• Madeline R Sterling, Nicola Dell, Benedetta Piantella, Jacklyn Cho, Harveen Kaur, Emily Tseng, Fabian Okeke, Mikaela Brown, Peggy B K Leung, Ariel F Silva, Amy L Shaw, and Lisa M Kern.
• Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, 420 E 70th Street, New York, NY, 10021, United States. mrs9012@med.cornell.edu.
• J Gen Intern Med. 2020 Jun 1; 35 (6): 1721-1729.

BackgroundReadmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal.ObjectiveWe aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist.Design And ParticipantsIn this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018.ApproachUsing a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image.Key ResultsStudy participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step.ConclusionsOur findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

12 keywords...

hide…