In 2014, 3.4 million Medicare beneficiaries received approximately 6.7 million skilled home health episodes from more than 12,400 home health agencies, costing Medicare approximately $17.7 billion (Medicare Payment Advisory Commission [MedPAC], 2016). Skilled home health patients often require care from an interprofessional team of home health clinicians, including RNs, physical therapists (PTs), occupational therapists (OTs), speech-language pathologists (SLPs), medical social workers (MSWs), and physicians (MedPAC, 2016). Medicare relies on home health clinicians to evaluate beneficiary needs and decide when to discharge from skilled home health or recertify patients for an additional 60-day episode of care. However, there is a paucity of research related to home health discharge and no empirically derived decision support tools available to assist in making these important and daily decisions. As a result, significant variation occurs in home health length of stay and clinician visit pattern among home health clinicians (O'Connor, Hanlon, Naylor, & Bowles, 2015).
Medicare-reimbursed, skilled home health services are provided in 60-day episodes, primarily to chronically ill beneficiaries with three or more comorbid conditions (Avalere Health, 2015). Home health has become increasingly more complex over time due to increasing incidence of multiple comorbid conditions and cognitive impairment among home health recipients (Murtaugh et al., 2009). During the episode, the home health clinician, in collaboration with the physician, must make a determination that the patient is ready for discharge. Currently, no standardized, evidence-based decision support tools exist to assist the interprofessional home health team in making optimal decisions. The concern arises if patients are discharged with unmet needs. Numerous studies have demonstrated that a lack of readiness for discharge from home health results in adverse outcomes, such as hospitalization, emergency department use, increased physician visits (Anderson, 2010), shorter time to death (Lum, Studenski, Degenholtz, & Hardy, 2012), medication errors (Foust, Naylor, Bixby, & Ratcliffe, 2012; Lancaster, Marek, Bub, & Stetzer, 2014), reduced quality of life (Han, Kim, Storfjell, & Kim, 2013), and decline in functional status (Covinsky, Pierluissi, & Johnston, 2011).
A retrospective study of national data indicated that because the Home Health Prospective Payment System (HH PPS) was implemented in 2000, Medicare patients are 2.9 times more likely to be discharged from home health within the first 60 days of admission than Medicare patients who received services before 2000 (Han & Remsburg, 2005). Other studies have also shown that, under the HH PPS system, many patients are discharged from home health with unresolved issues related to wounds, cognition, and behavioral and continence status, and that patients show less improvement overall compared to those who received home health services prior to implementation of the HH PPS (Schlenker, Powell, & Goodrich, 2005). Finally, a recent study among a national sample of older adults found that those who received a home health length of stay of at least 22 days or who received at least four skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits (O'Connor et al., 2015). In this study, more than 36% of older adults received ≤20 days in Medicare-reimbursed home health instead of the full 60-day episode, suggesting that some skilled home health patients may have insufficient time in home health and are prematurely discharged, and therefore potentially vulnerable for adverse outcomes.
Little is known about older adult discharge readiness from skilled home health and the factors interprofessional home health clinicians believe important to consider prior to discharge. Exploring these factors is a necessary first step in reducing adverse events following home health discharge among older adults and may result in more informed discharge decisions among interprofessional home health clinicians. The purpose of the current study was to explore interprofessional home health clinician perceptions of the factors they consider important to determine readiness for discharge among skilled home health recipients. The current study is the initial step in building a decision support tool based on home health experts' recommendations for discharge from skilled home health. Decision support is an understudied but growing area of science within health care. Similarly, decision support science in nursing is an emerging area of research and application is expected to become more common as evidence-based practice develops (Bowles et al., 2009).
To describe the understudied area of readiness for discharge from home health, a qualitative descriptive design (Sandelowski, 2000) was used with focus groups and individual interviews. Focus groups provided a mechanism to investigate complex phenomena in a real-life perspective (Yin, 2009), such as the factors health clinicians deem important in decision making for discharge. Focus groups were also instrumental in seeking diverse ideas on a specific topic and in generating rich data that can potentially contribute to the understanding of complex phenomena (Côté-Arsenault & Morrison-Beedy, 2005).
Setting and Participants
The study was conducted in a large, inner city Medicare-certified skilled home health agency in the Northeastern part of the United States. An interprofessional team comprising nurses, PTs, OTs, SLPs, MSWs, and physicians provided care to individual patients in their homes. Due to the interprofessional nature of skilled home health delivery, variation of discipline in the sample was imperative to achieve rich descriptions of clinicians' perceptions of the factors they believe are important in determining readiness for discharge. Initially, flyers were displayed at both home health agency offices where the focus groups took place. Agency administration also sent an e-mail to all agency clinicians that explained study aims, procedures, risks, and benefits. Participants were pre-screened for eligibility by home health supervisors. Eligibility criteria were having a minimum of 1 year of skilled home health experience. Interested clinicians contacted agency administration and focus group participants were purposively sampled by the research team to achieve a sample diverse in the disciplines that represented the agency's home health clinicians. Thirty-four interprofessional clinicians consented to participate. The four focus groups took place in private conference rooms at two satellite offices of the home health agency on the same day. Individual interviews were conducted over the telephone with the two visiting physicians who were unable to attend in person.
The Institutional Review Boards at Villanova University and the Visiting Nurse Service of New York approved the study. Written informed consent was obtained from all participants prior to data collection. Sociodemographic data, including discipline, years of experience, and education, were collected directly from participants. Participants were not compensated for their time and travel, and focus groups were conducted during their work day.
Data were collected through four focus groups among agency employees and individual phone interviews with two home-visiting physicians. To encourage participants to speak freely, two focus groups were conducted with clinicians and two separate focus groups with supervisors (Côté-Arsenault & Morrison-Beedy, 2005). The group leaders created a nonthreatening group atmosphere by emphasizing that all ideas were valued and respected (Yin, 2009). The leaders stressed that there were no right or wrong answers to questions, and that they were interested in their experiences and clinical judgment.
While the first author (M.O.) conducted the two interviews and moderated the focus groups, two co-authors (K.H.B., R.M.-B.) assisted focus group facilitation by taking notes and writing participant statements on a flip-chart. The focus groups and interviews were conducted using a semi-structured interview guide with the open-ended question, “What are the clinical and non-clinical factors you consider or believe to be important when you think about discharging an older adult from skilled home health?” In addition, prompts were used to encourage elaboration on factors that participants identified and also to elicit their perceptions about risk factors found in the literature as associated with adverse events after home health care discharge (e.g., poor functional status, living alone) (O'Connor, 2012). The focus groups and interviews took place in February 2014; focus groups lasted 1.5 hours each and each interview lasted 35 to 45 minutes. Focus groups and interviews were digitally recorded and transcribed verbatim by a professional transcription service. Transcripts from focus groups and individual interviews were analyzed together. All transcripts were compared to the audio files for accuracy prior to data analysis.
Using a naturalistic approach, qualitative content analysis (Sandelowski, 2000) was first used for manifest coding of all data and then for thematic analysis (Hsieh & Shannon, 2005) to group fragments of coded data into themes for describing participants' responses. Significant statements and key phrases were assigned codes by all members of the research team. Disagreements were discussed among co-authors until consensus was reached. Codes were then sorted and organized into themes. Refinements were made after discussion and the full team met to discuss the themes that emerged (Hsieh & Shannon, 2005). Atlas.ti version 7 was used to store and facilitate data organization, coding, and retrieval.
Three approaches were used to ensure trustworthiness of the data (Lincoln & Guba, 1985). First, during the coding process, the investigators created an audit trail by recording initial codes, themes, and operational memos. Second, debriefings were held with research team members to assist with data analysis and the identification and consensus of themes. Finally, member checks supported credibility; the team reviewed findings with four participants, all of whom agreed that the findings captured the ideas they shared or heard from others.
Of 34 participants, 32 were agency employees who participated in the focus groups (eight RNs, five PTs, four OTs, three SLPs, three MSWs, two physicians, three RN supervisors, two MSW supervisors, and two rehabilitation supervisors) (Table). The two home-visiting physicians who were interviewed individually were not employees of the home health agency. Of 27 non-supervisory clinicians, 20 were female; among the seven supervisors, four were female. The non-supervisory clinicians had 2 to 30 years of home health experience and the supervisors had 5 to 17 years of home health experience.
Sample Characteristics (N = 34)
During each focus group, every participant contributed to the discussion at least once, with all disciplines contributing equally. Derived from the four focus groups and the two individual interviews, five themes emerged as important when considering discharge from home health: (a) patient safety, (b) long-term plan is in place, (c) reached maximum self-care potential, (d) presence of a willing and able caregiver, and (e) patient attributes.
Clinicians in all focus groups and individual interviews viewed patient safety as a paramount concern to prevent injury, disability, and loss of independence when considering discharge from skilled home health. Patient safety concerns considered important included having the ability to leave home in an emergency and for the patient to have his/her needs met without injury, as one clinician explained, “Before discharge, no matter whether it is a very fragile patient or not, the person must be safe, and that is really one of the most important overall considerations.”
Safety issues also centered on environmental concerns. Several clinicians described home health patients with less than ideal home environments, with environmental hazards (e.g., clutter, missing railings, loose steps or carpets). However, having the appropriate assistive equipment in place and a stable home environment to accommodate patient needs can mitigate these environmental risks and is necessary for a successful discharge from services. For instance, having a grab bar, shower chair, or commode instead of trying to run to the bathroom can make a difference and improve a patient's home environment.
The current findings indicate that clinicians have special consideration for home health recipients who live alone, as they often present an additional challenge related to discharge readiness. It is a particular challenge for home health patients who live alone and require some supervision, but are not high risk or ill enough for nursing home placement. Clinicians acknowledged that patients who live alone may need additional time in home health or additional resources prior to safely discharging them from services, as one clinician stated, “If that person is alone...is a huge factor in affecting the ability to safely discharge someone or not.”
Long-Term Plan Is in Place
According to clinicians, avoiding hospitalization during and after skilled home health has ended is a priority for interprofessional home health team members, as exemplified by one team member's comment: “Community resources and the linkage to community and social support of the patient is key.” Clinicians stressed the theme of having a long-term plan in place that included connecting home health patients to resources available in the community to address any ongoing, unskilled additional needs. Community resources included services such as Meals on Wheels, phlebotomy, transportation, and opportunities for social interaction. Interprofessional home health team members recounted several instances in which a patient's limited social resources or financial concerns had an impact on connection to community resources, which often requires additional effort on the part of the clinician. For example, several clinicians described transportation as a community resource critical to health care follow up after discharge:
When they are going to see the doctor, a lot of times they say, “Okay there is no way for me to get back to the doctor to make the follow up appointment,” so transportation has to be set up before discharge.
Having a long-term plan in place also included patients having adequate support to meet their needs when services are discontinued; otherwise, clinicians anticipated that discharge would likely result in hospitalization, as one clinician explained: “Who will be there to assist them when we are gone? We need to make certain that they still have the support that they need in order to manage the illness in the community.” Having someone reliable to routinely check in with patients and meet additional needs that may arise, such as obtaining groceries and running errands, is critical.
One clinician remarked that making all interprofessional home health team members, including the patient, aware of the long-term plan and home health discharge in advance is essential to the patient's successful discharge from skilled home health. Another clinician explained that the patient is considered part of the home health team and that it is essential to have the patient agreeable to discharge from services, as it usually leads to a smoother transition to self-care or a caregiver's care on discharge. One clinician added:
Discharge is a mutual process. There needs to be discussion throughout the care plan and up to the point where the clinician is feeling that the goals are being neared, that there is a conversation that takes place with the patient.
Reached Maximum Self-Care Potential
Clinicians noted that achieving overall independence in their home, particularly independence in activities of daily living (ADLs), is a sign of discharge readiness. One clinician noted that “if a patient is at a high level of functioning, then it is a higher probability that this patient will be discharged quicker.” Another clinician expressed that a patient's knowledge and ability to self-manage his/her chronic conditions is also a good indicator of independence and discharge readiness. However, several clinicians described situations in which patients were not independent in ADLs but had reached their maximum potential, indicating the need to discharge from services. One clinician explained:
You try to get the patient to the level where they are able to take care of themselves. But when you come to a point where no more progress is being made or goals are no longer being achieved, discharge.
Similarly, clinicians also acknowledged that when patients have reached their previous level of function, discharge is imminent. One clinician asked:
Can this patient get better, achieve more? Or have they come to their baseline and maybe have hit a plateau, where now they are at the level that they are going to be? There is nothing more that can be done; they have reached their particular baseline.
Other reported indicators of discharge readiness were a patient's ability to express their preferences, obtain medications, and follow up with health care provider appointments. For example, one clinician stated that “how successful a patient will be after discharge is often dependent on whether or not they are going to their follow-up doctor appointments.” Clinicians also emphasized the role of patients' confidence in their ability to manage their care in assessing readiness for discharge. One clinician offered that patients who are confident in their ability to care for themselves “are able to communicate their preferences and manage their own care.” Another clinician's comments exemplified this prevailing theme:
You want to discharge a patient to the community feeling empowered that they can manage their care, whatever it is—incontinence, shortness of breath—[and] that they have knowledge as to how to deal with those things, and what they need to do. For me that is the biggest thing when you are considering discharging any patient, is that they know how to care for themselves or they have the support to assist them with whatever that care need might be.
Presence of a Willing and Able Caregiver
Several clinicians remarked that having a caregiver who is not only physically and mentally able to manage the patient's needs, but also willing to do this once home health services end, is critical to the patient's success after discharge. However, several clinicians reported that it is important to see evidence of their willingness prior to considering discharge. They elaborated that many times patients will report that they have a caregiver, but in reality, that caregiver is unable or unwilling to commit the time to the patient. Clinicians also recalled other situations where the caregiver was willing but not physically able to help due to his/her own physical limitations or health care needs, as one summarized:
You have to identify the caregivers who are available [and] willing and have the knowledge base to support the patient's care and manage [his/her] disease process. It may or may not be a family member; it could be a neighbor, or a significant other.
Clinicians indicated that particular patient attributes contribute to a skilled home health patient's readiness for discharge. These attributes included stable acute and chronic conditions, a patient's compliance with the treatment regimen, or when goals are met. Clinicians specifically reported that when wounds are healed and patients have an understanding of their medication regimen and are compliant with medications, it is time to consider discharge from services. However, one clinician noted that even when patients display attributes that indicate discharge readiness, there are other attributes that must be weighed carefully before considering discharge, such as being short of breath, requiring oxygen, their previous inpatient length of stay, or advanced age:
If it was a 50- or 60-year-old [patient] that came in after a voluntary surgery, they recover, they are ready to go back to work, easy discharge planning because they will be safe. But if it is an 80-year-old [patient] that was independent before [she] came in after she fell down and broke her hip and now she needs help, there is a lot more things to take into consideration before being discharged.
Every day, interprofessional home health clinicians evaluate patients' needs and make decisions whether to discharge or recertify them for an additional 60-day episode of care. Currently, discharge from skilled home health is dependent on individual clinician judgment, which could lead to variation in the quality of those decisions and potential adverse effects on already vulnerable patients (O'Connor et al., 2015). The current study investigated the factors home health clinicians perceive as important when considering an older adult for discharge from skilled home health by directly asking clinicians their opinions and ideas on the topic.
Through focus groups and interviews, interprofessional home health team members consistently verbalized the factors they believe important when determining discharge readiness from skilled home health: (a) patient safety, (b) having a long-term plan in place, (c) reached maximum self-care potential, (d) presence of a willing and able caregiver, and (e) patient attributes. These factors, if considered by the interprofessional home health team prior to discharge, have the potential to reduce poor outcomes among skilled home health recipients following discharge. Prior research has identified signs of discharge readiness from acute care hospitals (Weiss et al., 2007) and patients who are likely to have skilled needs following hospitalization (Bowles et al., 2009). However, the current results begin to elucidate the factors home health clinicians perceive to be important when considering discharge readiness from home health care, and to the current authors' knowledge, this is the first study to examine this topic.
Several clinicians shared that patient safety factors (e.g., adequate support to meet patient needs, patient advocacy, the ability to leave home in an emergency, a safe home environment) are primary concerns in preventing injury, disability, and loss of independence when considering discharge. These concerns are not surprising given that unintentional injuries were the eighth leading cause of death among older adults in 2013 (Kramarow, Chen, Hedegaard, & Warner, 2015). Furthermore, one in three older adults falls every year, with one in five falls causing serious injury (e.g., hip fractures, head injury) (Centers for Disease Control and Prevention, 2016) and costing $34 billion annually (Stevens, Corso, Finkelstein, & Miller, 2006). Environmental safety hazards can include clutter, unsanitary conditions, insect/vermin infestation, aggressive pets, and neighborhood violence (Gershon et al., 2008). Personal safety hazards can include impaired decision making, sensory deficits (NIH Seniorhealth, n.d.), and predatory caregivers (National Council on Aging, 2016). Home health clinicians are in an ideal position to detect and address personal and environmental safety concerns that could potentially prevent adverse events among older adults.
Clinicians expressed additional consideration for home health patients who live alone, as this can present other challenges to patient safety. Approximately 28% of older adults living in the community live alone. Forty-six percent of women 75 or older live alone (U.S. Department of Health and Human Services, 2015), and women comprise approximately 64% of the home health population (O'Connor et al., 2015). Older adults who live alone are more likely to fall (Elliott, Painter, & Hudson, 2009); have difficulty accessing resources; be socially isolated (Portacolone, 2013); and experience malnutrition, frailty, or symptoms of illness that go unnoticed (Makizako et al., 2015). These risk factors are consistent with clinicians' assessments that patients who live alone often need increased time in home health or require additional referrals to community resources to safely discharge them from services.
Clinicians reported that when patients are connected to long-term community resources that will meet their ongoing needs, including transportation, meal preparation, and socialization, this also indicates discharge readiness. These findings converge with prior research showing that well-coordinated long-term community services are key to successful management of chronically ill, community-dwelling older adults (Anderson, 2010). Making the other interprofessional team members aware of the discharge plan and including the patient in the decision to discharge were also important to clinicians when considering discharge from home health services. An extensive body of research indicates older adults are most vulnerable for poor outcomes during a care transition (Naylor & Sochalski, 2010), such as discharge from home health services to self-care or to a caregiver in the community, with inadequate communication among the health care team specifically cited as a cause of poor outcomes (Institute of Medicine [IOM], 1999; Sutcliffe, Lewton, & Rosenthal, 2004). Furthermore, communication among the patient, caregiver, and interprofessional health care team is recognized as an essential component of a successful care transition (Naylor & Sochalski, 2010) that reduces hospital readmissions and hospital length of stay among chronically ill patients with heart failure (Sochalski et al., 2009). Thus, according to home health clinicians, presence of an informed and aware patient, caregiver, and interprofessional team is indicative of patient discharge readiness and more likely to lead to a successful transition to community.
Reaching a maximum level of self-care potential was also a theme signifying readiness for discharge. Clinicians described independence as encompassing a patient's knowledge and ability to perform ADLs, manage his/her chronic conditions, obtain medications, and communicate his/her preferences. All of these areas reflect self-care, which is empirically known to contribute to improved quality of life and reduced hospitalizations—major goals for community-dwelling older adults with chronic illness (Buck et al., 2015). Similarly, a well-established body of research indicates that a patient's confidence in his/her ability to care for himself/herself is essential in managing chronic illness (Dickson, Buck, & Riegel, 2013; Riegel, Lee, & Dickson, 2011; Vellone et al., 2014).
Another consideration of discharge readiness, but one that is often an obstacle, relates to caregivers. Clinicians reported that the presence of a caregiver who is willing and able to manage the patient's needs is a critical factor to the patient's success following discharge. This finding corroborates prior home health research revealing that inadequate caregiver support contributed to hospital readmission and was a critical factor allowing an older adult to remain at home (Rosati & Huang, 2007; Rosati, Huang, Navaie-Waliser, & Feldman, 2003). Caregivers frequently are family members, friends, or neighbors who are often not paid for their services (Family Caregiver Alliance, 2016). According to the IOM (2008), 90% of long-term care services are provided by unpaid caregivers who are an essential part of successfully managing a chronically ill adult living in the community.
Finally, the interprofessional team recognized the role of several patient attributes in their perception of discharge readiness, including having a stable condition, a healed wound, and an understanding and compliance with the medication regimen. Medication management is a common problem among older adults, often leading to adverse events (Foust et al., 2012), thus confirming the importance of assessing this attribute. Additional patient attributes must also be considered in light of being ready for discharge, including the presence of shortness of breath, advanced age, the need for oxygen in the home, and the previous length of inpatient stay. Often these are issues that must be resolved or addressed prior to home health discharge or within the patient's long-term plan, and depend on a patient's confidence and ability to perform self-care (Riegel et al., 2011).
Most clinicians were from one Medicare-certified skilled home health agency in the Northeastern United States, thus limiting transferability of the findings. Future research should include samples of home health clinicians from varied settings and regions. A study strength was the sample comprised interprofessionally diverse clinicians with at least 1 year of experience caring for older adults in home health.
The current study revealed five overarching themes that reflect the factors interprofessional clinicians perceive are necessary to consider when evaluating discharge readiness from skilled home health. The ultimate goal of this line of inquiry is to develop an evidence-based home health discharge decision support tool to provide a standardized approach in determining readiness for discharge from skilled home health services that can be used by home health clinicians regardless of their discipline. Future research should include an in-depth examination of the discharge readiness criteria suggested by clinicians, such as a willing caregiver and patient safety, to more specifically define these criteria prior to the development of a decision tool. Future research must also further develop the domains for the decision support tool and include patient and caregiver perspectives as well as the clinical, functional, service, and sociodemographic factors important to recognize among older adults when making these important decisions. These factors must be explored and tested using a national sample to determine factors that are protective of and contribute to adverse events after home health services are discontinued. Home health discharge decision support could play a key role in improving the care and health of these vulnerable adults by identifying patients who are ready for discharge from home health services versus those who require additional home health episodes.
The current qualitative descriptive study has begun to build an understanding of the factors home health clinicians consider important when discharging older adults from skilled home health services. Clinicians identified five themes (i.e., patient safety, having a long-term plan in place, reached maximum self-care potential, having a willing and able caregiver, and patient attributes) to be key considerations prior to home health discharge. These findings will serve as the basis of a home health discharge decision support tool that is currently in development.
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Sample Characteristics (N = 34)
|Variable||n (%)||Years in Home Health (Mean)||Highest Level of Education (n)|
|Clinician focus groups|
| Nurses||8||11.4||Associate degree (1)
Bachelor's degree (6)
Master's degree (1)|
| Physical therapists||5||12.5||Bachelor's degree (1)
Master's degree (2)
| Occupational therapists||4||5.6||Master's degree|
| Speech-language pathologists||3||3.3||Master's degree|
| Social workers||3||6.2||Master's degree|
|Supervisor focus groups|
| Nursing||3||14.7||Bachelor's degree (2)
Master's degree (1)|
| Rehabilitation||2||9||Master's degree|
| Social work||2||15.3||Master's degree|
|In-home visiting physician interviews|