National Healthcare Quality and Disparities Report
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Topics
- Cardiovascular Conditions (1)
- Care Coordination (3)
- Caregiving (4)
- Care Management (2)
- Children/Adolescents (2)
- Communication (1)
- COVID-19 (1)
- Data (1)
- Decision Making (2)
- Elderly (9)
- Electronic Health Records (EHRs) (1)
- Healthcare Delivery (3)
- Health Information Technology (HIT) (1)
- Health Services Research (HSR) (2)
- Heart Disease and Health (2)
- (-) Home Healthcare (22)
- Hospital Discharge (8)
- Hospitalization (2)
- Hospital Readmissions (4)
- Hospitals (2)
- Long-Term Care (2)
- Medicaid (1)
- Medicare (2)
- Medication (2)
- Medication: Safety (1)
- Nursing (2)
- Nursing Homes (2)
- Patient-Centered Healthcare (1)
- Patient Experience (2)
- Patient Safety (2)
- Provider (1)
- Provider: Clinician (1)
- Racial and Ethnic Minorities (1)
- Rehabilitation (1)
- (-) Transitions of Care (22)
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 22 of 22 Research Studies DisplayedSquires A, Engel P, Ma C
Continuity of care versus language concordance as an intervention to reduce hospital readmissions from home health care.
The purpose of this study was to examine the relative effectiveness of continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. Participants included over 22,000 non-English-speaking patients from the New York City area who were admitted to their home health site following hospital discharge. Findings revealed that high continuity of care and high language concordance significantly decreased readmissions, along with high continuity of care and low language concordance; low continuity of care and high language concordance did not significantly impact readmissions. The authors concluded that enhancing continuity of care for those with language barriers the US home health system may help to address disparities and reduce hospital readmission rates.
AHRQ-funded; HS023593.
Citation: Squires A, Engel P, Ma C .
Continuity of care versus language concordance as an intervention to reduce hospital readmissions from home health care.
Med Care 2023 Sep; 61(9):605-10. doi: 10.1097/mlr.0000000000001884..
Keywords: Hospital Readmissions, Transitions of Care, Home Healthcare
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
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
Keeney T
Physical therapy in the COVID-19 pandemic: forging a paradigm shift for rehabilitation in acute care.
This point-of-view article discusses the importance of physical therapy for COVID-19 survivors in home and community-based settings as well as in post-acute care facilities, concluding that it is necessary to react to new and difficult circumstances with growth and self-advocacy in order to forge a future characterized by intensive skilled rehabilitation services in the inpatient setting, simultaneously benefiting the health care systems and the patient populations.
AHRQ-funded; HS000011.
Citation: Keeney T .
Physical therapy in the COVID-19 pandemic: forging a paradigm shift for rehabilitation in acute care.
Phys Ther 2020 Aug 12;100(8):1265-67. doi: 10.1093/ptj/pzaa097..
Keywords: Rehabilitation, COVID-19, Transitions of Care, Home Healthcare, Healthcare Delivery
Sockolow PS, Bowles KH, Wojciechowicz C
Incorporating home healthcare nurses' admission information needs to inform data standards.
Patient transitions into home health care (HHC) often occur without the transfer of information needed for critical clinical decisions and the plan of care. Owing to a lack of universally implemented standards, there is wide variation in information transfer. In this study, the investigators sought to characterize missing information at HHC admission. They conducted a mixed methods study with 3 diverse HHC agencies.
AHRQ-funded; HS024537.
Citation: Sockolow PS, Bowles KH, Wojciechowicz C .
Incorporating home healthcare nurses' admission information needs to inform data standards.
J Am Med Inform Assoc 2020 Aug;27(8):1278-86. doi: 10.1093/jamia/ocaa087..
Keywords: Home Healthcare, Transitions of Care, Electronic Health Records (EHRs), Health Information Technology (HIT)
Amar-Dolan LG, Horn MH, O'Connell B B
"This is how hard it is". family experience of hospital-to-home transition with a tracheostomy.
This study explores the experience of family caregivers of children and young adults with a tracheostomy during the transition from hospital to home care. Researchers sought to identify the specific unmet needs of families to direct future interventions. Using semi-structured interviews, they found a need for family-centered discharge processes including coordination of care and teaching focused on emergency preparedness.
AHRQ-funded; HS000063.
Citation: Amar-Dolan LG, Horn MH, O'Connell B B .
"This is how hard it is". family experience of hospital-to-home transition with a tracheostomy.
Ann Am Thorac Soc 2020 Jul;17(7):860-68. doi: 10.1513/AnnalsATS.201910-780OC..
Keywords: Transitions of Care, Home Healthcare, Caregiving, Patient Experience, Care Coordination, Hospital Discharge, Hospitals, Children/Adolescents, Patient-Centered Healthcare
Weerahandi H, Bao H, Herrin J
Home health care after skilled nursing facility discharge following heart failure hospitalization.
Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. In this study, the investigators examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization.
AHRQ-funded; HS022882.
Citation: Weerahandi H, Bao H, Herrin J .
Home health care after skilled nursing facility discharge following heart failure hospitalization.
J Am Geriatr Soc 2020 Jan;68(1):96-102. doi: 10.1111/jgs.16179..
Keywords: Home Healthcare, Nursing Homes, Heart Disease and Health, Cardiovascular Conditions, Hospitalization, Hospital Readmissions, Transitions of Care, Elderly
Jones CD, Falvey J, Hess E
Predicting hospital readmissions from home healthcare in Medicare beneficiaries.
The authors used patient-level clinical variables to develop and validate a parsimonious model to predict hospital readmissions from home healthcare (HHC) in Medicare fee-for-service beneficiaries. They found that variables available to HHC clinicians at the first post-discharge HHC visit can predict readmission risk and inform care plans in HHC. They recommend that future analyses incorporating measures of social determinants of health, such as housing instability or social support, have the potential to enhance prediction of this outcome.
AHRQ-funded; HS024569.
Citation: Jones CD, Falvey J, Hess E .
Predicting hospital readmissions from home healthcare in Medicare beneficiaries.
J Am Geriatr Soc 2019 Dec;67(12):2505-10. doi: 10.1111/jgs.16153..
Keywords: Home Healthcare, Hospital Readmissions, Medicare, Elderly, Transitions of Care
Chase JD, Russell D, Rice M
Caregivers' perceptions managing functional needs among older adults receiving post-acute home health care.
The researchers conducted telephone interviews to explore caregivers’ experiences managing physical functioning (PF) needs of older adults in the post-acute home health care setting. Caregivers depicted the enormity of caregiving tasks needed to manage older patients' PF needs and described their perceived roles and challenges in managing PF deficits, including a sense of isolation when they were the sole caregiver. The researchers conclude that their findings can guide nursing efforts to target caregiver training and support during the critical care transition period.
AHRQ-funded; HS022140.
Citation: Chase JD, Russell D, Rice M .
Caregivers' perceptions managing functional needs among older adults receiving post-acute home health care.
Res Gerontol Nurs 2019 Jul 1;12(4):174-83. doi: 10.3928/19404921-20190319-01..
Keywords: Caregiving, Elderly, Home Healthcare, Transitions of Care
Fraze TK, Beidler LB, Briggs ADM
'Eyes in the home': ACOs use home visits to improve care management, identify needs, and reduce hospital use.
Researchers used national survey data from physician practices and accountable care organizations (ACOs), paired with qualitative interviews, to learn about home visiting programs. They found that interviewed ACOs reported using home visits as part of care management and care transitions programs as well as to evaluate patients' home environments and identify needs, most often using nonphysician staff. Further, home visit implementation for some types of patients can be challenging because of barriers related to reimbursement, staffing, and resources.
AHRQ-funded; HS024075.
Citation: Fraze TK, Beidler LB, Briggs ADM .
'Eyes in the home': ACOs use home visits to improve care management, identify needs, and reduce hospital use.
Health Aff 2019 Jun;38(6):1021-27. doi: 10.1377/hlthaff.2019.00003..
Keywords: Transitions of Care, Home Healthcare, Healthcare Delivery, Care Management
Fabius CD, Robison J
Differences in living arrangements among older adults transitioning into the community: examining the impact of race and choice.
The federal Money Follows the Person Rebalancing Demonstration program allows nursing home residents to use Medicaid funds for home and community-based services rather than institutional care. Race, choice in housing, and challenges faced prior to transitioning may impact living arrangements following a discharge into the community. This study examined the influence of these factors on living arrangements for 659 program participants age 65 or older.
AHRQ-funded; HS000011.
Citation: Fabius CD, Robison J .
Differences in living arrangements among older adults transitioning into the community: examining the impact of race and choice.
J Appl Gerontol 2019 Apr;38(4):454-78. doi: 10.1177/0733464816687496..
Keywords: Elderly, Transitions of Care, Racial and Ethnic Minorities, Medicaid, Nursing Homes, Home Healthcare, Healthcare Delivery
Jones CD, Jones J, Bowles KH
Quality of hospital communication and patient preparation for home health care: results from a statewide survey of home health care nurses and staff.
The purpose of this study was to evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff. The authors concluded that communication between hospitals and HHC was suboptimal, and patients were often not prepared to receive HHC. They suggest that providing EHR access for HHC clinicians is a promising solution to improve the quality of communication.
AHRQ-funded; HS024569.
Citation: Jones CD, Jones J, Bowles KH .
Quality of hospital communication and patient preparation for home health care: results from a statewide survey of home health care nurses and staff.
J Am Med Dir Assoc 2019 Apr;20(4):487-91. doi: 10.1016/j.jamda.2019.01.004..
Keywords: Transitions of Care, Home Healthcare, Hospital Discharge, Hospitals, Communication
Jones CD, Jones J, Bowles KH
Patient, caregiver, and clinician perspectives on expectations for home healthcare after discharge: a qualitative case study.
The objective of this study was to evaluate and compare expectations for skilled home health care (HHC) from the patient, caregiver, and HHC perspectives after hospital discharge. Results showed that unclear expectations occurred when the patient and/or caregiver expectations were uncertain or misaligned with the services received; in most such cases, the patient and caregiver did not have prior experience with HHC. Recommendations to improve HHC transitions included actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services and assess and address additional care needs.
AHRQ-funded; HS024569.
Citation: Jones CD, Jones J, Bowles KH .
Patient, caregiver, and clinician perspectives on expectations for home healthcare after discharge: a qualitative case study.
J Hosp Med 2019 Feb;14(2):90-95. doi: 10.12788/jhm.3140..
Keywords: Caregiving, Health Services Research (HSR), Home Healthcare, Patient Experience, Provider, Provider: Clinician, Transitions of Care
Arbaje AI, Hughes A, Werner N
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
The goal of this study was to identify information management (IM) process failures made during home health visits to middle-aged and older adults after hospital discharge. Communication risks included information overload, information underload, information scatter, information conflict, and erroneous information.
AHRQ-funded; HS022916.
Citation: Arbaje AI, Hughes A, Werner N .
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
BMJ Qual Saf 2019 Feb;28(2):111-20. doi: 10.1136/bmjqs-2018-008163..
Keywords: Elderly, Home Healthcare, Hospital Discharge, Patient Safety, Transitions of Care
Auger KA, Simmons JM, Tubbs-Cooley HL
Postdischarge Nurse Home Visits and Reuse: the Hospital to Home Outcomes (H2O) Trial.
In this study, the investigators evaluated the effects of a pediatric transition intervention, specifically a single nurse home visit, on postdischarge outcomes in a randomized controlled trial. The investigators concluded that children randomly assigned to the intervention had higher rates of 30-day postdischarge unplanned health care reuse. They also noted that parents in the intervention group recalled more clinical warning signs 2 weeks after discharge.
AHRQ-funded; HS024735.
Citation: Auger KA, Simmons JM, Tubbs-Cooley HL .
Postdischarge Nurse Home Visits and Reuse: the Hospital to Home Outcomes (H2O) Trial.
Pediatrics 2018 Jul;142(1). doi: 10.1542/peds.2017-3919..
Keywords: Children/Adolescents, Home Healthcare, Hospital Discharge, Nursing, Transitions of Care
Jones CD, Burke RE
Inpatient notes - getting past the "black box"-opportunities for hospitalists to improve postacute care transitions.
The care provided after hospital discharge in skilled-nursing facilities and home health care is collectively termed postacute care (PAC). In this article, the authors outline 3 key problems with postacute care transitions and offer potential solutions.
AHRQ-funded; HS024569.
Citation: Jones CD, Burke RE .
Inpatient notes - getting past the "black box"-opportunities for hospitalists to improve postacute care transitions.
Ann Intern Med 2018 May 15;168(10):HO2-HO3. doi: 10.7326/m18-0940..
Keywords: Health Services Research (HSR), Home Healthcare, Hospital Discharge, Long-Term Care, Transitions of Care
Sockolow PS, Yang Y, Bass EJ
Data visualization of home care admission nurses' decision-making.
This study investigated nurses’ decision making regarding hospital to home care admissions. They conducted a focus group case study with six admitting home health nurses at a rural agency in Pennsylvania and analyzed the data using thematic analysis.
AHRQ-funded; HS024537.
Citation: Sockolow PS, Yang Y, Bass EJ .
Data visualization of home care admission nurses' decision-making.
AMIA Annu Symp Proc 2018 Apr 16;2017:1597-606..
Keywords: Data, Decision Making, Home Healthcare, Nursing, Transitions of Care
Werner NE, Malkana S, Gurses AP
Toward a process-level view of distributed healthcare tasks: medication management as a case study.
Researchers aimed to highlight the importance of using a process-level view in analyzing distributed healthcare tasks through a case study analysis of medication management (MM). Their findings identified key cross-system characteristics not observable at the task-level: (1) identification of emergent properties (e.g., role ambiguity, loosely-coupled teams performing MM) and associated barriers; and (2) examination of barrier propagation across system boundaries.
AHRQ-funded; HS022916.
Citation: Werner NE, Malkana S, Gurses AP .
Toward a process-level view of distributed healthcare tasks: medication management as a case study.
Appl Ergon 2017 Nov;65:255-68. doi: 10.1016/j.apergo.2017.06.020.
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Keywords: Care Management, Elderly, Home Healthcare, Medication, Transitions of Care
Jones CD, Bowles KH, Richard A
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. The authors argue that understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care.
AHRQ-funded; HS024569.
Citation: Jones CD, Bowles KH, Richard A .
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Circ Cardiovasc Qual Outcomes 2017 May;10(5). doi: 10.1161/circoutcomes.117.003676.
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Keywords: Home Healthcare, Heart Disease and Health, Transitions of Care, Care Coordination, Medicare
Baier RR, Wysocki A, Gravenstein S
A qualitative study of choosing home health care after hospitalization: the unintended consequences of 'patient choice' requirements.
The purpose of this qualitative study is to learn how quality reports are used when choosing home care. Focus groups with 13 home health consumers and interviews with 28 hospital case managers from five hospitals revealed that both groups were unaware of public reports about home care quality.
AHRQ-funded; HS021879
Citation: Baier RR, Wysocki A, Gravenstein S .
A qualitative study of choosing home health care after hospitalization: the unintended consequences of 'patient choice' requirements.
J Gen Intern Med. 2015 May;30(5):634-40. doi: 10.1007/s11606-014-3164-7..
Keywords: Decision Making, Elderly, Home Healthcare, Hospital Discharge, Transitions of Care
Nasarwanji N, Werner NE, Carl K
Identifying challenges associated with the care transition workflow from hospital to skilled home health care: perspectives of home health care agency providers.
The authors studied the workflow for transitioning older adults from the hospital to skilled home health care (SHHC). They found three overarching challenges to optimal care transitions: information access, coordination, and communication/teamwork. They recommended that future investigations test whether redesigning the transition from hospital to SHHC improves workflow and care quality.
AHRQ-funded; HS022916.
Citation: Nasarwanji N, Werner NE, Carl K .
Identifying challenges associated with the care transition workflow from hospital to skilled home health care: perspectives of home health care agency providers.
Home Health Care Serv Q 2015;34(3-4):185-203. doi: 10.1080/01621424.2015.1092908.
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Keywords: Care Coordination, Elderly, Home Healthcare, Hospital Discharge, Transitions of Care