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Tomorrow’s Home Care Informed by Today’s Clinical Experience

by Kathy Bowles, RN, PhD, Vice President and Director, Center for Home Care Policy & Research, and vanAmeringen Chair in Nursing Excellence & Professor of Nursing at University of Pennsylvania School of Nursing

Imagine a not-for-profit home- and community-based care organization caring for the largest and most diverse patient base in the country. Then imagine that agency establishing a research center to turn its experience treating those patients into guidance for establishing nationally accepted home care best practices. VNSNY is doing just that.

Home, Where the Health Is

Stakeholders from across the health care sector believe that care delivered in the home achieves the best results. A recent article published in the journal Home Health Care Management & Practice notes that, “The future of health care delivery hinges on the ability of payers and providers to leverage the spectrum of home-based care.” The same article also points out that “Older Americans overwhelmingly articulate a desire to age in place and receive care at home rather than in institutional settings.” That’s understandable — familiar surroundings help individuals, especially elderly patients with chronic conditions, feel safer, more comfortable, and more in control.

The project determined that . . . there was an eight percentage point decline in readmissions.

Now think of how much more effective that home-based care would be if the clinician arrived at the door of a patient with information about re-hospitalization risk and knowledge of evidence-based strategies to help refine the plan of care. That’s not just a goal at VNSNY — with the work of our Research Center, we’re already making it happen.

125 Years of Home Care Experience — and Decades of In-Depth Patient Knowledge

Founded in 1893, VNSNY is a home care pioneer and innovator, and a dedicated national advocate for the efficacy of home-based care. We employ 13,000 nurses, rehabilitation therapists, social workers, home health aides, and others, who form interdisciplinary teams that care for thousands of patients daily.

2018 marked not only the 125th anniversary of VNSNY, but also the 25th anniversary of the organization’s Center for Home Care Policy & Research, the only nonprofit home care research center of this type in the U.S. For over a quarter of a century, the Center has launched dozens of forward-looking, scientifically rigorous research projects that are adding to the national understanding of home care models and practices, and are guiding critical decisions made by providers, policy makers, and consumers alike.

The idea to found the Center for Home Care Policy & Research came about as VNSNY realized that it was well positioned to collect and analyze data about the home care it provided to its patients — and to turn that data into evidence-based adjustments in care.

As my colleague Margaret McDonald, the Center’s Associate Director, notes, “We were ahead of our time in developing an electronic health record, so we were able to capture usable assessment and service use data for our patients many years before commercial carriers did. Beginning in 2000, our researchers combined VNSNY data with the national OASIS (Outcome and Assessment Information Set) data for use in home health agencies to conduct large-scale dataset analyses (CMS did not require OASIS data submission until 2005). We used our database to answer policy and clinical questions, and at the same time to respond to our clinicians’ needs by creating and testing out actual patient interventions.”

The Center’s 20 salaried employees include seven investigators who work with clinical staff to generate new programs of research—all under the umbrella of improving the quality, utility, safety, financial viability, and outcomes of home- and community-based services and analyzing and informing related public health policies.

Studies Leading to Hands-On Interventions — and Reductions in Hospital Readmissions

The staff at the Center has found that our experience with care provided in the home offers a real laboratory for shaping the way health care will be delivered in the 21st century. Margaret observes, “We’re working every day to use our data to identify high-risk patients and then to make sure patients get the right service at the right time. We’re committed to providing that guidance to our clinicians, and publishing it throughout the industry so it can be helpful to others.”

With a national focus on readmission reduction, the Center’s scientists and our collaborators have produced several effective interventions over the years. In a sense, it’s a challenge to figure out which interventions to implement first and just how much information to “front-load” our clinicians with. There are so many studies that potentially will help refine care plans, and it takes time to systematically implement them, plus we don’t want to bombard the clinical staff with too much all at once. However, we feel this is a good problem to have as home care has been an understudied area. We are proud to be part of a group of scientists that is changing that.

Notable recent efforts include a 2016 study, funded by the Agency for Health Care Research and Quality (AHRQ),that analyzed national OASIS and VNSNY claims data to determine whether early and intensive nursing and physician follow-up care for heart failure patients discharged from the hospital to home care would help reduce re-hospitalization. The project determined that for patients who received a nursing visit within 24 hours of discharge, two more visits in the first week, and received a doctor’s office visit within 7 days, there was an eight percentage point decline in readmissions. This work represents the largest, national study to inform the home care industry about the effects of a specific pattern and type of front-loaded care.

The second study relates to patient risk assessment and care prioritization. While CMS regulations require that patients discharged from the hospital to a home care setting receive a nursing visit within 48 hours, our data indicated that for certain high-risk patients, 48 hours was too long to wait, potentially jeopardizing the patient’s health and leading to readmission. Based on our research, VNSNY helped in testing the PREVENT tool to enable clinicians to identify patients who may benefit from more timely attention. Field-testing PREVENT demonstrated that using the tool has allowed more effective prioritization of patient care, better use of staff, and a reduction in hospital readmissions.

Connecting Patients, Providers, and Payers

As the health care system transitions to value-based reimbursement and delivery, fundamental policy changes on this order require solid research and evidence-based support. Of course, the perfect situation is when the best care for the patient that can be applied most effectively by the provider also makes the most business sense. Our innovations that improve care quality while lowering costs are especially attractive to payers, showing them what works and what doesn’t, and helping them with benefits plan design. A prime example, as described above, is the adoption of front-loaded home care visits for newly discharged heart failure patients — better care, more successful health outcomes, and happier patients, at lower cost.

Large, Diverse Patient Base Supports Targeted Analyses

Living in and around New York City — the nation’s most populous urban center — the VNSNY patient base offers our researchers and analysts a rare opportunity to design targeted population health studies examining how cultural factors influence health. Margaret notes, “We can adjust the focus of our research to target traditionally underserved populations to see how we can address the disparities in care.

Among our studies has been research that focused on whether neighborhood environmental factors help to explain racial and socio-economic disparities in health care access and outcomes among urban older adults with diabetes. We also tested an intervention to address historical disparities in hypertension control in the African American population and are analyzing another set of interventions to address stroke risk.”

Upcoming Studies

Fueled by federal and state grants as well as funding from philanthropic individuals and groups, the Center’s scope of work continues to expand. Future research areas include improving care transitions; examining care provision and outcomes of Alzheimer’s patients and other cognitively impaired populations, in addition to studying infection control practices.

MaryGrace Trifilio, one of our Research Analysts, spent much of 2018 working with Columbia University College of Nursing researchers and home care clinicians supporting what we believe is the first infection control study done in a home-care setting.

Speaking of the process of turning primary research into hands-on practice, MaryGrace said it best: “I was able to shadow 50 nurses and observe 400 home visits throughout the year. That gave me a more holistic understanding of what their job is like, and how to support them. It’s been exciting to witness the links between the research at the Center and the clinical staff growing stronger, and to consider the potential of future interventions from the clinician’s perspective.”

These links are evidence of the essential role home care research is playing now and will play going forward as we shape a new, sustainable, evidence-based health care landscape for the future.