Care Continuity Likely Lowers Rehospitalization Risk for Home Health Patient with Dementia

Continuity of care — or pairing the same medical professionals with the same patients — is incredibly important in the delivery of home health services.

It’s even more essential when caring for people living with dementia, a new study suggests.

If home health patients with dementia are seen by the same clinicians visit after visit, they’re substantially less likely to be readmitted to hospital, a team of researchers from the NYU Rory Meyers College of Nursing found. The group published their findings in the journal Medical Care.


“When it comes to how we can do a better job of delivering home health care to people with certain needs, one way, our study shows, is by being more consistent when sending a nurse to visit a patient,” Chenjuan Ma, an assistant professor at NYU Meyers and the study’s lead author, told Home Health Care News. “There’s potentially a great benefit if we can improve this consistency in assigning the same nurse to the same patient during their care.”

To study the benefits that care continuity has on the home health dementia population, Ma and her colleagues analyzed several years’ worth of data from a large, urban nonprofit provider located in New York. That analysis included OASIS data, administrative records, human resources information and more.

Teaming up with the provider — one of the largest in the country — gave the researchers much deeper insight than Medicare claims data alone, Ma explained.


“This is really a collaboration with, I think, the largest nonprofit home health agency in the United States,” Ma said. “We were able to look into a lot of detailed data that’s usually not available via your typical claims data.”

In total, the analysis looked at 23,886 older adults with dementia who received home health services following a hospitalization.

“We’ve seen the importance of home health care, especially during COVID,” Ma said. “Home health care services are the future for our aging population.”

Roughly one in four of the older adults with dementia in the study experienced a rehospitalization while on home health services, the study determined. Infections, respiratory problems and heart disease were among the most common readmission factors.

Continuity of care varied greatly from patient to patient, with 8% of patients having no continuity of care at all, meaning they had a different nurse for each visit. Meanwhile, 26% of patients received all their visits from the same nurse.

After controlling for other clinical risk factors and the intensity of services, the researchers found that people with dementia receiving low or moderate continuity of care were 30% to 33% more likely to be readmitted to the hospital.

There could be several explanations for that, Ma said.

For one, pairing the same clinicians and patients can help establish a better level of trust and transparency, she said. Additionally, having the same clinician going into the home could lead to better communication with patients’ families, which could, in turn, lead to improved care.

“They get to know the risks of their clients, and they get to know their families,” Ma said. “They can become really familiar and develop trust. With consistency, they also can be able to calmly detect if there are any changes or decline in their patient’s behavior or symptoms.”

Somewhat surprisingly, the researchers found that the higher the visit intensity was, the lower the continuity of care was. In other words, the more hours of care provided, the more likely it was for a patient to be seen by different clinicians.

That could be explained by two possibilities, Ma said.

“When you have high continuity of care, you have nurses who really know the patients, the clients, so well,” she said. “Each time they visit their clients, they are able to maybe deliver care more efficiently.”

Alternatively, patients who need more hours and a higher intensity of care may simply require more clinicians to get the job done.

“When the number of visits increases to certain level, you may have to involve more providers,” Ma said.

To improve continuity of care, the researchers recommend addressing the shortage of home health care nurses, improving care coordination and embracing different technologies. That can include using telehealth and tools to improve scheduling, for example.

In 2018, more than 5 million Medicare beneficiaries received home health care. Of those, about 1.2 million were living with Alzheimer’s disease and related dementias.

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