Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission.

Objectives: Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer.

Design: Observational field study.

Setting And Participants: Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs).

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care.

Objectives: Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

Design: Observational field study.

Settings And Participants: Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics.

Incongruence of Patient Problem Information Across Three Phases of Home Care Admission: There's a Problem with the Problem List.

In home health care, the patient problem list is an important component of the admission and care planning processes and determines the subsequent care received. We examined the information received from the referring facilities and its relationship with the final patient problem list generated at home health care admission. Researchers observed 12 admissions and collected available documents related to the admission and care planning process.

Availability and Quality of Information Used by Nurses While Admitting Patients to a Rural Home Health Care Agency.

Home health care admission nurses need high quality patient information but that information is not uniformly available. Despite this challenge, these nurses must make four critical decisions at patient admission to construct the plan of care: (1) patient problems to address in the home health care episode; (2) patient medication management; (3) services in addition to skilled nursing; and (4) skilled nursing visit pattern. We observed 12 in-home admissions at a rural home health care agency and interviewed nurses before and after about these decisions.