Having the same nurse for home health visits may prevent rehospitalization for people with dementia

Home health care -- in which health providers, primarily nurses, visit patients' homes to deliver care -- has become a leading source of home- and community-based services caring for people living with dementia. These individuals often have multiple chronic conditions, take several medications, and need assistance with activities of daily living. In 2018, more than 5 million Medicare beneficiaries received home health care, including 1.2 million with Alzheimer's disease and related dementias.

"Nurses play a pivotal role in providing home health care," said Chenjuan Ma, PhD, MSN, assistant professor at NYU Meyers and the study's lead author. "As the population ages and older adults choose to 'age in place' as long as possible, the demand for home health care for people with dementia is expected to grow rapidly."

For most patients, their home health care often begins after being discharged from the hospital. Given that hospital readmissions are a significant quality, safety, and financial issue in healthcare, Ma and her colleagues wanted to understand if having continuity of care, or the same nurse coming to each home visit, could help prevent patients from being readmitted.

Using multiple years of data from a large, not-for-profit home health agency, the researchers studied 23,886 older adults with dementia who received home health care following a hospitalization. They measured continuity of care based on the number of nurses and visits during home health care, with a higher score indicating better continuity of care.

Approximately one in four (24 percent) of the older adults with dementia in the study were rehospitalized from home health care. Infections, respiratory problems, and heart disease were the three most common reasons for being readmitted to the hospital.

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

"This may suggest that it is hard to achieve continuity of care when a patient requires more care, though we cannot exclude the possibility that high continuity of care results in more efficient care delivery and thus fewer hours of care," explained Ma.

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

"Continuity of nursing care is valuable for home health care because of its decentralized and intermittent care model," said Ma. "While continuity of nursing care may benefit every home health care patient, it may be particularly critical for people with dementia. Having the same person delivering care can increase familiarity, instill trust, and reduce confusion for patients and their families."

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

"Multiple structural factors present challenges for continuity of care for home health nurses and other staff. These can include long commute times, few full- or part-time staff, agencies relying mostly on per diem staff, and organizational cultures that do not foster retention of home health care staff," said Allison Squires, PhD, RN, FAAN, associate professor at NYU Meyers and the study's senior author. "Proposed legislation in Congress that seeks to increase nursing and home health care frontline staff salaries will pay for itself because 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 achieve more continuity of care, the researchers note. They encourage policymakers to consider expanding coverage for telehealth visits in home health care.