When a patient returns home after being hospitalized for congestive heart failure, how important is it to provide multiple nursing visits and schedule a doctor's appointment that first week? Do non-English speaking patients do better when they're assigned a visiting nurse who speaks their native language? And, are outcomes improved if patients have the same caregiver for each home care visit?
With home health care playing an ever-larger role in the field of medicine and wellness, there's a growing need to ensure that home care services are being provided in a cost-effective fashion. That's why the Visiting Nurse Service of New York, under the direction of Kathy Bowles, who heads up VNSNY's Center for Home Care Policy and Research, 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.
Home Care for High-Risk Patients: What Works, What Doesn't?
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 Associate Director Christopher Murtaugh, are analyzing national home care records of 100,000 Medicare patients who had been hospitalized for congestive heart failure (CHF). A chronic condition that can turn life-threatening when symptoms flare up, 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 are determining whether the rate of hospital readmissions within 30 days of discharge is reduced when these patients have several "front-loaded" home visits from a nurse within one week of discharge and also see their physician that first week. To further reduce hospital readmissions among high-risk patients, our research center is also piloting 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 a physician-requested visit date," explains Kathy. "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 send a visiting nurse to see them as soon as possible after they arrive home."
We're also conducting a large randomized clinical trial that is part of a Center for Stroke Disparities Solutions collaborative with New York University and Columbia University Medical Centers. The trial is testing a new community-based intervention designed to reduce the risk of a recurrent stroke among patients who have already suffered a stroke. "It's an intense intervention, in which nurse practitioners and health coaches work closely with the patients to help them manage their blood pressure, diet, exercise and other important preventive factors," says Kathy. "Patient enrollment and follow-up evaluations will continue through this year. Study results should help address disparities in the outcomes of a very vulnerable patient population."
Charting a Path toward Personalized Home Care
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 an 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, will investigate whether assigning a nurse who speaks that patient's own language impacts outcomes like re-hospitalizations, functional status and number of home care visits. We're hoping that this study will provide some insights on how to achieve equally effective health care outcomes across different home care populations.
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 researchers at Columbia University, VNSNY's Dawn Dowding has been conducting 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 his or her 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."
We're also hoping to study how patient outcomes are affected by continuity of care -- for example, whether a patient does or doesn't have the same nurse on each home visit. If funded, this NIH study, led by VNSNY Senior Evaluation Scientist David Russell, will evaluate patient data from multiple U.S. home care agencies, looking at how factors such as cognitive impairment influence a patient's need for continuity of care.
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. Our Senior Scientist, Dawn Dowding is working on that, having recently received NIH funding to study how our nurses benefit from real-time dashboards with customized patient data displays.
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.