Growing Prevalence of Complex Chronic Illness in Older Americans

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Major Policy and Practice Changes in Home Care System, New Study Finds

— Multiple Chronic Conditions and Cognitive Impairment in Aging Home Care Patient Population

Presents Challenges for Home Care Agencies and Government Programs —

New York, NY – Multiple chronic health conditions and some degree of cognitive impairment are common in home care patients aged 65+ and lead to longer periods of home health care use, according to a new study from the VNSNY Center for Home Care Policy & Research. And, for each additional chronic condition, there is an increase in the number of days that older adults spend in home care, the investigators report in the current issue of the Journal for Healthcare Quality. 


In the first study to examine how chronic health conditions and cognitive impairment impact the duration of home health care use, researchers confirmed that the vast majority of home health care patients are 65 or older (87 percent).  Nearly 39 percent of home care patients are 75 to 85 years old, and 22 percent are age 85 or older. 


“People are living longer, yet many are living with one or more chronic diseases and decline in cognitive functioning, which has major implications for home health care agencies, clinicians and paraprofessionals,” said Christopher Murtaugh, Ph.D., Principal Investigator and Associate Director of the VNSNY Center for Home Care Policy & Research. 


“Clinically complex patients present health care planning and management challenges for home health care agencies.  More research-based evidence specific to older home care patients is necessary to help home care agencies effectively improve health outcomes for the patients they serve,” said Dr. Murtaugh.


Three quarters of home health care patients age 65+ were reported to have at least one chronic condition that contributes to the need for home health care upon admission to home health care, one quarter had two chronic conditions, and 17 percent had three or more, according to the study.  The top five chronic illnesses were hypertension (30 percent); diabetes (21 percent); arthritis and musculoskeletal diseases (16 percent); heart failure (13 percent); and chronic pulmonary disease (12 percent).


The researchers found that the more chronic health conditions patients had, the more days of home care they used.  For example, patients who had hypertension plus three or more other chronic conditions, such as diabetes, heart disease, and arthritis, had nearly 22 days more (78 days) of home care on average than patients with only hypertension (56 days).  In hospital and other inpatient settings, “length of stay” is typically used as a measure of resource use.


When older home health care patients had cognitive impairment and at least one chronic condition, the length of their home health care stay also increased. For example, patients with hypertension and cognitive impairment used home health care for 20 days longer than patients without cognitive impairment. 


Over a third (36 percent) of home care patients had some degree of cognitive impairment, according to the study.  “Mild” impairment was found in nearly a quarter of the patients (24 percent), and “moderate to severe” impairment was reported for 13 percent of home care patients.  Cognitive impairment has significant implications for home health care patients’ clinical outcomes and their ability to manage their own care.


On average, older adults used home health care for 53 days. The majority (81 percent) of the home health care patients age 65+ were discharged from home care within 60 days of admission. Only 1 percent of the patients received home care for more than a year. 


The study’s authors report that their findings support the critical need to address two key policy and practice issues to improve home health care for patients with clinically complex conditions:

Chronic conditions and cognitive function should be accurately assessed and recorded on the required Centers for Medicare & Medicaid’s (CMS) Outcome and Assessment Information Set (OASIS). Consideration should be given to incorporating a chronic disease checklist into the OASIS admission assessment and including the new methods for rigorously assessing mental status currently being tested in a CMS demonstration.
Better tools are needed to provide effective care to people with multiple chronic conditions and cognitive impairment. Clinical practice guidelines and evidence-based practice recommendations must address the complexity associated with multiple chronic conditions, especially in older adults. The nation’s current focus on chronic health conditions in the health care system should be paralleled in quality improvement and quality assurance efforts in home health care.

To conduct the study, researchers determined the ages of home health care patients, using OASIS data on 6.5 million home care discharges from Medicare-certified home health care agencies from 2004 through 2005.  Once they determined the ages of home care patients upon admission, the researchers used just the data on 5.6 million discharges for patients age 65 and older. 


“Complexity in Geriatric Home Healthcare,” by Christopher Murtaugh, Ph.D., Timothy Peng, Ph.D., Annette Totten, Ph.D., and Beth Costello, M.A., of the VNSNY Center for Home Care Policy & Research; Stanley Moore, B.S., Independent Contractor; and Hakan Aykan, Ph.D., Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, was published in the Journal for Healthcare Quality March/April 2009. [The views expressed in the paper are those of the authors and do not necessarily represent the views of the organizations where they are employed.]


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