by Marki Flannery, President and CEO
With home health care playing an ever-larger role in the fields of medicine and wellness, there’s a growing need to ensure that home care services are being provided in an evidence-based and cost-effective fashion. That’s why VNSNY’s Center for Home Care Policy & Research, under the direction of Dr. Kathryn Bowles, is actively investigating questions like those mentioned above.
The center is devoted to the study of clinical and policy issues related to delivering high-quality, cost-effective health services at home. What researchers at our center and other academic institutions are finding is that the key to effective and efficient home care involves understanding the specific needs of different patient populations and then tailoring home care services to meet those needs. In the process, a new paradigm of personalized home care is emerging.
Patients at high risk of re-hospitalization have been a particular focus of research. In one ground-breaking study funded by a grant from the federal Agency for Healthcare Research and Quality, VNSNY investigators, led by Senior Research Scientist Christopher Murtaugh, analyzed national home care records of 100,000 Medicare patients who had been hospitalized for congestive heart failure (CHF). CHF is a leading cause of hospital admissions in the U.S., and figuring out how to manage its symptoms in a home setting is a crucial goal for American health care.
In our study, investigators determined that the rate of hospital readmissions within 30 days of discharge is reduced by 8 percentage points when these patients have a combination of early, intensive nursing services and at least one outpatient physician visit in the week after hospital discharge. Study investigators are now working with operations staff on how to incorporate “front-loaded” visits and physician follow up into practice at VNSNY.
To further reduce hospital readmissions among high-risk patients, our research center also piloted an evidence-based screening tool that might help us to identify which patients should be seen within 24 hours after they arrive home from the hospital. “Current Medicare guidelines call for a home care nurse to visit every new patient within 48 hours of hospital discharge,” explains Dr. Bowles. “But some patients are so unstable that they’re at risk of being readmitted within that window. This tool will let our intake clinicians flag these patients while they’re still in the hospital, so that agencies can plan and send a visiting nurse to see them as soon as possible after they arrive home.” The tool showed promising results. Max Topaz, VNSNY Associate Professor of Nursing, is continuing his work to validate the tool in practice.
Some of the most interesting work at our research center is focused on providing a more personalized connection between home care providers and their patients. One of our most important studies in this regard is a National Institutes of Health (NIH)-funded study involving non-English speaking patients. The study, led by Allison Squires of NYU College of Nursing with VNSNY Senior Research Scientist Penny Feldman as a co-investigator, found that assigning a nurse who speaks the patient’s own language or maintaining continuity of care (having the same nurse see the patients over multiple visits, regardless of language concordance), had a positive impact on outcomes including hospital readmissions and number of home care visits. The study is being submitted for review and publication.
Another VNSNY research project is taking aim at health care disparities that affect members of the lesbian, gay, bisexual, and transgender (LGBT) community. While the American public is increasingly accepting of various orientations, evidence suggests that self-identified LGBT patients still tend to have less access to appropriate medical care than other groups. To get better information about these health disparities, New York State now wants health care providers, including home care nurses, to document their patients’ sexual orientation and gender identity. Until now, however, no one has asked nurses how they feel about being required to discuss such a personal subject with their patients. In collaboration with a doctoral student and researchers at Columbia University College of Nursing, Dawn Dowding, a former Senior Nurse Scientist at VNSNY Research, conducted focus groups among VNSNY nurses to explore this issue, including what training and support nurses might need to carry out the mandate.
“The requirement sounds straightforward but it’s actually far from simple, since patients can be very hesitant to discuss their sexual orientation,” explained Dawn. The study is finding that nurses have varying comfort levels around making such inquiries, and generally prefer to let the patient volunteer information about their orientation. One early conclusion is that a significant push is needed to educate nurses on why this information is important for their patients’ long-term health outcomes. “Nurses need to see the underlying value in collecting this information,” Dawn noted, “so they don’t feel it’s simply being done for its own sake.”
VNSNY and the Research Center also use the large amount of electronic health record and assessment data available to identify high-risk patients. A hospitalization risk score, developed by Center and Outcomes staff a few years ago, is provided to home care clinicians so that they can take this risk into account as they develop their plan of care. Margaret McDonald, Associate Director, and other Center and Outcomes staff are similarly collaborating with Columbia University School of Nursing on developing a infection risk prediction model. If a robust model can be developed, VNSNY can use this information to target treatment plans to reduce the risk of patients developing an infection during their home care stay.
For personalized home care to be truly effective, of course, the nation’s home care clinicians need to have each patient’s information at their fingertips. VNSNY investigators received NIH funding to study how our nurses benefit from real-time dashboards with customized patient data displays. Results showed that individual differences in numeracy and graph literacy may influence nurses’ comprehension of visualized information but, overall, bar graphs and tables may be the most influential display format.
While there is still much to learn, the active research now underway in the home health care field means that we will only get better at delivering targeted, cost-effective home care in the future. And that’s promising news for our nation’s health as we strive to provide the best evidence-based care possible.