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Phone checklist can help detect changes in clinical status among home care recipients

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BOSTON (August 11, 2016) — A simple phone checklist can help detect telltale changes in the health status of people receiving nonmedical home care, according to the findings of a pilot study led by investigators at Harvard Medical School.

Results of the research, published online Aug. 10 in the Journal of the American Geriatrics Society, are based on a program that requires home-care aides to record changes in status during a telephone clockout at the end of each shift.

The research was conducted in collaboration with Right at Home, a senior home care provider, and ClearCare, a company that provides a software platform for homecare agencies.

Analysis of the data captured over a six-month period across 22 Right at Home agencies reveals that changes in clinical status are relatively common — occurring in 2 percent of all caregiver shifs and affecting, on average, 2 percent of recipients. The majority of changes were in behavior (17 percent) and skin condition (16 percent), followed by changes in eating or drinking behavior (14 percent) and ability to stand or walk (9 percent).

The results, researchers said, underscore the potential of real-time monitoring systems to spot problems and avert complications before they escalate enough to require hospitalization. Indeed, over the course of the six-month trial, 14 percent of the home-care recipients were hospitalized.

Recipients of non-medical home care often have chronic health conditions that lead to hospitalizations, some of which may be preventable.

The research team cautioned that whether the real-time monitoring system could, in fact, prevent hospitalizations and reduce cost of care remains unknown. That, they said, is the subject of an ongoing randomized trial across 400 home-care locations in the United States. However, the research team said, the fact that a basic phone questionnaire could capture important indicators in clinical status points to the value of harnessing simple technologies to monitor those receiving care at home.

"Millions of elderly Americans receive supportive home-care services each year, and many of them require frequent hospitalizations, so we set out to determine whether a simple real-time checklist could help improve outcomes and lower health care spending," said study leaderDavid Grabowski, Ph.D., professor of health care policy at Harvard Medical School. "Our results are a first step to answering that question."

Under the pilot program, home caregivers were required to do a phone clock out at the end of their shifts. Caregivers receive an automated phone message prompting them to report any changes in health status. The message included a list of questions pertaining to changes in mental, neurologic, gastrointestinal, urinary and other indicators. Any changes reported via the automated system were immediately dispatched to a manager at the home-care agency office for further assessment and triage. The care manager determined whether the condition required closer monitoring, a change in care, a call into the doctor's office or all of the above. The idea, researchers said, is to prevent complications before they become grave enough to require hospitalization.

Patients who may benefit the most include those with chronic conditions such as diabetes, neurologic disorders or cardiovascular disease, in whom even seemingly innocuous changes could spell bigger trouble. That theme, researchers said, emerged clearly in a series of interviews with home-care workers. For example, one manager relayed the story of a person with diabetes whose caregiver reported a foot ulcer through the phone-based checklist. Normally, that injury would not have been reported until the end of the week, but because of the prompt alert, the care manager reached out to the patient's nurse, who initiated treatment immediately. One week later, the wound had healed. Sores, wounds and injuries are particularly dangerous in people with diabetes and can lead to rapid decay of tissue and, in some cases, limb amputations.

Frontline caregivers play a critical role in monitoring, reporting and preventing serious complications among patients with chronic conditions, the researchers said. Given that home-care services account for nearly $200 billion in Medicare spending a year, identifying opportunities to improve outcomes, avert complications and reduce overall healthcare spending is vital.

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The work was supported by the Laura and John Arnold Foundation.

Co-investigators from Harvard Medical School included Katie Dean, Laura Hatfield and Anupam Jena.

Competing interests disclosure: Study co-authors David Cristman, Michael Flair, Kylie Kator and Geoff Nudd are employed by Right at Home or ClearCare.

Harvard Medical School has nearly 9,500 full-time faculty working in 10 academic departments located at the School's Boston campus or in hospital-based clinical departments at 15 Harvard-affiliated teaching hospitals and research institutes: Beth Israel Deaconess Medical Center, Boston Children's Hospital, Brigham and Women's Hospital, Cambridge Health Alliance, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care Institute, Hebrew SeniorLife, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear/Schepens Eye Research Institute, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Spaulding Rehabilitation Network and VA Boston Healthcare System.

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Ekaterina Pesheva
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