Teddy bear in mask with sanitizer
by Jingjing Shang

Millions of older Americans with multiple chronic conditions use home health care (HHC) services every year, and that number is growing, according to a 2021 Medicare Payment Advisory Commission report. Those patients are often at increased risk of acquiring infections, researchers found in a data analysis published in the journal Research in Nursing & Health.

Over the years, our research team at the Columbia University School of Nursing has conducted studies to understand infection prevention and control in the HHC environment. From 2017-2021, we ran the Infection Prevention in Home Health Care (InHOME) Study with funding from the National Institutes of Health (NIH).

The study quantified infection-related hospitalizations that occur during HHC episodes from Outcome and Assessment Information Set (OASIS) and Medicare Provider Analysis and Review (MedPAR) data. The study also examined existing infrastructure and policies at home health agencies (HHAs) and whether those policies help prevent infections among home health patients.

Here are some of the things we discovered in the process of conducting that study.

Infection-Related Hospitalizations During Home Health Episodes
By analyzing longitudinal OASIS and MedPAR data, we found that 17% of unplanned hospitalizations during home health episodes were due to four types of infections:

  • respiratory
  • urinary tract
  • wound site (skin or soft-tissue)
  • intravenous catheter-related

Our findings emphasized  infection prevention and control in the home environment because infections occurring during HHC episodes were associated with substantial 30-day mortality, particularly following hospital transfers caused by sepsis.

Pre-Pandemic Prevention Policies & Control Infrastructure
To further understand existing infection prevention and control policies and procedures at HHAs, we interviewed HHC staff from agencies nationwide from May to November 2018. Several staff members identified infection prevention and control prioritization by agency leadership as crucial to preventing and reducing infections and infection-related hospitalizations among patients. This leadership support and buy-in would be vital in the midst of an infectious disease crisis like the COVID-19 pandemic.

We also conducted a nationwide survey of HHAs from November 2018 to December 2019. Since it was conducted before the COVID-19 pandemic, the survey captures the preparedness level for an infectious disease crisis. Our results indicated that, at that time, infection prevention and control in the home health setting was suboptimal, and many agencies were not adequately prepared for the pandemic.

Specifically, our findings indicated that agency staff in charge of infection prevention and control often had many other responsibilities, and over one-third had no formal training in infection prevention. Rural agencies were less likely to have anyone in charge of infection prevention and control compared to those in urban areas. Furthermore, agencies reported challenges in collecting and reporting infection data.

We also found that influenza vaccination rates among home health staff were alarmingly low, and only 26% of agencies required vaccination for work. Low staff vaccination rates are associated with an increased risk of respiratory infection-related hospitalizations among home health patients. We urge agency leadership to reflect on their experiences with the COVID-19 vaccination mandates and explore effective ways to improve staff flu vaccination rates.

Lastly, about 40% of agencies provided N95 respirators to their clinical staff before the pandemic. Rural agencies were significantly more likely to provide those supplies than urban agencies. At the beginning of the COVID-19 pandemic, clinical staff at urban HHAs likely had increased risk of exposure due to suboptimal agency preparedness, which was compounded by personal protective equipment shortages and more reliance on public transportation.

Let’s take a look at some of the current studies being done on homecare and infecton control.

1. Impact of COVID-19 on Care Transitions & Health Outcomes for Vulnerable Populations in Nursing Homes and Home Healthcare Agencies (ACROSS-CARE) Study, 2021-2025
Building upon prior work, our research team was funded by NIH for the ACROSS-CARE study. In ACROSS-CARE, we will describe how agency infection prevention and control programs have changed in response to the COVID-19 pandemic, specifically among HHAs serving large proportions of vulnerable populations (e.g., people of color, rural residents). We will also examine how COVID-19 disrupted hospital admissions and subsequent discharges to agencies, and determine if the disruptions disproportionately affected vulnerable populations. Participant recruitment for this study is ongoing.


2. Infection Prevention in Home Health Care (InHOME-CR) Study, 2021-2026
Our research team also received funding from NIH to continue our InHOME study. In the InHOME-CR study, we will use longitudinal national OASIS and Medicare claims data to examine the evolution of HHC infection prevention and control policies and procedures from pre-pandemic to 2024 and their impact on infection-related patient outcomes, including COVID-19 infection. The study findings will raise awareness of the importance of infection prevention and control in home health care among healthcare policymakers and the public. By collaborating with key stakeholders, we will also generate evidence-based recommendations to help HHAs prepare for future public health emergencies. Participant recruitment for this study is ongoing.

Getting Your Agency Involved in Research
In November, we started contacting agencies to participate in a nationwide survey about existing infection prevention and control policies and procedures and COVID-19 experiences. If you get invited, please contact us for any inquiries! Also, we are always looking for agencies to pilot research materials. If your agency is interested, please reach out to the study contact emails (see box). Thank you to those agencies who have participated in the past and we look forward to engaging new participants in our studies!

This kind of research helps generate new knowledge, find solutions to challenges, and identify avenues for industry improvement. Researchers often collect data about factual aspects of agencies (e.g., types of infection control policies in place, number of vaccinated staff) through surveys, as well as gather experiences through interviews and surveys. Your participation is valuable because your experiences represent those of staff members at other agencies like yours. The benefits are often not immediate, but knowledge gained from the research will help your agency and others like it in the future.

As part of the InHOME-CR Study, we will conduct a Delphi panel exercise with key stakeholders such as experts, leaders, advocates, patient and caregivers. Through this consensus process, clinical and policy recommendations will be developed, refined and endorsed, resulting in data-driven, evidence-based infection prevention and control recommendations that are specific to home health care.

If There’s Another Pandemic
Based on our prior findings and preliminary data from recent ACROSS-CARE interviews with staff, it is clear that U.S. home health agencies have strengthened their infection prevention and control capacity and adjusted their existing policies/procedures to respond to the COVID-19 pandemic.

However, any strides that have been made with infection prevention and control infrastructure (which we will quantify with the 2022 InHOME-CR survey) will need to be maintained for agencies to respond effectively to the next infectious disease emergency. It would benefit agencies to create a proactive
rather than reactive environment regarding infection prevention and control.

We look forward to reporting on the remarkable work agencies have done during the pandemic and creating home health-specific infection prevention and control recommendations so that there is an evidence-based road map to follow, whether during normal operating periods or an emergency.

Jingjing Shang, Ph.D., RN, OCN, FAAN, is a professor of nursing at the Columbia University School of Nursing in New York. An experienced nurse health services researcher, she studies infection prevention and control in the HHC setting.