C, McDonald MV, Feldman PH .
Continuity of nursing care in home health: impact on rehospitalization among older adults with dementia.
Med Care 2021 Oct;59(10):913-20. doi: 10.1097/mlr.0000000000001599..
Keywords: Elderly, Home Healthcare, Dementia, Neurological Disorders, Hospital Readmissions
Song J, Woo K, Shang J
Predictive risk models for wound infection-related hospitalization or ED visits in home health care using machine-learning algorithms.
Wound infection is prevalent in home healthcare (HHC) and often leads to hospitalizations. However, none of the previous studies of wounds in HHC have used data from clinical notes. Therefore, in this paper, the authors created a more accurate description of a patient's condition by extracting risk factors from clinical notes to build predictive models to identify a patient's risk of wound infection in HHC.
AHRQ-funded; HS024915.
Citation: Song J, Woo K, Shang J .
Predictive risk models for wound infection-related hospitalization or ED visits in home health care using machine-learning algorithms.
Adv Skin Wound Care 2021 Aug;34(8):1-12. doi: 10.1097/01.Asw.0000755928.30524.22..
Keywords: Home Healthcare, Injuries and Wounds, Risk, Hospitalization
Russell D, Burgdorf JG, Kramer C
Family caregivers' conceptions of trust in home health care providers.
Trust is important to family caregivers of older adults receiving home health care (HHC). Caregivers rely extensively on nurses, home health aides, and other providers to manage complex care tasks. The current study examined how family caregivers conceived of trust in HHC providers. The investigators found that caregivers' conceptions of trust in providers were affected by interpersonal aspects of their interactions with providers as well as the broader systems of care within which they participate.
AHRQ-funded; HS022140.
Citation: Russell D, Burgdorf JG, Kramer C .
Family caregivers' conceptions of trust in home health care providers.
Res Gerontol Nurs 2021 Jul-Aug;14(4):200-10. doi: 10.3928/19404921-20210526-01..
Keywords: Elderly, Home Healthcare, Caregiving
Burgdorf JG, Arbaje AI, Stuart EA
Unmet family caregiver training needs associated with acute care utilization during home health care.
This study estimated the proportion of family caregivers assisting Medicare home health patients who have unmet training needs and its’ potential impact on older adults’ risk of acute care utilization. Linked data from the 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 were used. Rates of unmet training needs varied from 8.2% of family caregivers assisting with household chores and 16% assisting with self-care tasks. After controlling for older adult and home health provider characteristics, older adults with family caregivers who had unmet training needs were twice as likely to incur acute care utilization during their home health episode.
AHRQ-funded; HS0000029.
Citation: Burgdorf JG, Arbaje AI, Stuart EA .
Unmet family caregiver training needs associated with acute care utilization during home health care.
J Am Geriatr Soc 2021 Jul;69(7):1887-95. doi: 10.1111/jgs.17138..
Keywords: Caregiving, Home Healthcare, Elderly, Healthcare Utilization, Training
Adams V, Song J, Shang J
Infection prevention and control practices in the home environment: examining enablers and barriers to adherence among home health care nurses.
This study’s aim was to examine the impact of individual, home environment, and organization factors on Infection Prevention and Control (IPC) practices in home health care. A survey of 350 nurses across two large home care agencies was conducted to examine the relationship between IPC adherence and these factors. Multiple barriers to IPC practices in patients’ homes were reported including clutter (74.5%), and a dirty environment (70.3%). They also reported limited availability of some IPC supplies including personal protective equipment.
AHRQ-funded; HS024723.
Citation: Adams V, Song J, Shang J .
Infection prevention and control practices in the home environment: examining enablers and barriers to adherence among home health care nurses.
Am J Infect Control 2021 Jun;49(6):721-26. doi: 10.1016/j.ajic.2020.10.021..
Keywords: Home Healthcare, Community-Acquired Infections, Infectious Diseases, Prevention, Provider: Nurse, Provider
Smith JM, Lin H, Thomas-Hawkins C
Timing of home health care initiation and 30-day rehospitalizations among Medicare beneficiaries with diabetes by race and ethnicity.
Older adults with diabetes are at elevated risk of complications following hospitalization. Home health care services mitigate the risk of adverse events and facilitate a safe transition home. In the United States, when home health care services are prescribed, federal guidelines require they begin within two days of hospital discharge. This study examined the association between timing of home health care initiation and 30-day rehospitalization outcomes in a cohort of 786,734 Medicare beneficiaries following a diabetes-related index hospitalization admission during 2015.
AHRQ-funded; HS022406.
Citation: Smith JM, Lin H, Thomas-Hawkins C .
Timing of home health care initiation and 30-day rehospitalizations among Medicare beneficiaries with diabetes by race and ethnicity.
Int J Environ Res Public Health 2021 May 25;18(11). doi: 10.3390/ijerph18115623..
Keywords: Elderly, Home Healthcare, Hospital Readmissions, Medicare, Diabetes, Chronic Conditions, Racial and Ethnic Minorities
Wang J, Ying M, Temkin-Greener H
Care-partner support and hospitalization in assisted living during transitional home health care.
This study examined the impact of care-partner support on outcomes among assisted living (AL) residents. Variation in care-partner and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services was investigated. Analysis of national data from various databases was used and a total of 741,926 participants were identified with Medicare HH admissions in 2017. Care-partner support during the HH admission was measured in seven domains: activity of daily living (ADLs), instrumental activities of ADLs), medication administration, treatment, medical equipment, home safety, and transportation. Care-partner support was categorized as assistance not needed, care-partner currently providing assistance, care-partner needs additional training/support to provide assistance, and care-partner is unavailable/unlikely to provide assistance. Among the cohort, inadequate care-partner support was identified for all seven domains ranging from 13.1% for transportation to 49.8% for treatment and was unavailable for 0.9% for transportation to 11.0% for treatment. Having inadequate or unavailable care-partner support was related to increased risk of hospitalization by 8.9% for treatment to 41.3% for medication administration.
AHRQ-funded; HS026893.
Citation: Wang J, Ying M, Temkin-Greener H .
Care-partner support and hospitalization in assisted living during transitional home health care.
J Am Geriatr Soc 2021 May;69(5):1231-39. doi: 10.1111/jgs.17005..
Keywords: Elderly, Transitions of Care, Caregiving, Hospitalization, Home Healthcare, Long-Term Care
Champion C, Sockolow PS, Bowles KH
Getting to complete and accurate medication lists during the transition to home health care.
This observational field study looked at the work that home health care (HHC) admissions nurses complete related to medication reconciliation tasks, explored the impact of shared electronic medication data (interoperability), and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies. Three diverse Pennsylvania HHC agencies participated, with each using different electronic health record systems. Six nurses per site admitted 2 patients each (36 patients total) and their tasks were examined in depth. Medication reconciliation tasks included changes in number of medications and change types and calls to the health provider (doctor or pharmacy) to resolve medication-related issues. A high percentage of patients used multiple medications (more than 12 medications on average), and were high-risk (on average more than 8 medications per patient). Medication reconciliation decreased the number of prescriptions between pre- and post-reconciliation for 91% of patients with 41% of the medications requiring changes. Two-thirds of the nurses called a provider to facilitate medication changes. Interoperability reduced the number of changes required but did not eliminate changes or calls to providers.
AHRQ-funded; R01 HS024537.
Citation: Champion C, Sockolow PS, Bowles KH .
Getting to complete and accurate medication lists during the transition to home health care.
J Am Med Dir Assoc 2021 May;22(5):1003-08. doi: 10.1016/j.jamda.2020.06.024..
Keywords: Medication, Medication: Safety, Transitions of Care, Home Healthcare, Patient Safety
Woo K, Adams V, Wilson P
Identifying urinary tract infection-related information in home care nursing notes.
Urinary tract infection (UTI) is common in home care but not easily captured with standard assessment. This study aimed to examine the value of nursing notes in detecting UTI signs and symptoms in home care. The investigators found that information in nursing notes was often overlooked by stakeholders and not integrated into predictive modeling for decision-making support. They indicate that their findings highlighted the value of nursing notes in early risk identification and care guidance.
AHRQ-funded; R01 HS024723.
Citation: Woo K, Adams V, Wilson P .
Identifying urinary tract infection-related information in home care nursing notes.
J Am Med Dir Assoc 2021 May;22(5):1015-21.e2. doi: 10.1016/j.jamda.2020.12.010..
Keywords: Urinary Tract Infection (UTI), Home Healthcare, Diagnostic Safety and Quality
Russell D, Dowding D, Trifilio M
Individual, social, and environmental factors for infection risk among home healthcare patients: a multi-method study.
This paper is a study of nurse perceptions of individual, social, and environmental factors for infection risk among home healthcare (HHC) patients and also identifies the frequency of environmental barriers to infection prevention and control in HHC. Data were collected in 2017-2018 from qualitative interviews with 50 HHC nurses and structured observations of nurse visits to patients’ homes (n = 400). Perceived infection risk among patients was characterized as being influenced by knowledge of and attitudes towards infection prevention and engagement in hygiene practices, receipt of support from informal caregivers and nurse interventions aimed at cultivating infection control knowledge and practices, and the home environment. Frequent environmental barriers observed during visits to patients included clutter (39.5%), poor lighting (38.8%), dirtiness (28.5%), and pets (17.2%).
AHRQ-funded; HS024723.
Citation: Russell D, Dowding D, Trifilio M .
Individual, social, and environmental factors for infection risk among home healthcare patients: a multi-method study.
Health Soc Care Community 2021 May;29(3):780-88. doi: 10.1111/hsc.13321..
Keywords: Home Healthcare, Community-Acquired Infections, Risk, Provider: Nurse, Provider
McDonald MV, Brickner C, Russell D
Observation of hand hygiene practices in home health care.
The purpose of this observational study was to describe nurse hand hygiene practices in the home health care (HHC) setting, nurse adherence to hand hygiene guidelines, and factors associated with hand hygiene opportunities during home care visits. The investigators concluded that hand hygiene adherence in HHC was suboptimal, with rates mirroring those reported in hospital and outpatient settings.
AHRQ-funded; HS024723.
Citation: McDonald MV, Brickner C, Russell D .
Observation of hand hygiene practices in home health care.
J Am Med Dir Assoc 2021 May;22(5):1029-34. doi: 10.1016/j.jamda.2020.07.031..
Keywords: Home Healthcare, Nursing, Provider: Nurse, Provider, Prevention, Healthcare-Associated Infections (HAIs), Guidelines
Sockolow PS, Bowles KH, Le NB
There's a problem with the problem list: incongruence of patient problem information across the home care admission.
The purpose of this observational field study was to illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. The investigators concluded that diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the plan of care. Because of the EHR structure, clinicians could not identify inactive problem or problem priority.
AHRQ-funded; HS024537.
Citation: Sockolow PS, Bowles KH, Le NB .
There's a problem with the problem list: incongruence of patient problem information across the home care admission.
J Am Med Dir Assoc 2021 May;22(5):1009-14. doi: 10.1016/j.jamda.2020.06.032..
Keywords: Home Healthcare, Electronic Health Records (EHRs), Health Information Technology (HIT)
Reistetter TA, Eschbach K K, Prochaska J
Understanding variation in postacute care: developing rehabilitation service areas through geographic mapping.
This study’s goal was to demonstrate a method for developing rehabilitation service areas for post-acute care. A secondary analysis of 2013-2014 Medicare records for older patients in Texas (n = 469,172) was conducted. The analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, and long-term care hospitals. The authors used Ward’s algorithm to cluster patient ZIP code tabulation areas based on which facilities patients were admitted to for rehabilitation. They set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions. Interclass Correlation Coefficient (ICC) and variance in the number of rehabilitation beds across areas were the methods used to evaluate rehabilitation service areas. The service areas had a higher ICC and variance in beds than the hospital referral regions.
AHRQ-funded; HS024711.
Citation: Reistetter TA, Eschbach K K, Prochaska J .
Understanding variation in postacute care: developing rehabilitation service areas through geographic mapping.
Am J Phys Med Rehabil 2021 May;100(5):465-72. doi: 10.1097/phm.0000000000001577..
Keywords: Elderly, Rehabilitation, Medicare, Nursing Homes, Long-Term Care, Home Healthcare, Access to Care
Burgdorf JG, Stuart EA, Arbaje AI
Family caregiver training needs and Medicare home health visit utilization.
This study looked at family caregiver training needs and Medicare home health visit utilization. Medicare home health providers are now required to give family caregiver training, but service intensity is not known. This observational study linked National Health and Aging Trends Study (NHATS), Outcomes and Assessment Information (OASIS), and Medicare claims data to evaluate the relationship between caregivers’ training needs and number/type of home health visits. A total of 1217 NHATS participants receiving Medicare-funded home health between 2011 and 2016 were included. Nurse visits were more likely when family caregivers had medication management or household chore training needs. Therapy visits were more likely when caregivers had self-care training needs. Aide visits were more likely when caregivers had household chore or self-care training needs. Medication management training needs resulted in an additional 1.06 nursing visits, and household chore training an additional 3.24 total and a subset of 1.32 aide visits.
AHRQ-funded; HS000029.
Citation: Burgdorf JG, Stuart EA, Arbaje AI .
Family caregiver training needs and Medicare home health visit utilization.
Med Care 2021 Apr;59(4):341-47. doi: 10.1097/mlr.0000000000001487..
Keywords: Caregiving, Elderly, Home Healthcare, Medicare, Training, Healthcare Utilization
Smith JM, Jarrín OF, Lin H
Racial disparities in post-acute home health care referral and utilization among older adults with diabetes.
The purpose of this study was to examine the association between race/ethnicity and hospital discharge to home health care and subsequent utilization of home health care among a cohort of adults (age 50 and older) who experienced a diabetes-related hospitalization. The investigators found that among those discharged to home health care, all non-white racial/ethnic minority patients were less likely to receive services within 14-days.
AHRQ-funded; HS022406.
Citation: Smith JM, Jarrín OF, Lin H .
Racial disparities in post-acute home health care referral and utilization among older adults with diabetes.
Int J Environ Res Public Health 2021 Mar 19;18(6):3196. doi: 10.3390/ijerph18063196..
Keywords: Elderly, Home Healthcare, Diabetes, Chronic Conditions, Racial and Ethnic Minorities, Disparities, Access to Care, Healthcare Utilization
Misra-Hebert AD, Rothberg MB, Fox J
Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.
This retrospective cohort study assessed the association of home visits by advanced practice registered nurses (APRNs) and paramedics with healthcare utilization and mortality of patients released home after hospital discharge The authors looked at adult medical patients discharged to home from November 2017-September 2019. They assessed outcomes for home visit vs. matched comparison patients at 30, 90, and 180 days, including hospital admission, emergency department (ED) use, and death using two phases. Phase 1 was defined as APRN or paramedic visits assigned by geographic location and Phase 2 defined as APRN and paramedic visit teams assigned to patients. They also compared patients who declined home visits with those accepting them. Phase 1 outcomes showed no differences in readmissions, ED visits, or death at 30,90, and 180 days. Phase 2 showed patients who had home visits had fewer 30-day readmissions and no differences in other outcomes. Patients who accepted home visits had lower odds of readmission compared to patients who declined. Forty-four interviews were also conducted, and themes of Medication Understanding, Knowledge Gap after Discharge, Patient Medical Complexity, Social Context, and Patient Engagement/Need for Reassurance emerged.
AHRQ-funded; HS024128.
Citation: Misra-Hebert AD, Rothberg MB, Fox J .
Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.
Healthc 2021 Mar;9(1):100518. doi: 10.1016/j.hjdsi.2020.100518..
Keywords: Home Healthcare, Transitions of Care, Hospital Discharge, Hospital Readmissions
Wang J, Ying M, Temkin-Greener H
Utilization and functional outcomes among Medicare home health recipients varied across living situations.
Home health (HH) is a major type of home-based skilled care available to Medicare beneficiaries. In this study, the investigators examined the association between living situation and utilization and functional outcomes among Medicare HH recipients. The investigators concluded that, in the study population, patients living with others at home had the highest risk of hospitalization and ED visits, whereas assisted living (AL) residents had the lowest risk of hospitalization and patients living alone at home had the lowest risk of ED visits.
AHRQ-funded; HS026893.
Citation: Wang J, Ying M, Temkin-Greener H .
Utilization and functional outcomes among Medicare home health recipients varied across living situations.
J Am Geriatr Soc 2021 Mar;69(3):704-10. doi: 10.1111/jgs.16949..
Keywords: Home Healthcare, Medicare, Outcomes
Dowding D, Russell D, McDonald MV
"A catalyst for action": factors for implementing clinical risk prediction models of infection in home care settings.
This study looked at how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses. It was a qualitative study using semi-structured interviews with 50 home care nurses. The interviews were audio-taped and transcribed with data evaluation using thematic analysis. Findings indicated that the nurses would find a clinical risk prediction model useful, as long as it provided both context around the reasons why a patient was deemed to be high risk and provided some guidance for action.
AHRQ-funded; HS024723.
Citation: Dowding D, Russell D, McDonald MV .
"A catalyst for action": factors for implementing clinical risk prediction models of infection in home care settings.
J Am Med Inform Assoc 2021 Feb 15;28(2):334-41. doi: 10.1093/jamia/ocaa267..
Keywords: Home Healthcare, Nursing, Risk, Healthcare-Associated Infections (HAIs), Prevention, Provider: Nurse, Provider
Kendall L, Eschler J, Lozano P
Engineering for reliability in at-home chronic disease management.
The researchers examined how individuals responsible for managing their own or others’ chronic conditions integrate reminders and notification systems into their daily routines. Based on the participants’ experiences, they contend that many self-management failures should be viewed as systems failures, rather than individual failures and non-compliance.
AHRQ-funded; HS021590.
Citation: Kendall L, Eschler J, Lozano P .
Engineering for reliability in at-home chronic disease management.
AMIA Annu Symp Proc 2014 Nov 14;2014:777-86..
Keywords: Chronic Conditions, Patient Self-Management, Home Healthcare, Patient Adherence/Compliance
Smucker DR, Regan S, Elder NC
Patient safety incidents in home hospice care: the experiences of hospice interdisciplinary team members.
The study objective was to explore the types and characteristics of patient safety incidents in home hospice care from the experiences of hospice interdisciplinary team members. Based on interviews of 19 experienced hospice leaders, the most commonly described categories of patient harm were injuries from falls and inadequate symptom control.
AHRQ-funded; HS018245
Citation: Smucker DR, Regan S, Elder NC .
Patient safety incidents in home hospice care: the experiences of hospice interdisciplinary team members.
J Palliat Med. 2014 May;17(5):540-4. doi: 10.1089/jpm.2013.0111..
Keywords: Patient Safety, Home Healthcare, Falls, Chronic Conditions
Huckfeldt PJ, Sood N, Escarce JJ
Effects of Medicare payment reform: evidence from the home health interim and prospective payment systems.
The researchers contrasted the effects of two Medicare payment reforms for home health agencies: the interim payment system (IPS) and the prospective payment system (PPS). The 1997 IPS reform lowered payments for both fee-for-service and episode-based care, as predicted by their conceptual model. The PPS in 2000 raised average but lowered marginal payment.
AHRQ-funded; HS018541
Citation: Huckfeldt PJ, Sood N, Escarce JJ .
Effects of Medicare payment reform: evidence from the home health interim and prospective payment systems.
J Health Econ. 2014 Mar;34:1-18. doi: 10.1016/j.jhealeco.2013.11.005..
Keywords: Medicare, Healthcare Costs, Home Healthcare
Thomas KS
The relationship between Older Americans Act in-home services and low-care residents in nursing homes.
This study examining the relationship between the proportion of older adults in a State who receive in-home services funded by the Older Americans Act and the proportion of residents in nursing homes finds that for every additional 1 percent of the 65+ population that receives personal care services, there is a 0.8% decrease in the proportion of low-care residents in nursing homes.
AHRQ-funded; HS00011
Citation: Thomas KS .
The relationship between Older Americans Act in-home services and low-care residents in nursing homes.
J Aging Health. 2014 Mar;26(2):250-60. doi: 10.1177/0898264313513611..
Keywords: Elderly, Long-Term Care, Home Healthcare, Nursing Homes, Healthcare Delivery
Sockolow PS, Bowles KH, Adelsberger MC
Challenges and facilitators to adoption of a point-of-care electronic health record in home care.
In order to identify challenges to the adoption of electronic health records (EHR) in the home care setting, the researchers assessed clinician satisfaction, informed by workflow and patient outcomes. Using a combination of surveys, observations, and interviews in an agency with 137 clinicians, the researchers found that adoption challenges included: (a) hardware problems coupled with lack of field support; (b) inadequate training; and (c) mismatch of EHR usability/functionality and workflow.
AHRQ-funded; HS021008.
Citation: Sockolow PS, Bowles KH, Adelsberger MC .
Challenges and facilitators to adoption of a point-of-care electronic health record in home care.
Home Health Care Serv Q 2014;33(1):14-35. doi: 10.1080/01621424.2013.870098..
Keywords: Health Information Technology (HIT), Electronic Health Records (EHRs), Home Healthcare
Sockolow PS, Bowles KH, Adelsberger MC
Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes.
The study objective was to assess the impact of attaining efficiency and health goals of a point-of-care EHR in home care. To realize this objective, the researchers compared clinical documentation workflow, financial time-to-billing and patient physiological and behavioral outcomes to evaluate its impact. The findings indicate that EHR use significantly improved the timeliness of clinical documentation and billing for reimbursement but had limited impact on improving patient outcomes.
AHRQ-funded; HS021008.
Citation: Sockolow PS, Bowles KH, Adelsberger MC .
Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes.
Appl Clin Inform 2014;5(2):445-62. doi: 10.4338/aci-2013-12-ra-0106..
Keywords: Health Information Technology (HIT), Electronic Health Records (EHRs), Home Healthcare