Adverse events, of course, occur across all venues in the healthcare continuum. We tend to focus most on hospitals, ambulatory surgical centers, and ambulatory care sites. But one particular venue that has been underrepresented in the patient safety literature is home care. As hospitals have ratcheted down lengths of stay and with the increasing focus on avoiding readmissions, home care has taken on an increasingly important role in quality improvement and patient safety. Home care often deals with patients during their most vulnerable transitions of care. Yet we’ve largely ignored it for many years.
Now our Canadian colleagues have taken the lead in a series of studies analyzing adverse events occurring in the home care setting (Sears 2013, Blais 2013, Doran 2013). The first study analyzed adverse events in 430 patients in 3 publicly funded home care programs in Ontario, Canada (Sears 2013). In the second study, the authors did chart review of 1200 patients receiving publicly funded home care randomly selected in 3 Canadian other provinces (Blais 2013). The third study (Doran 2013) includes many of the authors of the other two publications and uses some of the same data sources but further expands on some of the contributing factors. Though there may be differences in the health systems between Canada and the US we suspect that most of the findings and lessons learned apply equally to home care in the US.
The studies used a dual chart review technique. Nurses did chart abstractions and reviews and flagged cases meeting pre-specified screening criteria for adverse events (AE’s). Then physician reviewers did chart reviews to determine the presence of adverse events and assessed the preventability of those events.
The Sears study found 66.5% of charts reviewed were positive for one or more of the screening criteria. Adverse events were found in 12.8% of patients sampled and after adjustment for the number of patients at each site determined the overall AE rate was 13.2%. Overall a third of the AE’s (32.7%) were rated as preventable.
The Blais study found that 4.2% of patients discharged from the home care programs in a 12-month period experienced an adverse event. However, to account for varying lengths of time patients were receiving home care services the authors converted the rates to an adverse event per client-year rate. That adverse event rate was 10.1% per client-year. Importantly, over half the events (56%) were considered potentially preventable by the reviewers.
It is highly likely that these AE rates represent underestimates of the actual rates. The Blais study found a significant discrepancy between adverse events found by the chart reviewers and those actually documented as such in the patient charts. Only 17.3% of such charts indicated that an incident report had been completed.
The most common adverse events encountered in the Blais study were falls, wound infections, medication errors, and psychosocial, behavioral or mental health problems. In the Sears study the most commonly encountered adverse events were falls, medication errors, decubiti/skin breakdown, general decline, and delayed healing or infection.
As expected, some patient level factors were associated independently with the risk of adverse events. In the Blais study these included the number of comorbid conditions and impairment of the ability to perform activities of daily living. Sears et al. also found number of comorbid conditions and impaired ADL’s as risk factors. They also found age >65, living alone, communications difficulties due to cognition, history of falls, use of psychotropic medications, depression, anxiety and anger, and social isolation as risk factors for adverse events in the home care setting.
Blais et al. point out that one of the most significant differences between hospital care and home care is that in home care the patient and family or other informal caregiver provide much of the care. So, while the authors found the healthcare personnel contributed to 46% of the adverse events, they also found that patients themselves and informal caregivers contributed to 48.4% and 20.4% of adverse events, respectively. Similarly, Sears et al. found that decisions and care provided by healthcare workers likely contributed to adverse events in 29.5% of cases, informal care giving by family or friends in 27.9%, and patient self-care in 52.6% but in many cases there were multiple contributing sources.
The Doran study (Doran 2013) identified six safety-related themes:
1. The unacknowledged challenge of taking healthcare to a private home
2. System design issues that force clients and caregivers to deal with a patchwork of services
3. “Duty creep” and changes: unpaid caregivers must take on more and more responsibilities, while dealing with changes to their own health, lifestyle and role as caregiver
4. A rationing of portable oxygen concentrators, which leads to rationed living, especially for COPD clients
5. Clients “doing what it takes” to stay at home, sometimes hiding their needs for fear of being told they can no longer live independently
6. The serious decline of caregivers’ health, who are often elderly spouses or retired children
In addressing the first theme they note that homes, particularly those of the chronically ill, are rarely suited to the provision of safe healthcare, often being run down, cluttered, dirty, with icy walkways, halls blocked by wheelchairs and walkers, and cramped spaces with little room for treatment-related equipment. They often also have hazards related to snow, tobacco smoke and pets.
The second theme deals with a host of system issues that make it difficult to provide and receive care in the home. They note that the services tend to come from multiple sources and the providers are ever-changing. Patients have difficulty finding out about available programs and how to apply for services. Staff turnover is high in the home care field and communication poor. The communication deficiencies impact not only the patients but also the home care worker, perhaps contributing to the high turnover. There may be waiting times for equipment and therapists. Standards, formal training and certification of HC workers are needed to improve safety.
Regarding duty creep, unpaid caregivers often have to cut down their own work hours or even quit their jobs. They have less time for their regular family responsibilities and for the activities that they would normally enjoy.
“Doing what it takes to stay at home”: Clients and caregivers have a tendency to hide their needs and even to refuse care out of fear that they might have to give up living independently. Some take fewer services than they are entitled to because they do not want strangers coming into their homes.
Caregivers are often elderly spouses or retired children and the physical and emotional demands of caring can lead to serious declines in their health with stress, isolation, depression and anxiety.
Doran et al. also identified four themes dealing with systemic weaknesses:
1. Inconsistencies in the way care is planned and delivered in HC
2. Lack of integration of HC teams, lack of care coordination across healthcare sectors and failures in communication
3. Poor standardization of processes, equipment and packaging of medication
4. Clients and caregivers sometimes make decisions that put their health at risk
Examples of inconsistently planned and delivered care include that most of the falls-related incidents occurred with clients who had well-established histories of falls and in most cases medication was a contributing factor. There was often ambiguity regarding which of the healthcare workers had the responsibility and authority to act and what options they had available. Once allocated home care services reached their maximum case managers had little or no authority to increase needed care. Poor documentation and communication in a setting of frequently changing providers often resulted in failure to identify patient deterioration. Typically there was no single person who had a complete overview of the patient.
Lack of an interdisciplinary health care team, like we usually utilize in hospitalized patients, is also problematic. An example they give is a home care patient with multiple comorbidities and multiple medications who develops urinary urgency, possibly related to a change in medication, and then falls during one of many increased trips to the bathroom, suffering a fractured hip. Communication from the primary care provider or pharmacist to the home care workers that might have helped avoid this adverse event did not occur.
Packaging of medication and direction for its use is often problematic for home care patients. Similarly for care-associated equipment there are variations in makes, models, and instructions-for-use that often lead to confusion. Standardization in both areas is much needed.
Lastly, balancing a patient’s right to autonomy, independence and ultimate decision-making against the risk those decisions might put the patient’s safety in jeopardy is difficult. Efforts to provide the patient and informal care givers with the necessary training is critical.
The Doran paper goes on to make a series of recommendations for organizations, policy makers, and researchers. For organizations they recommend offering unpaid caregivers training, ongoing support, counseling and health assessments. They also recommend a focus on implementing policies and procedures to safely manage medication in the HC setting. And, perhaps most important in our mind, they recommend assigning a case manager for each home care client. That case manager should have skills across the continuum of care, be knowledgable across disciplines, and be vested with the authority and responsibility required to ensure the planning and delivery of a consistent quality of safe care and basically act as “a quarterback”. Development of a “transitions checklist” for each home care patient is also a recommendation.
Recommendations for policymakers include developing standard competencies for home support workers, exploring opportunities for increased collaboration between home care and institutional care, building integrated, interdisciplinary healthcare teams to ensure continuity across all transitions, implementing a common electronic chart accessible by all caregivers from all sectors, expanding the use of electronic reporting and communication tools, and standardizing medication packaging and equipment. Also, because they had noted that patients with COPD often ran out of oxygen they recommended that restrictions on supply of portable oxygen be lifted.
For researchers they recommend development of a national set of reportable adverse events and development and standardization of policies specific to the process and timing for risk assessments.
One of the problems we commonly see in the US in the home care setting is that one physician (often a hospitalist or hospital-based specialist) may make the initial referral to home care but never again actually care for that patient. The patient’s primary care physician often gets subsequent calls and questions about that patient and he/she may not have even seen the patient in the interim. For that reason we usually recommend that the hospitalist make a physician-to-physician contact with the PCP at discharge or that the PCP actually be invited to call in to the interdisciplinary meeting occurring in preparation for hospital discharge.
The lack of integration or interoperability between medical records in the hospital and ambulatory setting and the home care agency has been another major problem in the US. The development of RHIO’s and HIE’s is a first step but full integration is a long way off.
Home care in the US is plagued by the same high turnover rates and lack of continuity found by the Canadian researchers. In addition, in many areas hours of availability of home care workers is a major issue. And in rural areas home care availability is considerably less than in urban areas.
Access to homes may be problematic. As in the Canadian studies, we often see that patients are reluctant, for a variety of reasons, to let strangers enter their homes. That is where we have found that use of the community health worker may be beneficial. Such workers are lay people who are well-known and trusted in their communities who may be able to improve communication between patients and the medical community.
In the US, the move to develop accountable care organizations (ACO’s) has prompted groups to integrate care across the entire continuum. Yet one of the weakest links we have seen in accountable care organizations has been home care. Often home care is not considered a core service of the ACO and is “farmed out” or contracted out to existing home care agencies. The result is often a lack of common incentives.
Particularly in recent years in the US there has been a downturn in the financial viability of home care agencies and a decline in reimbursement for many home care services. So many are getting out of the home care business as a business per se. Yet from a system perspective (eg. ACO) the reimbursements for individual home care services is of lesser importance compared to the potential savings from avoiding adverse events that might lead to emergency department visits or hospital admissions.
Commentaries from readers in the Toronto, Ontario media after publication of the Canadian reports are also very revealing and help point out some of the likely root causes contributing to adverse events in the home care setting (Goar 2013, Readers’ Letters 2013). They note that that home care workers generally earn 5-6 dollars less than similar workers based in hospitals. They often also lack pensions and other benefits. They also often have sparse work hours and may not be paid for time spent between clients.
We find particularly compelling the arguments about salary levels for home care workers. The average payments for nurses and aides providing home care is generally less than that paid in hospital or office or other traditional ambulatory settings. In addition, home care workers often are part-time. Having pay scales and working conditions more conducive to avoiding the high turnover rates might be cost-effective in the long run if it helped avoid unnecessary visits to the emergency department or unnecessary hospitalizations.
We think you’ll find these 3 excellent Canadian studies to be extremely helpful if you are already an ACO or are contemplating becoming one. You have to recognize the key role that home care plays in the big picture. Even if you are not considering becoming an ACO you need to recognize the risks for your patients in home care and what you can do to mitigate those risks. Lastly, hospitals at risk for readmission penalties need to recognize that adverse events related to home care are a major factor in readmissions.
Sears N, Baker GR, Barnsley J, et al. The incidence of adverse events among home care patients. Int J Qual Health Care 2013; 25:16–2
Blais R, Sears NA, Doran D, et al. Assessing adverse events among home care clients in three Canadian provinces using chart review. BMJ Qual Saf doi:10.1136/bmjqs-2013-002039 (published online first 4 Jul 2013)
Doran D, Blais R, et al. Safety at Home. A Pan-Canadian Home Care Safety Study. Canadian Patient Safety Institute 2013
Goar C. Ontario home care more hazardous than families told: Goar. Research by two professors shows that home care is less safe than institutional elder care. Toronto Star 2013; July 5, 2013
Readers’ Letters. Home care safer for most than hospital. Toronto Star 2013; July 10, 2013
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