Focus Groups to Inform Further Development of a Digital Therapeutic Platform for Home Care Agencies in Dementia Care (Preprint)

BACKGROUND Persons living with dementia (PLWD) require increasing levels of care and the care model for PLWD has evolved. The Centers for Medicare & Medicaid Services is transitioning long-term care services from institutional care to home or community-based services, including reimbursement for non-clinical services. Although home care companies are positioned to handle this transition, they need innovative solutions to address the special challenges posed by caring for PLWD. To live at home longer, PLWD require support from formal caregivers (i.e., paid professionals), who often lack knowledge of PLWDs’ personal histories and have high turnover, and/or informal caregivers (e.g., family or friends), who may have difficulty coping with behavioral and psychological symptoms of dementia. The Generation Connect (GC) platform was developed to support PLWD and their formal and informal caregivers. In preliminary studies, the GC platform improved moods for PLWD and influenced caregiver satisfaction. To enhance platform effectiveness, Generation Connect received a National Institutes of Health Small Business Innovation Research (NIH SBIR) grant to improve clinical outcomes, reduce healthcare costs, and lower out-of-pocket costs for PLWD who receive care through home care agencies. OBJECTIVE To conduct stakeholder focus groups to develop a better understanding about existing processes, needs, barriers, and goals for the use of the GC platform by home care agencies and formal and informal caregivers. METHODS A series of focus groups were conducted with 1) home care agency corporate leadership, 2) home care agency franchise owners, 3) home care agency formal caregivers, and 4) informal caregivers of PLWD. The qualitative approach allowed for the unrestricted generation of ideas that would best inform the development of the GC platform developers to enable home care providers to differentiate their dementia care services, involve informal caregivers, improve formal caregiver well-being, and extend PLWD ability to age in place. Using the Technology-Enabled Caregiving in the Home framework, an inductive and iterative content analysis was utilized to identify thematic categories from the transcripts. RESULTS A total of 39 participants participated across the six stakeholder focus groups. Five overarching themes were identified: (1) Technology-Related; (2) Care Services; (3) Data, Documentation, Outcomes; (4) Cost, Finance, Resources; and (5) Resources for Caregivers. Within each theme, the most frequent sub-themes were identified. Exemplar stakeholder group statements were compiled to provide support for each of the identified themes. CONCLUSIONS Focus group results will inform further development of the GC platform to reduce the burden of caregiving for PLWD, evaluate changes in cognition, preserve functional independence, and promote engagement between PLWD and caregivers. The next step is to evaluate the effectiveness of the GC platform in a NIH SBIR Phase 2 clinical trial to assess its efficacy of evidence-based interventions and market viability. CLINICALTRIAL This Phase 1 study did not meet the criteria for an Applicable Clinical Trial and therefore it was not registered on clinicaltrials.gov.

Facilitating co-production in public services: Empirical evidence from a co-design experience with family caregivers living in a remote and rural area

The involvement of vulnerable actors in co-production activities is a debated topic in the current public service literature. While vulnerable actors should have the same opportunities to be involved as other actors, they may not have the needed competences, skills and attitudes to contribute to this process. This paper is part of a broader project on family caregivers’ engagement in remote and rural areas. In particular, it investigates how to facilitate co-production by looking at four co-design workshops with family caregivers, representatives of a local home care agency and researchers. The transcripts of the workshops were coded using NVivo, and the data were analysed based on the existing theory about co-production. Two main findings were identified from the analysis. First, the adoption of co-production by vulnerable actors may occur in conjunction with other forms of engagement. Second, the interactions among facilitators and providers play a crucial role in encouraging the adoption of co-production. We identified at least two strategies that may help facilitators and providers achieve that goal. However, there is a need for an in-depth understanding of how facilitators and providers should interact to enhance implementation of co-production.

A Cyclic Model Describing the Process of Sustaining Meaningfulness in Practice: How Nurses Continue Working at One Home Care Agency

This study aimed to elucidate the experiences of home care nurses who had continued working a single agency, to gain insight into the prevention of premature turnover. We adopted a grounded theory approach to qualitative exploration of the experiences of 26 Japanese nurses working in a home care agency, using semistructured interviews and participant observation. Nurses’ experience progressed through three phases: “encountering difficulty,” “enjoying the fruitfulness,” and “becoming dissatisfied.” Nurses’ cognitive rounding involving these phases was conceptualized as “cycle of sustaining meaningfulness.” To move from encountering difficulty to enjoying the fruitfulness, nurses needed to discover the meaningfulness of practice, and to move from becoming dissatisfied to encountering difficulty, they needed to requestion their practice. During their time at the agency, nurses progressed through the phases of the cycle of sustaining meaningfulness repeatedly. Knowing the point at which nurses are in the cycle and assisting their further progress could aid in their retention.

Abstract 23: Reducing Stroke Readmissions Utilizing a Home Care Based Transitions Coaching Program

Background: The Center for Medicare and Medicaid Services (CMS) has instituted utilization of all-cause, unplanned 30 day hospital readmissions following discharge for ischemic stroke as part of the Hospital Inpatient Quality Reporting Program. While readmission reduction following stroke is a hospital imperative, there is minimal evidence on stroke-specific readmission reduction programs. Purpose: We sought to reduce 30 day readmissions following ischemic stroke through utilization of an established care transitions program in collaboration with our institution’s affiliated home care agency. Methods: Our institution’s home care agency has reduced readmission rates in the general medical population utilizing the Coleman Care Transitions Model © . This model incorporates motivational interviewing in visits prior to hospital discharge, with a home visit 24 to 48 hours after discharge, and by telephone at least weekly by a trained transitions coach. The coach ensures understanding of medications, follow up visits, and recognition of red flag symptoms. A one year pilot program for stroke patients utilizing this established program was initiated in October 2015. Basic stroke training was provided for all coaching staff. Quarterly readmission rates for 1 year prior to the intervention and 6 months following were analyzed. Results: During the first 6 months of the pilot program 18.2% of patients discharged with a diagnosis of ischemic stroke qualified for and completed the coaching program. Of those in the program 3.3% were readmitted. Overall, there were 15 readmissions in 13 patients, 85% of whom did not receive transitions coaching services. The readmission rate in the year prior to intervention was 7.8%, in the 6 months following 4.5%. These findings represent a 42.7% overall reduction in readmissions (p = 0.06) and a treatment effect of 1.7. Conclusions: Utilizing the Coleman Care Transitions Model © led to a meaningful reduction of hospital readmissions for patients with ischemic stroke in this pilot program. In an area in which readmission reduction has proven challenging, expanding the availability of a home care based program for specific patient populations may be an effective strategy.

Lessons in Retrospect

Baccalaureate community health education often includes clinical practice in home care agencies. Complexity with securing home care agency practice sites has led to the proliferation of alternative models for community health clinical. Nurse-managed wellness centers (NMWCs) are one such alternative that provides robust clinical experience for students and valuable home health services for vulnerable population groups. Despite anecdotal evidence of the value of the NMWC home care service, sustainability was dependent on the ability to report outcomes. An effort to quantify emergency department and hospital cost and utilization outcomes was unsuccessful. This resulted in failure to obtain financial support, and NMWC services were terminated in one community. In retrospect, the NMWC model was identified as having potential for integration into home care agency services.

Abstract TMP77: Development of a Collaborative Transition Coaching Program for Reduction of Post-stroke Hospitalizations

Issue: All-cause 30 day hospital readmission rate following discharge for ischemic stroke has been instituted by CMS as a quality measure. Successful readmission reduction planning is a hospital imperative. Purpose: We set out to establish a stroke-specific transitions coaching program with the intention of decreasing readmissions in our ischemic stroke population. Methods: Fiscal year 2013 stroke readmissions to our hospital were individually reviewed for factors leading to readmission. After determining 62.5% of avoidable readmissions were attributed to outpatient factors, a regional home care agency was contacted for collaboration. The agency has proven readmission reductions utilizing the Coleman Care Transitions Model. This model incorporates visits prior to discharge, by telephone, and at home by a trained transitions coach to ensure understanding of medications, follow up visits, and recognition of concerning symptoms. Cost estimates for expanding the program to stroke patients were made using the prior year’s volume based on primary payer, county, and discharge destination. A business plan was established and training and informational sessions planned. Results: Of the outpatient factors contributing to readmission the most common were medication issues, seeking emergency care prematurely, and need for education or support. Based on the data and prior successes of the home care agency a pilot program was developed. The estimated cost for patients not covered by their primary insurance is $52,000 annually. The estimated cost for one hospital readmission is $11,200. Preventing 5 readmissions per year would save $56,000. A successful collaborative was formed resulting in the ability to enroll a larger number of ischemic stroke patients in the transitions coaching program. Conclusions: Solving the problem of readmissions after ischemic stroke is complex and requires extensive planning and collaboration. Identifying our issues and establishing a pilot program took nearly a year. Key stakeholders and a committed team are essential components of establishing a collaborative process of this magnitude. The pilot program will be evaluated by comparting readmission rates in the ischemic stroke population pre and post initiation.

Pain assessment

Pain is multifactorial and affects the whole person and family caregivers, and multiple barriers to pain assessment exist. Patients should be screened for pain on admission to a hospital, clinic, nursing home, hospice, or home care agency. If pain or discomfort is reported, a comprehensive pain assessment should be performed at regular intervals, whenever there is a change in the pain, and after any modifications in the pain management plan. The patient’s self-report of pain is the gold standard, even for those patients who are nonverbal or cognitively impaired. Multiple pain scales are available for use in nonverbal or cognitively impaired patients or residents; these should be used in combination with clinical observation and information from healthcare professionals and family caregivers.