Language Concordant Home Care Visits Reduce 30 Day Readmissions in - - PowerPoint PPT Presentation

Language Concordant Home Care Visits Reduce 30 Day Readmissions in Limited English Proficiency Patients

Allison Squires, PhD, RN, FAAN Sarah Miner, PhD, RN Chenjuan Ma, PhD Penny Feldman, PhD (VNSNY) Simon Jones, PhD (NYU SOM) 2018

Background: Qualifying for Home Health Care

• A newly-diagnosed, change,
• r decline in condition
• Frequent hospitalizations or

emergency room use

• Difficulty leaving the home or

is ‘homebound’

• Teaching Needs: disease

process, injections, I.V. therapy, etc.

Source: https://www.medicare.gov/coverage/home-health-services.html#1334

• Diabetes: newly-diagnosed,

uncontrolled, unable to self- manage, or requiring education

• Therapy Needs: Physical,

Occupational, Nutritional, and Speech

• Unsteady gait, falls, or fractures,

joint replacement recovery

• Medication management needs
• Unhealed wounds requiring

management

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Background: Home Health Care in the US

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Source: 2018 MedPac Report

• Sources of readmissions are not well differentiated

in research (Burke & Ibrahim 2018)

• Home care services can reduce modifiable

readmission risks, but the topic is understudied (Ma

et al 2017)

• Continuity of care (i.e. same nurse seeing the

patient) improves home care outcomes (David & Kim

2018)

• Communication failures between nurses &

physicians contribute to readmission risk (Pesko et al 2018)

Home Care Has the Potential to Reduce 30 Day Readmissions

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Background – Limited English Proficiency Patients

• One in 5 US households

speaks a language other than English at home (Ryan 2013)

• Limited English Proficiency

(LEP) individuals do not speak English well enough to safely and effectively communicate with their health care provider

• LEP patients are accessing

home care services in growing numbers annually

Readmission & LEP Patients in Home Care

• What is known
• Sources of health

disparities in home care are not well understood (Davitt

et al 2015; Narayan & Scafide 2017)

• LEP status is a known risk

factor for hospital readmission, with risk rates varying between 15-25%

(Karliner et al 2010)

• Discharge instructions

rarely come in the language of the patient

(Karliner et al 2012)

• What we need to know
• No studies have specifically

examined LEP readmission risk from home care

• Studies do not differentiate

risk by language preference

• Interpreting modality’s

effects on readmission rates not known

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• To compare the 30-day all cause readmission among LEP patients

recently discharged from the hospital who receive home care services from a language concordant nurse to those who do not.

• Parent Study: A Mixed Methods Analysis of Post-Acute Outcomes

in Limited English Proficiency Home Care Patients (AHRQ R01 HS023593)

Purpose

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• Dates: January 1, 2010 to March 15, 2015
• Outcomes Assessment Information System (OASIS) records
• Visiting Nurse Service of New York (VNSNY) Administrative Data
• VNSNY human resources data for staff reported language skills

Data Sources

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• Sample of 90,421(including English speakers), with 19,654 LEP only
• Inverse probability weighting with a marginal structural model conducted
• Matched for continuity of care factors (e.g. did the same person care for

the patient throughout the episode?)

• As a robustness check, multiple regression model to look at predictive

factors

Methods

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Question 1: Does readmission rate vary by language preference?

• Matching

variables before and after weighting

• Treatment =

English preferred language

0.1 0.2 0.3 0.4 0.5 0.6 0.7

SMD

Unweighted Weighted Limit

Results: Continuity of Care (COC) by Language Preference (Unweighted)

Kruskal-Wallis rank sum test p < 0.001

Better Worse

Adjusting for COC is Important in Home Care When Assessing Readmission Rates & Risk

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ATE = Average Treatment Effect

Readmission rates by patient’s language preference N of Patients Readmitted Readmission Rate 95% CI Overall 87,561 17,097 19.5% 19.3% - 19.8% English 66,079 12,567 19.0% 18.7% - 19.3% Spanish 17,656 3,824 21.7% 21.1% - 22.3% Chinese 1,721 278 16.2% 14.4% - 17.9% Korean 341 56 16.4% 12.6% - 20.5% Russian 1,764 372 21.1% 19.2% - 23.0% Kruskal-Wallis chi-squared = 37.957, p-value = 7.232e-10

Results: Language Preference Other Than English Affects Readmission Rates from Home Care

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• It's complicated.
• Explanations from the qualitative data (73 LEP patients, 35 home

care staff):

• Patients request LC providers and VNSNY tries to accommodate
• Some, but not all, managers make staff assignments based on

language skills

• Staff who speak other languages frequently take on extra assignments
• utside their service area

Question 2: Does a language concordant nurse reduce the risk for readmission?

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Results from Adjusted Data

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• 6.00%
• 5.00%
• 4.00%
• 3.00%
• 2.00%
• 1.00%

0.00% 1.00% 2.00% 25% 50% 75% 100%

ATE Language Concordance

ATE language concordance on of Re-hospitalization

Odds of Rehospitalization Depends on a Combination of COC and LC Nurses

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0.88 0.9 0.92 0.94 0.96 0.98 1 1.02 1.04 LowCOC, Low LngC Reference (n=9182) Low COC, High LangC (n=547) High COC, Low Lang C (n=7742) High COC, High Lang C (n=2183)

Odds Ratio of Rehospitalization

• If we control for COC, LC visits need to reach 90% to reduce

readmission.

• Logistic regression with 4 groups says:
• Just language concordance has no effect on readmission rate
• Having COC has an effect on readmission rate
• Having both COC and LC is most effective in reducing readmission rate
• Risk for reverse causality due to how managers assign staff

(confirmed by qual data)

Summary of Results

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• Single site, urban study, long organizational experience with LEP patients
• Assumption that there are no unobserved confounders, but plausible
• nes do exist
• Challenging disentangle the impact of COC and LC
• Data on Spanish speakers may largely apply to Puerto Rican and

Dominican populations due to NYC demographics

• “Chinese” classification in VNSNY system does not differentiate by

dialect, so outcomes between Mandarin, Cantonese, and other dialect speakers not differentiable

Limitations

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• Readmission risk from home care is differentiated by patient

language preference

• Continuity of care combined with language concordant visits may
• ffer best intervention for reducing readmission risk in LEP

patients

• But US workforce demographics do not match demand for LC services
• Based on the data, does telephone interpretation really appear to

be effective in home health care?

Discussion

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Acknowledgements

• NYU & Other Study

Team Members

• Eva Liang
• Gavin Arneson
• Maichou Lor
• Gary Yu
• Research Assistants
• Consultant: Liz Jacobs,

MD, MPAA

• VNSNY
• Melissa Trachtenberg
• Penny Feldman
• Yolanda Barron Vaya
• Sridevi Sridharan
• VNSNY staff
• Funding:
• AHRQ R01 HS023593

Allison Squires, PhD, RN, FAAN aps6@nyu.edu

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doi:10.1001/jama.2017.21884.

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Res Gerontol Nurs. 2015;8(3):119-129. doi:10.3928/19404921-20150219-01.

• Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine
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Rates and Estimated Hospital Expenditures for Patients With Limited English Proficiency. Med Care. 2017;55(3):199-206. doi:10.1097/MLR.0000000000000643.

• Ma C, Shang J, Miner S, Lennox L, Squires A. The Prevalence, Reasons, and Risk Factors for Hospital Readmissions Among Home

Health Care Patients: A Systematic Review. Home Health Care Manag Pract. November 2017:108482231774162. doi:10.1177/1084822317741622.

• Napoles AM, Santoyo-Olsson J, Karliner LS, Gregorich SE, Perez-Stable EJ. Inaccurate language interpretation and its clinical

significance in the medical encounters of Spanish-speaking latinos. Med Care. 2015;53(11). doi:10.1097/MLR.0000000000000422.

• Narayan MC, Scafide KN. Systematic Review of Racial/Ethnic Outcome Disparities in Home Health Care. J Transcult Nurs. March

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References

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