Home health may improve patient outcomes and lower overall care costs, but it might be working better for white patients compared to minority groups, a recent study has found.

About 12 million people in the United States rely on home health care, often to help manage conditions including diabetes, heart failure, osteoarthritis and hypertension, according to Johns Hopkins Medicine. In post-acute cases, when patients receive in-home care after a hospital stay, home health care has been widely proven to cut rehospitalizations rates and prevent costly ER trips.

That notion holds true, but discrepancies may exist depending on racial and ethnic demographics, according to the study, published in January by the Journal of Applied Gerontology.

“Overall, I think home health care is doing a good job of preventing rehospitalizations and ER visits,” researcher Jo-Ana Chase, an assistant professor at the University of Missouri’s Sinclair School of Nursing, told Home Health Care News. “But there are differences [in rates] by race and ethnicity.”

In their study, Chase and fellow researchers found that home health patients who identified as black or African-American were 45% more likely to visit the ER and 34% more likely to be rehospitalized compared to patients who identified as non-Hispanic whites. Patients who identified as Hispanic also had a higher likelihood of having to go to the ER.

All groups still had lower rates for rehospitalizations and ER trips than the broader population of older adults not receiving home health care.

Findings were based on medical records from the Visiting Nurse Service of New York (VNSNY). Specifically, researchers looked at the records of patients served by VNSNY in New York City between 2013 and 2014. After tossing out cases with incomplete information, the research team was left analyzing outcomes from more than 22,000 patients, looking at rehospitalizations and ER trips separately. All  patients were Medicare recipients age 65 or older who had been hospitalized prior to their home health care episode.

Founded in 1893, VNSNY is the largest not-for-profit home- and community-based health care organization in the country. In 2017, the organization and its roughly 13,200 employees provided care to more than 135,000 New Yorkers.

Individual health factors among patients, such as illness, living arrangements, gender and age, only accounted for a small percentage of the disparity, the study found. In other words, the vast majority of the gap between racial and ethnic groups could not be explained by unique health circumstances from patient to patient.

Past research does offer some possible explanation, however. For example, past research has suggested some minority elders might have difficulty communicating care preferences.

Chase, who plans on further studying the relationship of race and home health care, said she was surprising with “how little our models explained regarding these differences.”

“By controlling or examining for all those factors, our analyses suggest that there are other factors that might better explain these differences we’re seeing,” she said. “I think [the study] is sort of a foundational piece, almost like a starting block.”

Culturally competent workforce

VNSNY was an appealing provider to work with because of its “very diverse patient population,” Chase said.

Nationally, New York was the fifth-most diverse state in the United States in 2017, ranking only behind California, Texas, Hawaii and New Jersey, according to WalletHub. Mirroring that diversity, more than 40% of VNSNY patients last year spoke languages other than English.

That diversity isn’t a challenge for VNSNY, Yvonne Eaddy, the provider’s vice president for clinical operations for the Brooklyn and Staten Island regions, told HHCN. Instead, it’s a real-world opportunity to improve care and further educate caregivers on cultural nuances, Eaddy said.

“Working with this organization, the exposure to different patients from different walks of life, different ethnic background and different cultural backgrounds provides education for the staff,” she said. “It’s a win-win because when you walk into a patient’s home who’s from a different ethnic background, who’s from a different culture, then you learn about that and the things they do, how they manage, and that helps [staff] going forward.”

Eaddy has “not looked at the research data” herself and—like the study—could not entirely explain the reasons behind the higher rates of rehospitalizations and ER visits for patients who identifed as black or African-American and Hispanic. One thing is certain, though, according to Eaddy: All VNSNY nurses work to provide equally effective care regardless of a patient’s race, religion, creed or sexual orientation.

“All of our nurses are trained to be culturally sensitive, culturally competent,” she said. “The care that’s rendered is delivered regardless of ethnicity or gender.”

To avoid readmissions and ER stays, home health providers should educate patients about the importance of having a regular medical follow up and not always seeking care through the emergency department, Eaddy said.

The National Institute of Health and the National Institute of Nursing Research provided funding for the Journal of Applied Gerontology study. Additional support came from the University of Pennsylvania School of Nursing Center for Integrative Science in Aging Frank Morgan Jones Fund.

Moving forward, Chase said she hopes the results of the study could be used to help providers form risk-assessment tools to prepare clinicians and further understand patient risk factors.

“Home health care is doing a great job, but these are just findings that can help us do an even better job,” she said.

Written by Robert Holly