Featured articleHome healthcare patient, caregiver and provider perspectives on use of unscheduled acute care and the usability and acceptability of on-demand telehealth solutions
Introduction
As the population of older Americans with chronic conditions continues to increase, the role of home health care (HHC) services in improving transitions between acute care and independent residential living has become a national priority. In 2016, over 12,000 home health care agencies (HHAs) certified by the Centers for Medicare & Medicaid Services (CMS) served approximately 3.5 million Medicare beneficiaries and provided over 110 million home visits.1 Approximately, 1 in 5 HHC patients are readmitted during their HHC stay with up to 70% of readmissions occurring within the first two weeks of HHC admission.2 Telehealth, defined as “the use of telecommunications and information technology to provide care and communication across distance,”3 has been identified as a potential innovative solution to transform the way that care is delivered in HHC and improve patient outcomes including reducing hospital readmissions.4 Although telehealth services connect patients in the community with health care providers virtually and have been identified as a way to improve care quality and efficiency, HHC patients have not reaped the benefit of these services due to lack of adoption at the agency level in the U.S.
Research on telehealth in HHC has been shown to improve patient functioning and reduce hospitalizations and emergency department (ED) visits, however, studies have been limited to subpopulations with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and diabetes.5, 6, 7, 8, 9 Additionally, studies have mainly focused on telemonitoring, leaving a gap in knowledge related to the acceptability of on-demand telehealth services to fill acute care needs in the HHC setting.10,11 Given this gap, the objective of this study was to examine reasons HHC patients use acute care services and assess the acceptability of on-demand telehealth services among HHC patients, caregivers and HHC personnel for addressing acute care needs.
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Methods
This study was a secondary analysis of data from a qualitative study utilizing single, in-depth interviews of HHC personnel, patients and caregivers from a Medicare-certified HHC agency affiliated with a large healthcare system in the Greater Philadelphia area. Data collection and analysis was described in detail elsewhere and the objective of this paper was to assess the unmet needs of home health care patients and their caregivers.12 In brief, telephone interviews with HHC personnel were
Results
A total of 30 interviews were completed including 10 HHC personnel (7 registered nurses, 2 home health aides and 1 intake coordinator), 15 patients and 5 caregivers. The majority of patients were female (67%) with a mean age of 70 years. Detailed participant characteristics are presented in Table 1. Three themes emerged related to reasons for seeking care in the ED and associated decision-making: sense of urgency, behavioral and psychosocial factors, and access to care. Regarding potential use
Sense of urgency
Nurses and home health aides reported a variety of emergent conditions that prompt HHC patients to seek care in the ED including exacerbation of congestive heart failure (CHF), chest pain, diabetes/increased blood sugar, respiratory difficulty, uncontrolled pain, injury from a fall and signs of infection. Nurses and caregivers discussed the perceived sense of urgency as a reason patients go to the ED. One nurse shared, “patients decide to go to the emergency room when they get that instinctive
Barriers to using telehealth
Although both nurses and patients identified numerous benefits of telehealth, nurses were skeptical that patients would be able to use the technology. They discussed potential barriers to patients’ use of telehealth including lack of comfort with physicians not known to them, patient preference for an in-person physical examination, low trust in healthcare, language barriers, cost, and limitations in access and ability to use technology. The biggest concern providers identified is cost and
Discussion
This study provides insight into reasons HHC patients seek unscheduled acute care and the potential role that on-demand telehealth services can play in reducing unnecessary acute care episodes. Consistent with the literature, in our study, participants outlined psychosocial and behavioral factors for why patients go to the ED, including anxiety on the part of the patient or caregiver and lack of access to their primary care provider or the provider they had seen in the hospital (e.g. surgeon
Limitations
Our study was conducted in a single HHC agency affiliated with a large academic medical center and limited to English-speaking patients, 18 years and older without a major communication impairment potentially limiting generalizability of findings. Additionally, interviews with HHC providers were conducted prior to the emergence of the COVID-19 pandemic, while interviews with patients and their caregivers were conducted at the beginning of pandemic, which may have contributed to patients’ high
Conclusion
This study identified reasons HHC patients seek unscheduled acute care and the potential use and acceptability of on-demand telehealth services to increase access to care among HHC patients. These findings underscore the need to improve communication and coordination between HHC providers, patients and providers in the community in order to improve patient outcomes. Findings also highlight the potential that on-demand telehealth services can have in transforming communication and care in HHC.
Author Contributions
MPM, AG, RKL: study concept and design; All authors: acquisition, analysis and interpretation of data, and preparation of the manuscript.
Declaration of Competing Interest
The authors have no conflicts of interest, including personal and financial, to report.
Acknowledgments
Research reported in this publication was supported by an intramural grant from Thomas Jefferson University. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.
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