Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow‐Up

Murtaugh, Christopher M.; Deb, Partha; Zhu, Carolyn W.; Peng, Timothy R.; Barrón, Yolanda; Shah, Shivani; Moore, Stanley; Bowles, Kathryn H.; Kalman, Jill; Feldman, Penny Hollander; Siu, Albert L.

doi:10.1111/1475-6773.12537

Cited by 83 publications

(85 citation statements)

References 34 publications

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“…If independently validated in other studies, these risk profiles could be used by primary care and other community-based clinicians to identify older adults living in the community who may be at risk for poor outcomes and trigger clinicians to initiate individualized, targeted interventions. Targeted interventions may include the initiation, continuation or increased frequency of several community-based services such as nurse-led care coordination, 34 home health care, 39,40 hospice, phone calls between visits, 41 telehealth, 42 physician follow up 43 and handyman services 44 to mitigate risk. Additionally, the risk profiles, if further refined, could be integrated into clinical decision support systems to assist clinicians identify specific community-based referrals needed by older adults according to their level of risk.…”

Section: Discussionmentioning

confidence: 99%

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults

et al. 2017

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Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.

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Section: Discussionmentioning

confidence: 99%

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults

et al. 2017

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“…15 Another study of heart failure patients found that neither one week home health nor one week primary care visits were preventative of 30-day readmissions but, in combination, they significantly reduced the likelihood of hospital readmissions. 14 …”

Section: Introductionmentioning

confidence: 99%

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Carnahan

Slaven

Callahan

et al. 2017

Journal of the American Medical Directors Association

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Background Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent post-discharge adverse outcomes are poorly understood. Objective To identify whether early post SNF discharge care reduces likelihood of 30 day hospital readmissions. Design Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set. Participants/Setting Older (age > 65), community dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after a SNF stay (n=1,543). Measurements The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge. Results Out of 8,754 community dwelling, hospitalized older adults, 3,025 (34.6%) were discharged to a SNF, of whom 1,543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission (adjusted hazard ratio (aHR) 0.61, p<0.001) but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR=0.67, p= 0.821). Conclusion For patients discharged from a SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30 day hospital readmissions suggests a potential avenue for intervention.

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“…Some of the study participants described it as providing early, frequent visits, while others specified the number of visits, such as at least three times per week, or every other day, or even back-to-back visits. In a recent definition of frontloading, a panel of experts in HH and heart failure suggested a specific number and timing of nursing visits within the first posthospital week (Murtaugh et al, 2017). Their definition is broadly aligned with our findings and provides direction to visiting nurses as they develop visit plans.…”

Section: Discussionmentioning

confidence: 99%

“…Early and intensive skilled nursing visits contribute to decreased hospital readmission when combined with a physician follow-up visit in the first week after hospital discharge (Murtaugh et al, 2017). Nurses need to identify who would benefit from this treatment combination to prevent or at least delay hospital readmissions.…”

Section: Discussionmentioning

confidence: 99%

“…This practice has been referred to in the literature as frontloading , recently defined as providing “at least one nursing visit on the day of or day after hospital discharge and at least three nursing visits (including the first visit) in the first posthospital week” (Murtaugh et al, 2017, p. 5). Although initial intensive assessment is key for early interventions, maintaining a steady pattern of visits can also influence patient outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Home health nurse decision-making regarding visit intensity planning for newly admitted patients: a qualitative descriptive study

Irani

Hirschman

Cacchione

et al. 2018

Home Health Care Services Quarterly

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Despite patients referred to home health having diverse and complex needs, it is unknown how nurses develop personalized visit plans. In this qualitative descriptive study, we interviewed 26 nurses from three agencies about their decision-making process to determine visit intensity and analyzed data using directed content analysis. Following a multifactorial assessment of the patient, nurses relied on their experience and their agency’s protocols to develop the personalized visit plan. They revised the plan based on changes in the patient’s clinical condition, engagement, and caregiver availability. Findings suggest strategies to improve visit planning and positively influence outcomes of home health patients.

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Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow‐Up

Abstract: Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.

Cited by 83 publications

References 34 publications

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Home health nurse decision-making regarding visit intensity planning for newly admitted patients: a qualitative descriptive study

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