Background: Academic medical centers and other quaternary hospitals struggle with capacity challenges that manifest in longer ED wait times, delayed or cancelled elective surgical procedures, and delayed transfers from community hospitals[1]. The Hospital at Home model is an obvious and elegant solution to increase capacity[2], but its nationwide implementation has been limited due to lack [...]

Background: Despite recent advancements in the medical management of acute and chronic Heart Failure (HF), smooth transitions of care for patients hospitalized with HF remain elusive for most health care systems. Use of home health services and other ancillary services have been promoted in recent years as a means of reducing readmission rates among HF [...]

Background: Communication between referring Veterans Health Administration (VHA) facilities and home health care agencies in the community is imperative for comprehensive care for Veterans. However, to date little is known about communication during care transitions from VHA facilities to home health care. The purpose of the present study is to conduct a preliminary exploratory survey [...]

Background: Communication is critical to high-quality care transitions, yet little is known about the quality of information transfer from the hospital to home health care (HHC) setting. We performed a cross-sectional survey of HHC nurses and staff to evaluate their perspective on the completeness of medical information transferred from hospitals to HHC agencies in Colorado. [...]

Background: In 2012, nearly one-third of older adults (>65 years) with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between healthcare settings is frequently inadequate. We sought to describe care coordination challenges and potential solutions from the perspective of HHC nurses. Methods: We conducted a qualitative descriptive [...]

Background: In an increasingly digital world, there are still many manual and paper based workflows in healthcare. Paper scripts are an area that is prevalent and is the gold standard for certain prescribing behaviors. Paper scripts have numerous challenges, they can be lost, are difficult to track, and physically have to be delivered to the [...]

Background: Communication between home health care agencies and referring facilities is important for comprehensive care for patients. Yet, both home health care providers and hospitalists feel that this communication is frequently lacking. Purpose: To implement weekly teleconferences to discuss patients recently discharged from the Rocky Mountain Regional VA Medical Center (RMR VAMC) who are initiating [...]

Background: Early introduction of palliative care for medically complex patients can improve patient-centered outcomes. Yet, little is known about how to address these issues as patients are cared for by multiple teams in multiple care settings between hospital, home health care and primary care. Here we highlight clinician perspectives about introducing palliative care in the [...]

Background: Since early 2020, the entire world has been enveloped within the COVID-19 pandemic. As research surrounding healthcare processes during the pandemic has surged, little has been studied regarding the pandemic’s impact on home-healthcare agencies (HHA). Previous research during the 2009 H1N1 pandemic found varied pandemic preparedness among HHAs. Therefore, this study aims to understand [...]