In summary, there was a substantial 30 day rehospitalization rate among these patients (26%), most of whom had a HF diagnosis (42%) and many rehospitalizations were considered potentially avoidable (34% for the primary diagnosis of HF). From the multivariate analyses, patient factors were the most influential variables with relatively little influence from the geographic and agency factors. Among the patient factors, the number of prior hospitalizations was the strongest factor within each model followed by dyspnea interfering with activity.
The rehospitalization rate of 26% found in this study falls between the national HF registry studies and other large studies that report 20–21% of patients having 30 day rehospitalization rates (Bueno et al. 2010
; Jencks, Williams, and Coleman, 2009
) and the 29% rate from national risk-adjusted reports of hospitalization among Medicare home health care recipients. The Jencks et al and risk-adjusted home health care reports include patients with all diagnoses and conditions versus a heart failure-specific population, suggesting that the HF-specific population is a “classic” condition for experiencing rehospitalization. Thus, a better understanding of and interventions that have an impact on patients with HF may also have an influence on patients with other chronic diseases and conditions (e.g. COPD) although more research would be needed on this.
The patient variables were the strongest factors associated with rehospitalization, regardless of whether the outcome was rehospitalization or time to rehospitalization. There were consistent findings between the models with only differences in the relative order of association with the outcome. The consistency of the results between the models indicates that the substantive influence of the patient variables on rehospitalization rates is where to focus practice and policy interventions.
The strongest factors predictive of rehospitalization were the number of prior hospital stays and dyspnea. While there were other variables that met the statistical significance criteria, the coefficients and hazard ratios were more modest. Related to the number of prior hospital stays, past research has indicated that a greater number of hospital stays is associated with subsequent hospital admissions (Jencks, Williams, and Coleman 2009
; Fonarow 2008
). It is not clear whether this is a function of the patient’s clinical condition (i.e. disease progression or the development of a new problem); physician provider behavior where a provider sends the patient to the hospital with the development of HF symptoms or new problems; patient preference for hospital care when health issues occur; home health care provider behavior that encourages patients to seek hospital care when symptoms occur; or, most likely, some combination of the above. As this was such a strong predictor of rehospitalization, home health care agencies would benefit from having this information as part of their identification of patients who may be a high risk for a rehospitalization. This may not be a challenge if the patient is “known” to the agency from past care episodes but can be difficult to determine for patients who are “new” to the agency. Regardless, the national focus on rehospitalization has identified how difficult the problem is to address. The current demonstration projects focused on the patient-centered medical home and transitional care models (Holland et al. 2005
; Konstam and Greenberg 2009
; Naylor et al. 2004
; Parry et al. 2009
) address some of these issues although how the current home health care system will be integrated into these new models of care has yet to be determined. From a practice perspective, more research into what leads patients into a rehospitalization should inform interventions that may be effective in addressing this national priority.
The primary clinical variable associated with rehospitalization was dyspnea interfering with activity. As dyspnea is a cardinal symptom of HF exacerbation, higher levels of dyspnea interfering with activity would be expected to be associated with more likelihood of rehospitalization. The relationship between increasing levels of dyspnea interfering with activity and rehospitalization were consistent in both models and was not surprising. The etiology for dyspnea, however, is not straightforward as the dyspnea is likely to be influenced by both the disease process and deconditioning associated with inactivity. As well, home health care patients often have multiple diagnoses and conditions so that the dyspnea may be the result of other diagnoses (e.g. chronic lung disease). Our results for the potentially avoidable hospitalizations support this as 32% were identified as having a secondary diagnosis of COPD. Regardless of the etiology, identification of patients with dyspnea and clinical interventions to address dyspnea may be worth further examination.
Visit intensity and its influence on rehospitalization as well as time to rehospitalization may be a result of the home health care provider judgment regarding patient needs where more visits are provided to patients who are more complex to manage (i.e. are more medically fragile, need more medication or self-management instruction or more frequent physical assessment). There is very little research on how home health care staff decide on visit frequency: in some agencies, the decisions are made by the frontline staff whereas in other agencies the decisions are made at a supervisory level. There is some preliminary research that frontloading visits (providing the majority of the planned home health care visits earlier in the episode) are associated with lower rehospitalization rates for patients with HF in one study (Rogers, Perlic, and Madigan, 2007
), although further research has not been done on this topic. Thus the findings of the visit intensity association with longer time to rehospitalization may be a function of some agencies providing more visits earlier in the episode based on patient acuity, or patient need driving more visits for intensive monitoring and follow-up.
Among the geographic and agency factors, only hospital based agencies were associated with time to rehospitalization and less likelihood of rehospitalization in 30 days. The hazard ratio was small but informative when considering that the patient factors are the most likely factors driving rehospitalization. Explanations for this finding are speculative as there is little research on agency differences but may be a function of closer communication with referring providers and more system level approaches (i.e. health system level disease management approaches) to managing HF care by hospital-based agencies. As health care reform measures consider such approaches as bundling payment for hospital and post-acute care, more research on how hospital-based agencies work within their hospital systems may inform practice and research. Our finding is in contrast to the findings of Brega and colleagues (2003)
who found that proprietary agencies had higher visit intensity and shorter lengths of stay while hospital-based agencies had shorter lengths of stay and somewhat shorter visit intensity. The samples were similar (HF as primary diagnosis in the present study while Brega et al included HF or diabetes as the primary diagnoses) so the lack of effect in the present study is primarily attributed to the time difference (Brega’s data collection was in 1998–2000, the same time that the prospective payment system was being implemented in home health care Medicare payment, while the present study used 2005 data). Access to home health care services is not a concern based on the 2010 Medicare Payment Advisory Commission report that indicates 99% of Medicare beneficiaries live in an area served by a home health care agency (Medicare Payment Advisory Commission, 2010
). However, based on the findings from the present study, the issues of concern are not access to home health care services but the persistent rates of rehospitalization. In some ways, the findings are not surprising as HF is a chronic and progressive disease that often requires hospital level care for diuresis and medication titration. While most of the factors identified with rehospitalization are not “actionable” per se, the findings do indicate that home health care agencies and referring providers might use the findings to identify the patients at highest risk for rehospitalization and target services to potentially reduce the rehospitalization rates among the highest risk patients. These targeted services might include telehealth, frontloading visits, prompt physician follow-up, patient education on self-management, and other evidence-based strategies (Bueno et al. 2010
; Jencks, Williams, and Coleman, 2009
; Kane 2011
). The extent to which these interventions are currently implemented in home health care is unknown but, based on the present rates of rehospitalization, there appears to be room for improvement in HF management in home health care and in coordination of care with physicians that may prevent or reduce the rehospitalization rate. It is clear that a “silo” approach where each type of provider focuses only on their own setting of care has not been successful in addressing rehospitalization rates. The extent to which the rehospitalizations were potentially avoidable needs further research within home health care. While there were many rehospitalizations that met the AHRQ criteria, it is not clear what interventions could be implemented within home health care to reduce these events.
For care coordination, recent policy changes as part of the 2010 Affordable Care Act may have a positive influence. Notably, a CMS policy change for Medicare home health care to be implemented in 2011 requires a face-to-face physician encounter within 90 days prior to or within 30 days following the start of home health care. This policy change requires the physician or other provider (physician assistant or nurse practitioner) to certify that the patient meets the homebound requirement and indicate the patient-specific need for skilled services. For patients who have been in the hospital, a hospitalist may provide this certification. There is research by Wolff and colleagues (Wolff et al. 2009
) reporting that more extensive physician involvement (through a process known as management and evaluation of the care plan) was associated with a higher likelihood of home health care patients being discharged from services and remaining at home (versus being discharged with a hospital stay). Thus, this policy change may improve care coordination between home health care staff and the ordering physician, which often has been anecdotally reported as a paper trail where the physician simply signs the paperwork versus true care coordination where the physician and home health care agency staff work together.
Another factor reported anecdotally as interfering with care coordination for home health care is the hospitalist-primary care physician relationship where the primary care physician may not have seen the patient following a hospital stay prior to the development of a medical problem. Depending on the health care system, the primary care physician may not have easy access to the hospital discharge summary from the hospitalist. If the patient develops symptoms of HF exacerbation or a new problem within a short time frame following the hospital discharge and prior to seeing the primary care physician, the primary care physician is understandably reluctant to provide additional home health care orders that would delay rehospitalization (i.e. changes in medication doses). Thus there are system and policy issues interfering with care coordination that are outside the control of the home health care agency. There are, however, effective care management approaches that have been identified (as noted above) that can be used. Addressing this thorny and complex issue of rehospitalization will take concerted and coordinated effort.
There are a number of limitations to the study. First, we cannot compare those who used home health care with those HF patients who do not use home health care. While our results for rehospitalization rates suggest our patients are representative of the larger HF population, we also recognize the complexity of the decision in how patients are admitted for a rehospitalization and that home health care patients are likely to be different (i.e. sicker, more proactive in seeking assistance at home). Second, we cannot claim that the variables identified are causally related to rehospitalization although we do have associations that we think are worth further exploration. We recommend instrumental variable (IV) analysis in future research to address these issues of endogeneity. Without such an approach, our estimates are likely to be biased and suggestive of causal relationships that may not be found with an IV approach. Third, there are remaining unknown influences among the variables used to predict rehospitalization, particularly visit intensity and type of provider that merits further investigation. Finally, the use of clinical and administrative databases does not sufficiently represent all the variables of interest for the complex issue of rehospitalization. Additional variables such as the severity of illness during hospitalization or the use of HF-recommended medications are important in a better understanding of the phenomenon.
In conclusion, there are current policy and practice challenges to addressing the persistently high rates of rehospitalization among patients with HF. Health policy changes, both current and expected, may positively influence the rates although there remains much uncertainty regarding the necessity of such care and for whom it is most beneficial.