Date of Award

2014

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Graduate Group

Nursing

First Advisor

Kathryn H. Bowles

Abstract

Background and aims: Millions of Americans are discharged from hospitals to home health every year and about third of them return to hospitals. A significant number of rehospitalizations (up to 60%) happen within the first two weeks of services. Early targeted allocation of services for patients who need them the most, have the potential to decrease readmissions. Unfortunately, there is only fragmented evidence on factors that should be used to identify high-risk patients in home health. This dissertation study aimed to (1) identify factors associated with priority for the first home health nursing visit and (2) to construct and validate a decision support tool for patient prioritization. I recruited a geographically diverse convenience sample of nurses with expertise in care transitions and care coordination to identify factors supporting home health care prioritization. Methods: This was a predictive study of home health visit priority decisions made by 20 nurses for 519 older adults referred to home health. Variables included sociodemographics, diagnosis, comorbid conditions, adverse events, medications, hospitalization in last 6 months, length of stay, learning ability, self-rated health, depression, functional status, living arrangement, caregiver availability and ability and first home health visit priority decision. A combination of data mining and logistic regression models was used to construct and validate the final model. Results: The final model identified five factors associated with first home health visit priority. A cutpoint for decisions on low/medium versus high priority was derived with a sensitivity of 80% and specificity of 57.9%, area under receiver operator curve (ROC) 75.9%. Nurses were more likely to prioritize patients who had wounds (odds ratio [OR]=1.88), comorbid condition of depression (OR=1.73), limitation in current toileting status (OR= 2.02), higher numbers of medications (increase in OR for each medication =1.04) and comorbid conditions (increase in OR for each condition =1.04). Discussion: This dissertation study developed one of the first clinical decision support tools for home health, the "PREVENT"- Priority for Home Health Visit Tool. Further work is needed to increase the specificity and generalizability of the tool and to test its effects on patient outcomes.

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