Agencies invited to help develop best practices, new course to be offered
by Liz Carey
June 15, 2018

Home health agencies (HHA) provide services that are a critical link between acute care and independent residential living, with increasingly complex care being provided. In 2013, about 3.5 million Medicare beneficiaries received HHA services at a cost of $17.9 billion.

Home health is the fastest growing health care sector in the nation because 1) the American population is aging, 2) with bundled payments, discharges from hospitals occur earlier and there are financial incentives for treating patients at home, and 3) most patients prefer to be cared for at home when possible. Indeed, the U.S. Bureau of Labor Statistics predicts that the demand for home health aides will grow 38 percent from 2014 to 2024, which is much faster than the average for all other occupations.

Many older patients at risk for infections are receiving home health care services. One reason for this risk is that care in the home is significantly less controllable than other settings. Resources can vary wildly from person to person across populations. Infection, as a single care factor, connects generally to the availability of resources, self-care skills, personal hygiene and cleanliness in the care environment.

Certain conditions such as diabetic wounds or surgical site healing, and certain services such as parenteral nutrition or tending to bladder and bowel needs, raise the risk of infections. Adding to risk is care provided by informally-trained caregivers, and the reported overuse of antibiotics, which opens the door to antibiotic-resistant infections, such as C. (clostridium) difficile, commonly referred to as "C.diff."

According to a recent article in the American Journal of Infection Control (AJIC), the Centers for Disease Control and Prevention (CDC) determined that antibiotic-resistant organisms are responsible for more than 2 million infections and 23,000 deaths per year in the U.S., at a direct cost of $20 billion. A 2014 report commissioned by former UK Prime Minister, David Cameron, and the Wellcome Trust suggested that without global action, 10 million deaths from antimicrobial resistance (AMR) infections will occur worldwide by 2050. Also in 2014, former President Barack Obama implemented the National Strategy on Combating Antibiotic Resistant Bacteria through Executive Order 13676, followed in March 2015 by release of the National Action Plan for Combating Antibiotic-Resistant Bacteria, which is still rolling out today.                       

Infection prevention and control and antimicrobial stewardship programs aim to keep patients safe and improve outcomes, regardless of where care is delivered. Updated home health conditions of participation (484.70) have emphasized infection prevention and control, specifying that home health agencies maintain and document their infection control program and incidents of infection.

While health care-associated infection (HAI) surveillance programs have focused on facility settings, such as hospitals and long-term care (LTC), little has been studied and collected about infections acquired during the home health care episode.

As a complement to previous work, researchers at Columbia University School of Nursing, in partnership the RAND Corporation and Thomas Jefferson University, recently received funding from the National Institutes of Health (NIH) National Institute of Nursing Research (NINR) (R01NR016865) to conduct a national home health study and develop a body of research about infections acquired while patients are receiving home health care.

Furthermore, the Columbia University School of Nursing study is supplemented with funding from the Alliance for Home Health Quality and Innovation (AHHQI) to explore how value-based purchasing (VBP) and other quality improvement initiatives are impacting home health care agencies.

Infections can be deadly. Hospital admissions stemming from an initial infection are an unwelcome sight for payers and providers, as well as patients and their families. Recent related data from the Columbia Nursing research team shows that 17 percent of unplanned hospitalizations among homecare patients were caused by four types of infections including respiratory, wound, urinary and IV catheter-related infections. Respiratory infection was the second most common reason for unplanned hospitalization.

Jingjing Shang, PhD, assistant professor of nursing at Columbia University School of Nursing and the study's lead investigator said, “We also found that agency-level infection rates varied widely, ranging from 0 to 100 percent with most between 0 to 34 percent. Furthermore, in a survey conducted in two agencies, we found a positive association between home health care nurses’ self-reported infection control compliance and attitudes. It suggested that efforts to improve compliance with infection control practices in home health care should focus on strategies to alter perceptions about infection risk and other attitudinal factors. Our current study will provide a more comprehensive picture of incidence of infections in patients receiving home health care, as well as current infection prevention and control infrastructure and policies in home health agencies.”

The study will also compare the effectiveness of the various infrastructures and policies in preventing infections in home health care, and estimate survival and health care utilization associated with infections in these patients. For more information about the Columbia Nursing study see their website

Creating educational strategies for clinicians, as well as patients and their families, along with the new conditions of participation emphasis, is seen as essential to reducing the rate of infections and communicable diseases, hospitalizations and infection-related deaths.

While infections are considered largely preventable, the CDC offers little specifically where home health is concerned. The Columbia Nursing study will fill this gap in knowledge.

However, the Centers for Medicare & Medicaid Services (CMS) and CDC are collaborating on the development of a new free online training course in infection prevention and control for nursing home staff in the long-term care setting. The new CDC-CMS specialized infection prevention and control training course will be free of charge and available online and on-demand Spring 2019. Completion of this course will provide specialized training in infection prevention and control, according to CMS.

The new infection control training targets the following areas:

  • Infection prevention and control program overview
  • Infection preventionist responsibilities
  • Quality assessment and assurance committee
  • Infection surveillance
  • Outbreaks
  • Hand hygiene
  • Principles of standard and transmission-based precautions Medication and sharps safety
  • Respiratory etiquette
  • Device and wound management
  • Environmental cleaning, disinfection and sterilization
  • Vaccine-preventable respiratory infections and tuberculosis
  • Employee and occupational health considerations
  • Linen management
  • Water management
  • Antibiotic stewardship program
  • Infection prevention and antibiotic stewardship considerations during care transitions

The five elements of a quality assurance and performance improvement (QAPI) may be used to generally implement the framework for improving infection control and overall quality through: design and scope; governance and leadership; feedback, data systems and monitoring; performance improvement projects; and systematic analysis and systematic action.

For long-term care settings, the broader infection control program was effective November 28, 2016. In November 28, 2017, agencies were required to develop an antibiotic stewardship program to combat the growing concern of multi-drug resistant organisms. Phase 3 includes additional components including specialized training is effective November 28, 2019.

Patricia Stone, PhD, Centennial Professor of Health Policy at Columbia University School of Nursing and one of the study investigators said, “Home health care patients may be receiving care in other health care settings, such as outpatient clinics, making attribution of the infection difficult to impossible. Furthermore, for many, the home is becoming the new long-term care setting. Through our study, we may find that home may actually present a lower infection risk than other settings. So, our goal is to describe variations in practice and identify best-practices in infection prevention and quality improvement that everyone can learn from. To do this, we are interviewing home health professionals and will be conducting a national survey to learn more about best practices and their impact on outcomes. With all the changes happening in other sectors and the growth in the home health care industry, we need to understand how best to organize resources and educate workers so that our home health care agencies can provide quality care efficiently.”

The current phase of the study involves interviews with home health professionals. If your agency is interested in study participation, please contact the project manager at ac4192@cumc.columbia.edu or (212) 305–3431.