Home Healthcare, Hospice, and Information Technology Innovations Conference

Innovations in Home Healthcare, Hospice, and Information Technology

A forum towards achieving evidence-based diffusion and implementation of innovations

Fri, Nov 3, 2017

Friday, Nov 3, 2017, Washington - D.C.

H3IT: Home Healthcare, Hospice, and Information Technology Conference Nashville, TN, 2015

Identifying Home Care Providers’ Information

Needs for Managing and Reducing Fall Risks

Dari Alhuwail

, Güneş Koru

alls are the leading cause of home injuries for older adults,

1–3

often cause hospital admissions,

and are costly.

In 2013, more than $34 billion was spent as a direct medical cost for falls.

In home care, the Centers for

Medicare and Medicaid Services (CMS) reports that, injuries from falls contributed to unplanned ER visits

and ranked as the highest amongst potentially avoidable events (PAEs).

PAEs reﬂect a serious health condition

or decline in health status for a patient that potentially could have been avoided while the patient was under care at a home

health agency (HHA).

Unfortunately, home care providers often start the episode of care devoid of information

critical to

fall risk management and quality care. This study aims to (i) identify information needs of home care provider, (ii) classify

them, (iii) and identify gaps in existing workﬂows as they relate to managing and reducing the risk falls.

Methods: A qualitative research approach was preferred as it allowed the research team to obtain rich and context-speciﬁc

information.

10–12

A detailed and rich literature review on the topic was conducted initially. Data from three branches of

a Maryland HHA were collected through: (a) direct observations (n=6), (b) face-to-face focus groups (n=22), (c) a face-

to-face meeting (n=19), and (d) semi-structured interviews (n=20) sequentially. Participants included, nurses, physical

and occupational therapists, home aides, care transition employees, managerial staﬀ, and health IT administrators. The

Framework Method was used for the analysis of the results.

12,13

Results: Broadly, information needs of home care providers were clinical and non-clinical in nature. These needs were

categorized into four main domains: (i) clinical, (ii) educational, (iii) social, and (iv) administrative. Overall, home care

providers had similar information needs, but emphasis on the required information varied based on discipline. There was

general agreement amongst providers on the importance of having a brief history of the patient and their journey throughout

the healthcare system. When asked about important information needed for managing falls, one home care nurse notes

that "There are a lot of information that referral sources do esn’t give us, we just have to do our own investigation". Home

care providers deal with inconsistent data about their patients; often times the information in the HHA’s electronic health

record (EHR) and printed hospital discharge record are diﬀerent. A physical therapist states: "What is an issue is been

able to get the same information, that’s available for a patient when they are in the hospital." Speciﬁcally for falls, a clinical

supervisor notes that "The biggest complaint I get from the therapists is weight bearing status being inaccurate and that’s

a big problem." Not knowing the weight bearing status of a patient can p otentially lead to harm during and after a home

visit. Often medical orders are imprecise; "The orders are often just so vague." Speciﬁcally for fall risk management, prior

rehabilitation notes, are extremely helpful to evaluate a patient’s fall risk; "Did they go to rehab. If they did, I would read

some of the therapy notes from the rehab. that is really helpful to know." Additionally, due to the nature of home care

and the provider’s inability to continuously monitor the patient for falls, it is important to know "Who they live with and

availability of caregivers and willingness of those caregivers." Information gaps were attributed to (a) the HHA not being part

of a local/state Health Information Exchange (HIE), (b) no integration or information exchange between HHA or hospital

system, or (c) the HHA intake staﬀ did not pass through the required information.

Discussion: Our results concur with earlier studies that home care episodes remain devoid of important information that

informs the plan of care.

Our study provides speciﬁc evidence to HHAs and reports on essential data required to better

manage and reduce the risk of falls. Breaks in the information ﬂow, as well as incompleteness in the exchanged information

for fall risk management, creates gaps in the continuity of care and challenge home care providers.

Important non-clinical

and contextual information is critical to personalized medicine, care workﬂows, and safer care practices in home health;

having such information helps providers tailor their care to better manage and reduce the risk of falls. Having a correct

address and contact information of the patient and their care giver can improve providers’ utilization of time and direct their

attention to better care for their patients. While some information might be assumed to be available and error-free, providers

often ﬁnd themselves "Making sure that the addresses are correct. Making sure that the physicians that they have in the

system are the ones that are going to be following the patients." Our results also conﬁrm that the focus of exchanged and

documented information is on the clinical condition,

however, information in the educational and social domains such as

patient preferences, culture, and psychosocial state, are rarely exchanged in either written or electronic formats; it remains

in the memory of providers.

To date, fax and phone remain the predominate mode of exchanging health information.

Currently, EHRs, HIEs, and information ﬂows are fragmented, disconnected and do not allow for full capturing of important

contextual information. Better integration and exchange of information between EHRs, participation in HIEs, and designing

University of Maryland, Baltimore County

H3IT: Home Healthcare, Hospice, and Information Technology Conference Nashville, TN, 2015

health IT solutions capable capturing non-clinical and contextual information can help close these gaps.

Conclusion: Evidence from this study highlights essential information for managing and reducing fall risk and categorizes

them into four domains. Results highlight the importance of capturing essential information, both clinical and non-clinical,

throughout the patient’s journey to and in home care. Without understanding the information needs of home care providers,

improvement opp ortunities to manage and reduce falls will not be realized.

References

1. Stevens, JA, Corso, PS, Finkelstein, EA, and Miller, TR. The costs of fatal and non-fatal falls among older adults.

Injury prevention 2006;12:290–295.

2. Lord, SR, Menz, HB, and Sherrington, C. Home environment risk factors for falls in older people and the eﬃcacy of

home modiﬁcations. Age and ageing 2006;35:55–59.

3. Titler, M, Dochterman, J, Picone, DM, Everett, L, et al. Cost of hospital care for elderly at risk of falling. Nursing

Economics 2005;23:290.

4. Health, F of. Preventing hospital readmissions and loss of functional ability in high risk older adults. corporate 2011.

5. Centers for Disease Control. Cost of Fall Injuries in Older Persons. url: https://www.cdc.gov/homeandrecreationalsafety/

Falls/data/cost-estimates.html.

6. Costs of Falls Among Older Adults | Home and Recreational Safety | CDC Injury Center. url: https://www.cdc.gov/

homeandrecreationalsafety/falls/fallcost.html.

7. OASIS C Based Home Health Agency Patient Outcome, Process and Potentially Avoidable Event Reports - Centers for

Medicare & Medicaid Services. url: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/OASIS/09aa_hhareports.html.

8. Centers for Medicare and Medicaid Services. Outcome-based quality monitoring (OBQM) manual. url: https : //

www.cms.gov/Medicare/ Quality- Initiatives- Patient- Assessment- Instruments /HomeHealthQualityInits/

downloads/hhqiobqmmanual.pdf.

9. Bowles, KH, Pham, J, O’Connor, M, and Horowitz, DA. Information deﬁcits in home care: A barrier to evidence-based

disease management. Home Health Care Management & Practice 2010;22:278–285.

10. Kitzinger, J. Qualitative research. Introducing focus groups. BMJ: British medical journal 1995;311:299.

11. Parsons, M and Greenwood, J. A guide to the use of focus groups in health care research: Part 1. Contemporary Nurse

2000;9:169–180.

12. Ritchie, J and Spencer, L. Qualitative data analysis for applied policy research. The qualitative researcher’s companion

2002;573:305–329.

13. Smith, J and Firth, J. Qualitative data analysis: the framework approach. Nurse researcher 2011;18:52–62.

14. Olsen, R, Hellzén, O, Skotnes, L, and Enmarker, I. Breakdown in informational continuity of care during hospitalization

of older home-living patients: A case study. International journal of integrated care 2014;14.

15. Anderson, MA and Helms, L. Home health care referrals following hospital discharge: communication in health services

delivery. Journal of Healthcare Management 1993;38:537.

16. Haggerty, JL, Reid, RJ, Freeman, GK, Starﬁeld, BH, Adair, CE, and McKendry, R. Continuity of care: a multidisci-

plinary review. BMJ: British Medical Journal 2003;327:1219.