Continuity of nursing care improves patient outcomes

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People with dementia receiving care at home are less likely to be readmitted to hospital when nurses are consistent, according to a new study by NYU researchers Rory Meyers College of Nursing. The discoveries are published in the journal Medical care, a journal of the American Public Health Association.

Home care, in which health providers, primarily nurses, visit patients’ homes to provide care, has become one of the main sources of home and community services for people with dementia. These people often have multiple chronic illnesses, take multiple medications, and need help with activities of daily living. In 2018, more than 5 million Medicare beneficiaries received home care, including 1.2 million with Alzheimer’s disease and related dementias.

“Nurses play a central role in providing home health care,” said Chenjuan Ma, PhD, MSN, assistant professor at NYU Meyers and lead author of the study. “As the population ages and older people choose to ‘age in place’ for as long as possible, the demand for home health care for people with dementia is expected to increase rapidly. “

For most patients, their home care often begins after discharge from hospital. Since hospital readmissions are a significant issue of quality, safety and funding in healthcare, Ma and her colleagues wanted to understand whether continuity of care, or the same nurse coming on every home visit , could help prevent readmission of patients.

Using several years of data from a large nonprofit home care agency, researchers studied 23,886 elderly people with dementia who received home health care after hospitalization. They measured continuity of care as a function of the number of nurses and visits during home care, with a higher score indicating better continuity of care.

About one in four (24 percent) of the elderly with dementia in the study were readmitted from home health care. Infections, respiratory problems and heart disease were the three most common reasons for hospital readmission.

Researchers have found large variations in the continuity of nursing care during home visits for people with dementia. Eight percent had no continuity of care, with a visit from a different nurse each time, while 26 percent received all visits from a nurse. They also found that the higher the intensity of visits, or the more hours of care provided each week, the lower the continuity of care.

“This may suggest that it is difficult to ensure continuity of care when a patient needs more care, although we cannot rule out the possibility that high continuity of care translates into care delivery. more efficient and therefore less hours of care, ”explained Ma.

Notably, increased continuity of home health care resulted in a lower risk of rehospitalization, even after researchers controlled for other clinical risk factors and intensity of home health care (the average number of hours treatment per week). Compared to people with high continuity of nursing care, people with dementia receiving low or moderate continuity of nursing care were 30 to 33% more likely to be readmitted to hospital.

“Continuity of nursing care is valuable for home health care because of its decentralized, intermittent model of care,” said Ma. “While continuity of nursing can benefit all patients receiving home care , it can be particularly critical for people with dementia. Having the same caregiver can increase familiarity, build trust, and reduce confusion for patients and their families. “

To improve the continuity of nursing care, the researchers recommend addressing the shortage of home nurses, improving the coordination of care, and adopting telehealth in home care.

“Multiple structural factors present challenges to the continuity of care for home nurses and other staff. These can include long commute times, few full-time or part-time staff, agencies relying primarily on per diem staff, and organizational cultures that do not favor retention of home care staff ” said Allison Squires, PhD, IA, FAAN, associate professor at NYU Meyers and lead author of the study. “Legislation proposed to Congress that seeks to increase salaries for frontline nursing and home care staff will pay off as agencies can improve continuity of care and therefore reduce penalties associated with hospital readmissions. “

A hybrid care model of in-person visits and telehealth visits could also help ensure greater continuity of care, the researchers note. They encourage policy makers to consider expanding coverage of telehealth visits to home health care.

In addition to Ma and Squires, study authors include Margaret McDonald and Penny Feldman of the Visiting Nurse Service of New York, Sarah Miner of the Wegmans School of Nursing at St. John Fisher College, and Simon Jones of the NYU Grossman School of Medicine. The research was supported by the Agency for Healthcare Research and Quality (R01HS023593) and the NYU Center for the Study of Asian American Health under a grant from the National Institute on Minority Health and health disparities (3U54MD000538-18S1).

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