Organizational readiness for change towards implementing a sepsis survivor hospital to home transition-in-care protocol.

Background: Organizational readiness for change, defined as the collective preparedness of organization members to enact changes, remains understudied in implementing sepsis survivor transition-in-care protocols. Effective implementation relies on collaboration between hospital and post-acute care informants, including those who are leaders and staff. Therefore, our cross-sectional study compared organizational readiness for change among hospital and post-acute care informants.

Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.

Study Aim: This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach.

Background: Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described.

Methods: We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER.

The Symptom Experience of Older Adults with Mobility Difficulties: Qualitative Interviews.

Eighteen million older adults have mobility limitations, defined as difficulty walking a quarter of a mile or climbing stairs unassisted. Little is known about how symptom burden impacts mobility difficulty in older adults. Understanding the burden of symptoms responsible for mobility difficulties may be an area for intervention to improve mobility and to prevent adverse outcomes.

Exposing Undergraduate Nursing Students to Older Adults: A Qualitative Analysis.

Care of the older adult can be complex and influenced by ageism. The purpose of this pilot study was to expose nursing students to older adults earlier in the undergraduate curriculum. This study examined the experiences of student participation in caring for older adults.

Mismatch identified in symptom burden profiles in lung transplantation.

Background: There is considerable heterogeneity in symptom burden among lung transplant candidates that may not be explained by objective measures of illness severity.

Objectives: This study aimed to characterize symptom burden, identify distinct profiles based on symptom burden and illness severity, and determine whether observed profiles are defined by differences in social determinates of health (SDOH).

Methods: This was a prospective study of adult lung transplant candidates.

Improving transitions and outcomes of sepsis survivors (I-TRANSFER): a type 1 hybrid protocol.

Background: This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol.

Rural and urban disparities in quality of home health care: A longitudinal cohort study (2014-2018).

Purpose: Home health care is one of the fastest growing health care sectors in the United States. However, little is known of differences in trends in quality performance between rural and urban home health agencies over time. This study aimed to examine disparities in quality performance between rural and urban home health agencies between 2014 and 2018.

Parkinson's Disease Medication Administration During a Care Transition: The Impact of Interprofessional Team Simulation on Student Competency, Comfort, and Knowledge.

Aim: This study investigated the impact of an interprofessional mock code on students' comfort and competency related to Parkinson's disease (PD) medication administration during care transitions.

Backgroud: Patients with PD are at increased risk for medication errors during hospitalization. Individualization of PD medication creates vulnerability during care transitions.

Applying the Health Belief Model to Quantify and Investigate Expectations for Computerized Cognitive Training.

Despite the demonstrated benefits of computerized cognitive training for older adults, little is known about the determinants of training behavior. We developed and tested scales to quantify expectations about such training, examine whether expectations predicted training adherence, and explore if training expectations changed from pre- to post-training. Participants (=219) were healthy older adults aged 55-96 years (=75.

Patients' and caregivers' perspectives in determining discharge readiness from home health.

There are no national, empirically derived clinical decision support tools to assist the interprofessional home health team in determining readiness for discharge from skilled home health. Eliciting patient and family caregiver perspectives around readiness for home health discharge is integral to developing tools that address their needs in this decision-making process. The purpose of this study was to describe the factors home health patients and their family caregivers perceive as critical when determining readiness for discharge from services.

Handgrip Weakness and Asymmetry Independently Predict the Development of New Activity Limitations: Results from Analyses of Longitudinal Data from the US Health and Retirement Study.

Objectives: Examining strength asymmetries in assessments of muscle function may improve screenings for limitations in independent living tasks such as instrumental activities of daily living (IADL). We sought to determine the associations between handgrip strength (HGS) asymmetry and future IADL limitations in aging Americans.

Design: Longitudinal panel.

Surviving COVID-19 After Hospital Discharge: Symptom, Functional, and Adverse Outcomes of Home Health Recipients.

Background: Little is known about recovery from coronavirus disease 2019 (COVID-19) after hospital discharge.

Objective: To describe the home health recovery of patients with COVID-19 and risk factors associated with rehospitalization or death.

Design: Retrospective observational cohort.

Using Machine Learning on Home Health Care Assessments to Predict Fall Risk.

Falls are the leading cause of injuries among older adults, particularly in the more vulnerable home health care (HHC) population. Existing standardized fall risk assessments often require supplemental data collection and tend to have low specificity. We applied a random forest algorithm on readily available HHC data from the mandated Outcomes and Assessment Information Set (OASIS) with over 100 items from 59,006 HHC patients to identify factors that predict and quantify fall risks.

Handgrip Strength Is Associated with Poorer Cognitive Functioning in Aging Americans.

Background: Measures of handgrip strength may show promise for detecting cognitive erosion during aging.

Objective: To determine the associations between lower handgrip strength and poorer cognitive functioning for aging Americans.

Methods: There were 13,828 participants aged at least 50 years from the 2006 wave of the Health and Retirement Study included and followed biennially for 8 years.

Relationships Between Race/Ethnicity and Health Care Utilization Among Older Post-Acute Home Health Care Patients.

Few studies have explored racial/ethnic differences in health care outcomes among patients receiving home health care (HHC), despite known differences in other care settings. We conducted a retrospective cohort study examining racial/ethnic disparities in rehospitalization and emergency room (ER) use among post-acute patients served by a large northeastern HHC agency between 2013 and 2014 ( = 22,722). We used multivariable binomial logistic regression to describe the relationship between race/ethnicity and health care utilization outcomes, adjusting for individual-level factors that are conceptually related to health service use.

Transitional Care Experience in Home Health: Exposing Students to Care Transitions Through Scenarios and Simulation.

Chronically ill older adults are at risk for avoidable adverse events especially during care transitions, the transfer to one care setting or one level of care to another. Because of the expected increase in the older adult population, increased demand for transitional care is anticipated. Despite the consistent call for expanded competencies in care transitions, nursing education has not incorporated these concepts into nursing curricula.

Transportation and Aging: An Updated Research Agenda to Advance Safe Mobility among Older Adults Transitioning From Driving to Non-driving.

Engagement in civic, social, and community life plays an important role in health, well-being, and quality of life, and requires individuals to be mobile in their environment. In this article, we review what is currently known about 2 areas relevant to safe mobility for older drivers and identify future research in these areas. Using a framework for transportation and safe mobility, 2 key areas were selected for review: the process of transitioning to non-driving and the maintenance of mobility after driving has ceased.

Racial/ethnic disparities in disability outcomes among post-acute home care patients.

Objective: To examine activities of daily living (ADL) disability outcomes among racially/ethnically diverse elders receiving home care (HC) after hospitalization.

Method: We conducted a retrospective cohort analysis of single-agency, 2013-2014 Outcome and Assessment Information Set data from older adults who received post-hospitalization HC ( n = 20,674). We measured overall change in ADL disability by summing the difference of standardized admission and discharge scores from nine individual ADL.

The Impact of Three Cognitive Training Interventions on Older Adults' Physical Functioning Across 5 Years.

Objective: Physical functioning is closely associated with cognition. The current study assessed the impact of three cognitive training programs on objective measures of physical functioning across 5 years.

Method: Older adults randomized to a processing speed ( n = 702), reasoning ( n = 694), or memory ( n = 703) training intervention were compared with those randomized to a no-contact control condition ( n = 698).

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults.

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles.

Influence of Social and Health Indicators on Pain Interference With Everyday Activities Among Older Black and White Cancer Patients.

This prospective study aimed to determine the influence social and health factors have on pain interference with everyday activities among older patients receiving outpatient treatment services from a comprehensive cancer center. Participants were surveyed on questions assessing pain interference, and social (communication), health (pain severity, comorbidities), behavioral (self-efficacy, affect), and demographic characteristics. Multivariate analyses were specified to examine determinants of pain interference, with items loading on separate cluster composites: physical interference and psychosocial interference.