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Millions of older Americans with multiple chronic conditions use home health care (HHC) services each year, and that number is growing, according to the 2021 Medicare Payment Advisory Commission report. Those patients are often at increased risk of acquiring infections, researchers found in an analysis of the data published in the journal Research in Nursing & Health.
Over the years, our research team at Columbia University School of Nursing has conducted studies to understand infection prevention and control in the HHC setting. From 2017-2021, we led the Infection Prevention in Home Health Care (InHOME) study with funding from the National Institutes of Health (NIH).
The study quantified infection-related hospitalizations occurring during episodes of HHC from the Outcomes and Assessment Information Set (OASIS) and Medicare Provider Analysis and Review (MedPAR) data. The study also examined the existing infrastructure and policies of home health agencies (HHAs) and whether those policies help prevent infections among patients at home.
Here are some things we discovered in the process of conducting that study.
Infection-related hospitalizations during home health episodes
By analyzing longitudinal OASIS and MedPAR data, we found that 17% of unplanned hospitalizations during home health episodes were caused by four types of infections:
- respiratory
- urinary tract
- wound site (skin or soft tissue)
- related to an intravenous catheter
Our findings emphasized the prevention and control of infection in the home setting because infections occurring during episodes of HHC were associated with significant 30-day mortality, especially after hospital transfers caused by sepsis.
Pre-pandemic prevention policy and control infrastructure
To better understand existing HHA infection prevention and control policies and procedures, we interviewed HHC staff from agencies across the country from May to November 2018. Several staff members identified infection prevention and control priorities from agency leadership as critical to preventing and reducing infections and infection-related hospitalizations among patients. This leadership support and backing would be vital in the midst of an infectious disease crisis like the COVID-19 pandemic.
We also conducted a national HHA survey from November 2018 to December 2019. Because it was conducted before the COVID-19 pandemic, the survey captures the level of preparedness for an infectious disease crisis. Our results showed that at that time infection prevention and control in the home healthcare environment was suboptimal, and many agencies were not adequately prepared for the pandemic.
Specifically, our findings showed that agency staff charged with infection prevention and control often had many other responsibilities, and more than one-third had no formal infection prevention training. Rural agencies were less likely to have someone in charge of infection prevention and control compared to those in urban areas. Furthermore, agencies reported challenges in collecting and reporting infection data.
We also found that flu vaccination rates among home health care workers were alarmingly low, and that only 26% of agencies required vaccination for work. Low staff vaccination rates are associated with an increased risk of hospitalization for respiratory infections among home health patients. We urge agency leadership to reflect on their experiences with the COVID-19 vaccination mandates and explore effective ways to improve staff influenza vaccination rates.
Finally, about 40% of agencies provided N95 respirators to their clinical staff prior to the pandemic. Rural agencies were significantly more likely to secure these supplies than urban agencies. At the onset of the COVID-19 pandemic, clinical staff in urban health care settings likely had an increased risk of exposure due to suboptimal agency preparedness, compounded by a lack of personal protective equipment and greater reliance on public transportation.
Let’s take a look at some of the current studies being done on home care and infection control.
1. Impact of COVID-19 on Care Transitions and Health Outcomes for Vulnerable Populations in Nursing Homes and Home Health Care Agencies (ACROSS-CARE) Study, 2021-2025.
Building on previous work, our research team was funded by the NIH for the ACROSS-CARE study. In ACROSS-CARE, we will describe how agency infection prevention and control programs have changed in response to the COVID-19 pandemic, particularly among HHAs that serve large segments of vulnerable populations (eg, people of color, rural residents). We will also examine how COVID-19 has disrupted hospital admissions and subsequent discharges to agencies, and determine whether the disruptions have disproportionately affected vulnerable populations. Recruitment of participants for this study is ongoing.
2. Study on prevention of infections in home health care (InHOME-CR), 2021-2026.
Our research team also received funding from the NIH to continue our InHOME study. In the InHOME-CR study, we will use longitudinal national OASIS and Medicare claims data to examine the evolution of HHC infection prevention and control policies and procedures from pre-pandemic to 2024 and their impact on patient outcomes associated with infection, including COVID-19. infection. The findings of the study will raise awareness of the importance of infection prevention and control in home health care among health policy makers and the public. In collaboration with key stakeholders, we will also generate evidence-based recommendations to help healthcare facilities prepare for future public health emergencies. Recruitment of participants for this study is ongoing.
Involving your agency in research
In November, we began contacting agencies to participate in a national survey about existing infection prevention and control policies and procedures and experiences with COVID-19. If you are invited, please contact us with any questions! Also, we are always looking for agencies to pilot research materials. If your agency is interested, please refer to the studio contact emails (see box). Thank you to those agencies that have participated in the past and we look forward to engaging new participants in our studies!
This type of research helps create new knowledge, find solutions to challenges and identify avenues for industry improvement. Researchers often collect data on factual aspects of agencies (eg, types of infection control policies in place, number of staff vaccinated) through surveys, as well as gather experiences through interviews and surveys. Your participation is valuable because your experiences represent those of other agency staff members like yours. The benefits are often not immediate, but the knowledge gained from research will help your agency and others like it in the future.
As part of the InHOME-CR study, we will conduct a Delphi panel exercise with key stakeholders such as experts, leaders, advocates, patients and caregivers. Through this consensus process, clinical and policy recommendations will be developed, refined, and endorsed, resulting in evidence-based infection prevention and control recommendations specific to home health care.
If there is another pandemic
Based on our earlier findings and preliminary data from recent ACROSS-CARE staff interviews, it is clear that US health agencies have strengthened their infection prevention and control capacities and adapted their existing policies/procedures to respond to the COVID-19 pandemic.
However, any strides made in the infection prevention and control infrastructure (which we will quantify with the InHOME-CR 2022 survey) will need to be sustained in order for agencies to effectively respond to the next infectious disease emergency. Agencies would benefit from creating proactive
rather than a reactive environment in terms of infection prevention and control.
We look forward to reporting on the outstanding work agencies have done during the pandemic and creating home health-specific infection prevention and control recommendations so that there is an evidence-based roadmap to follow, whether during normal operations or in an emergency.
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