Errors during care transitions of older adults are common, costly, and sometimes lethal. A care transition is defined as the movement of a person from one healthcare setting to another and is commonly associated with adverse outcomes. The aging of the population is leading to greater reliance on care delivered in the home, the most common and poorly understood healthcare delivery setting. For unclear reasons, those who require skilled home healthcare (SHHC) services (e.g., home nursing) after hospital discharge are among those at highest risk of experiencing hospital readmission. Strategies tailored to the complexity of the hospital/SHHC transition are needed to ensure safe transitions, yet there is relatively little research to guide improvement efforts. The overall goal of the proposed study is to develop an index to be used by SHHC agencies in real time to identify and reduce potential risks to older adults' safety during hospital/SHHC transitions.
SPECIFIC AIM 1 : To identify potential risks to older adults' safety related to (1) information management among SHHC providers across settings, and (2) establishment of older adult, caregiver, and SHHC provider roles for execution of healthcare tasks. We will use prospective risk identification methods to identify potential risks: (a) direct observations of older adults' hospital/SHHC transition; and (b semi-structured interviews of older adults/caregivers/SHHC providers.
SPECIFIC AIM 2 : To develop an index that will be used by SHHC agencies in real time to identify risks to older adults' safety during hospital/SHHC transitions with regard to processes of information management and establishment of roles. Through focus groups, SHHC providers will rate each risk identified in SA1 on its importance to ensuring safety and its frequency of occurrence.
SPECIFIC AIM 3 : To evaluate psychometric properties of the index and ascertain feasibility of use. 3a. To evaluate index inter-rater reliability among SHHC providers and establish initial construct validity among care transitions that differ in quality. For inter-rater reliability, we wll determine the correlation between index scores calculated by pairs of SHHC providers evaluating a series of care transitions. For construct validity, we will compare index scores among cases that differ in care transition quality. 3b. To further evaluate construct validity usin a different standard and ascertain feasibility of use among SHHC providers. In a prospective sample of older adults receiving SHHC after hospital discharge, we will determine the correlation between SHHC provider-generated index scores and a general measure of patient-reported care transition quality (Care Transitions Measure, or CTM-3). The proposed study will fill critical gaps in the understanding of care transitions of older adults who are particularly vulnerable to safety issues. Study findings have the potential for applicability to a broader group of patients who transition from hospital to home and require complex care.

Public Health Relevance

The aging of the population is leading to greater reliance on care delivered in the home, the most common and poorly understood healthcare delivery setting. Older adults who require nursing services after hospital discharge are at high risk of returning to the hospital within a short time frame. The overall goal of the proposed study is to develop a tool to provide real-time feedback to home healthcare nurses to identify and reduce potential safety risks when older adults return home from the hospital.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Clinical Investigator Award (CIA) (K08)
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HSR Health Care Research Training SS (HCRT)
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Willis, Tamara
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Johns Hopkins University
Internal Medicine/Medicine
Schools of Medicine
United States
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Arbaje, Alicia I; Hughes, Ashley; Werner, Nicole et al. (2018) Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study. BMJ Qual Saf :
Arbaje, Alicia I; Yu, Qilu; Wang, Jiangxia et al. (2017) Senior services in US hospitals and readmission risk in the Medicare population. Int J Qual Health Care 29:845-852
Lindquist, Lee A; Miller, Rachel K; Saltsman, Wayne S et al. (2017) SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients' Healthcare from Skilled Nursing Facilities to the Community. J Gen Intern Med 32:199-203
Werner, Nicole E; Malkana, Seema; Gurses, Ayse P et al. (2017) Toward a process-level view of distributed healthcare tasks: Medication management as a case study. Appl Ergon 65:255-268
Keller, Sara C; Gurses, Ayse P; Werner, Nicole et al. (2017) Older Adults and Management of Medical Devices in the Home: Five Requirements for Appropriate Use. Popul Health Manag 20:278-286
Wong, Evan G; Parker, Ann M; Leung, Doris G et al. (2016) Association of severity of illness and intensive care unit readmission: A systematic review. Heart Lung 45:3-9.e2
Arbaje, Alicia I; Werner, Nicole E; Kasda, Eileen M et al. (2016) Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf :
Keller, Sara C; Gurses, Ayse P; Arbaje, Alicia I et al. (2016) Learning from the patient: Human factors engineering in outpatient parenteral antimicrobial therapy. Am J Infect Control 44:758-60
Werner, Nicole E; Gurses, Ayse P; Leff, Bruce et al. (2016) Improving Care Transitions Across Healthcare Settings Through a Human Factors Approach. J Healthc Qual 38:328-343
Kohli, Preeti; Arbaje, Alicia I; Leff, Bruce et al. (2015) Assisted living facility use by the program of all-inclusive care for the elderly. J Am Geriatr Soc 63:594-6

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