Abstract Background Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans’ social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans’ social needs during the transition from hospital to home with skilled HHC. Methods Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans’ hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans’ social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). Results We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. Conclusions HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.
AIM The aim was to develop and psychometrically test the self-care of chronic illness Inventory, a generic measure of self-care. BACKGROUND Existing measures of self-care are disease-specific or behaviour-specific; no generic measure of self-care exists. DESIGN Cross-sectional survey. METHODS We developed a 20-item self-report instrument based on the Middle Range Theory of Self-Care of Chronic Illness, with three separate scales measuring Self-Care Maintenance, Self-Care Monitoring, and Self-Care Management. Each of the three scales is scored separately and standardized 0-100 with higher scores indicating better self-care. After demonstrating content validity, psychometric testing was conducted in a convenience sample of 407 adults (enrolled from inpatient and outpatient settings at five sites in the United States and ResearchMatch.org). Dimensionality testing with confirmatory factor analysis preceded reliability testing. RESULTS The Self-Care Maintenance scale (eight items, two dimensions: illness-related and health-promoting behaviour) fit well when tested with a two-factor confirmatory model. The Self-Care Monitoring scale (five items, single factor) fitted well. The Self-Care Management scale (seven items, two factors: autonomous and consulting behaviour), when tested with a two-factor confirmatory model, fitted adequately. A simultaneous confirmatory factor analysis on the combined set of items supported the more general model. CONCLUSION The self-care of chronic illness inventory is adequate in reliability and validity. We suggest further testing in diverse populations of patients with chronic illnesses.
Heart failure (HF) patients need to perceive symptoms quickly, label them correctly, and manage them well if they want to avoid hospitalization. Little is known about why some are better at this th...
(1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index. We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program. We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk. We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022. The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA. Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.
Abstract Older Veterans discharged from the hospital with skilled home health care (HHC) have their HHC delivered by community home health agencies (HHA) and financed primarily through the Department of Veteran’s Affairs (VA) or Medicare. We sought to understand perspectives of VA personnel on the process of HHC agency selection and financing for Veterans referred for HHC. We used a sequential mixed methods study design and conducted in-person and virtual site visits at three VA Medical Centers (VAMCs) in the highest decile of VA-paid HHC services (3 in-person) and three VAMCs in the highest decile of Medicare-paid HHC services (1 in-person, 2 virtual). We observed processes related to HHC referrals and conducted interviews with key informants. Interviews were recorded, transcribed, and analyzed using inductive-deductive content analysis to identify themes related to referral processes, agency selection, and financing. We conducted 29 interviews with 39 personnel at 6 VAMCs. We identified 4 themes related to uncertainty around agency and payor selection: 1) VA roles are siloed and next steps are a “black box;” 2) VA personnel are uncertain how HHAs are selected for local networks; 3) Local VAMCs develop strategies to determine HHA quality and reputation; and 4) Veterans’ role in selecting HHA or financing is unclear. Understanding points of uncertainty has implications for VA’s ability to provide high-quality HHC for older Veterans. Our findings suggest that providing accessible information on HHA quality and clear guidance around Veterans’ role in HHA and payor selection may streamline the process of providing HHC to Veterans.
Abstract Medicare Advantage (MA) is a major payer of post-acute home health care, but little is known about how MA approaches home health benefit design and provision. In-depth, semi-structured interviews were conducted with 18 leaders from MA plans and care management companies and transcribed; content analysis was used to characterize underlying themes. Across interviews, participants agreed that as long as clinically appropriate, home was the preferred setting for post-acute care. Participants described the role of MA plans and care management companies in the provision of home health care, with most taking a hands-off approach to selecting the setting of post-acute care, instead deferring to patients’ choices and citing CMS regulations restricting involvement. Other organizations had more involvement in the selection of post-acute setting, with participants saying that while they don’t “steer” or “direct” setting of care, hospital discharge planners often engaged with their staff for help with difficult to place patients. In the initiation of post-acute home health, participants reported a variety of strategies for service authorization and utilization management. Plans described various approaches to care management to complement post-acute home health services, which in some cases included engaging with care management companies to deliver this aspect of care. In discussing MA approaches to post-acute home health, participants also highlighted substantial challenges facing the home health industry, particularly staffing concerns, and especially in rural areas. Insights from this work can help policymakers understand how MA plans cover home health services and coordinate with providers.
Abstract Medicare-eligible Veterans who require post-acute skilled home health (HH) after a hospitalization can have HH paid for by the Veterans’ Administration (VA) or Medicare. Our prior work showed Veterans enrolled in Medicare Advantage (MA) are more likely to have the VA pay for HH than MA. In this analysis, we look at differences in 90-day rehospitalization among MA-enrolled Veterans receiving VA-paid post-acute HH versus MA-paid post-acute HH. All Veterans enrolled in MA and receiving HH after an index hospitalization at a VA medical center between October 1, 2016 and September 30, 2019 were included. Data were extracted from the VA electronic medical record. We used inverse probability weighting to address baseline differences in age, patient complexity, and past utilization. We used cox proportional hazards models to estimate the effect of VA- versus MA-paid HH on the risk of 90-day rehospitalization. There were 14,501 eligible hospitalizations requiring HH; 8,753 (60.4%) received VA-paid HH, and 5,748 (39.6%) received MA-paid HH. On average, Veterans receiving VA-paid HH waited 3.7 days (SD: 3.2) to start HH, compared to 4.8 days (SD: 3.8) for Veterans receiving MA-paid HH. After preliminary weighting, Veterans who received VA-paid HH had a lower risk of 90-day rehospitalization, compared to Veterans who received MA-paid HH (adjusted hazard ratio=0.88; 95% CI: 0.83,0.93). Veterans whose HH was paid for by MA received services one day later, on average, and had higher risk of 90-day rehospitalization compared to Veterans receiving VA-paid HH. Potential implications on quality of post-acute care for MA-enrolled Veterans discussed.
