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Two-thirds of older adults have multimorbidity (MM), or co-occurrence of two or more medical conditions. Mild cognitive impairment (CI) is found in almost 20% of older adults and can lead to further cognitive decline and increased mortality. Older adults with MM are the primary users of home health care services and are at high risk for CI development; however, there is no validated cognitive screening tool used to assess the level of CI in home health users. Given the prevalence of MM and CI in the home health setting, we conducted a review of the literature to understand this association. Due to the absence of literature on CI in home health users, the review focused on the association of MM and CI in community-dwelling older adults. Search terms included home health, older adults, cognitive impairment, and multimorbidity and were applied to the databases PubMed, CINAHL, and PsychInfo leading to eight studies eligible for review. Results show CI is associated with MM in older adults of increasing age, among minorities, and in older adults with lower levels of education. Heart disease was the most prevalent disease associated with increased CI. Sleep disorders, hypertension, arthritis, and hyperlipidemia were also significantly associated with increased CI. The presence of MM and CI was associated with increased risk for death among older adults. Further research and attention are needed regarding the use and development of a validated cognitive assessment tool for home health users to decrease adverse outcomes in the older adult population.

Information does not yet exist on the characteristics and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) who are discharged to the home setting. Using rich data from home health care (HHC), the authors describe characteristics of COVID-19 survivors upon admission to HHC, the home visits they received, and the extent of recovery among those discharged from HHC. They also profile the risk factors associated with rehospitalization and death., Background: Little is known about recovery from coronavirus disease 2019 (COVID-19) after hospital discharge. Objective: To describe the home health recovery of patients with COVID-19 and risk factors associated with rehospitalization or death. Design: Retrospective observational cohort. Setting: New York City. Participants: 1409 patients with COVID-19 admitted to home health care (HHC) between 1 April and 15 June 2020 after hospitalization. Measurements: Covariates and outcomes were obtained from the mandated OASIS (Outcome and Assessment Information Set). Cox proportional hazard models were used to estimate the hazard ratio (HR) of risk factors associated with rehospitalization or death. Results: After an average of 32 days in HHC, 94% of patients were discharged and most achieved statistically significant improvements in symptoms and function. Activity-of-daily-living dependencies decreased from an average of 6 (95% CI, 5.9 to 6.1) to 1.2 (CI, 1.1 to 1.3). Risk for rehospitalization or death was higher for male patients (HR, 1.45 [CI, 1.04 to 2.03]); White patients (HR, 1.74 [CI, 1.22 to 2.47]); and patients with heart failure (HR, 2.12 [CI, 1.41 to 3.19]), diabetes with complications (HR, 1.71 [CI, 1.17 to 2.52]), 2 or more emergency department visits in the past 6 months (HR, 1.78 [CI, 1.21 to 2.62]), pain daily or all the time (HR, 1.46 [CI, 1.05 to 2.05]), cognitive impairment (HR, 1.49 [CI, 1.04 to 2.13]), or functional dependencies (HR, 1.09 [CI, 1.00 to 1.20]). Eleven patients (1%) died, 137 (10%) were rehospitalized, and 23 (2%) remain on service. Limitations: Care was provided by 1 home health agency. Information on rehospitalization and death after HHC discharge is not available. Conclusion: Symptom burden and functional dependence were common at the time of HHC admission but improved for most patients. Comorbid conditions of heart failure and diabetes, as well as characteristics present at admission, identified patients at greatest risk for an adverse event. Primary Funding Source: No direct funding.

Limited functional status is a common health problem in patients living with heart failure (HF), which often requires rehospitalization.Home-based transitional telehealth programs (TTPs) focused on health monitoring, education, promotion of self-management, and multidisciplinary team consultation have been shown to improve functional status and satisfaction with care while reducing rehospitalization rates in this population. Nonetheless, these variables and outcomes have yet to be assessed in a Thai patient with HF. Thus, the aim of this study was to investigate the effectiveness of a TTP on functional status, rehospitalization, and satisfaction with care in Thai patients with HF. Eligible participants (N = 146) were randomly assigned to either the control or TTP group. The TTP included in-hospital discharge planning and 6-week telemonitoring via a mobile phone application to provide follow-up home care. Data on the outcome variables were collected at 6 and 8 weeks post-enrollment and analyzed by descriptive statistics, independent t-tests, repeated measures ANOVA, and Z-tests. Functional status and satisfaction with care scores in the TTP group were significantly higher than those of the control group, and rehospitalization rates in the TTP group were significantly lower than those of the control group at 6 and 8 weeks post-enrollment. Thus, the TTP effectively improved functional status, increased satisfaction with care, and reduced rehospitalization rates in Thai patients with HF. TTP implementation could be considered to improve the quality of transitional care in Thailand.

During the pandemic, have you been looked down upon or dismissed by other healthcare professionals because you're ‘just’ a dental nurse? Melissa O'Connor addresses dentistry's damaged reputation and suggests dental nurses are the powerhouses of any practice

Background: Type 1 diabetes (T1DM) is a chronic autoimmune disease that affects the body’s production of the hormone insulin. T1DM is diagnosed during childhood and adolescence and may have significant impacts on mental health. Understanding the impact of T1DM on mental health during adolescence may increase our understanding of the mental health needs of young adults with T1DM. Purpose: To describe the lived experiences of young adults with T1DM and how it relates to their mental health status during adolescence. Methods: A qualitative explorative study using semi-structured interviews. A purposive sample of young adults with T1DM were recruited through social media and through an announcement in the monthly, national newsletter of the College Diabetes Network. Participants were interviewed individually via Apple Facetime and Google Hangouts. Self-reported demographic and clinical information was also collected. Professionally transcribed data were analyzed using thematic analysis. Results: The sample was comprised of 18 young adults, the mean age was 20.4 years ± 1.21. Average age of diagnosis was 9.7 years ± 3.76. The interviews generated 4 major themes: (1) isolation, (2) maturity, (3) social support, and (4) challenges experienced by participants. Conclusions/Implications: The young adults in this study report many positive and negative influences on mental health during adolescence. Many participants agreed that while they had support through family and friends, they felt they would best be reached by other people with T1DM. Participants also identified a lack of resources for managing T1DM in adolescence and negative judgement from healthcare providers regarding lifestyle/food choices. This research provides information about the importance of addressing mental health needs of young adults with T1DM during adolescence. Continued education for educators and health care providers regarding the importance of using person-centered non-judgement language is essential. Disclosure M. Ottignon: None. M. OConnor: None. C. Whitehouse: None.

Background: Caregivers play a crucial role in the management of older adults with type 2 diabetes mellitus (T2DM). Caregivers often lack support and experience caregiver burden. Purpose: The purpose of the study was to investigate the needs and experience of caregivers of recently hospitalized older adults with T2DM. Methods: Qualitative interviews were conducted using a semi-structured interview guide with open-ended questions that highlighted the caregivers’ experience caring for a recently hospitalized older adult with T2DM. All interviews were digitally recorded and professionally transcribed. Once transcribed, transcripts were uploaded to ATLAS.ti to organize and retrieve data. Transcripts were analyzed using qualitative content analysis. Results: A total of 20 caregivers were interviewed. Most of the subjects were caregivers for a family member, with a majority of subjects caring for their parents. Participants were mostly female (75%), above age 50, and non-Hispanic Black (80%). The main themes that emerged from the qualitative data were: (1) the role itself, (2) challenges, (3) role preparation, and (4) additional comorbid diagnoses. Conclusion: Our findings provide an understanding of experience, tasks, and needs of caregivers for older adults with T2DM. This study revealed that many caregivers feel that care taking is an obligation and a full-time role. A majority of caregivers indicated they did not receive education regarding caring for someone with DM, despite being solely responsible for providing care. Although many of the caregivers did not identify T2DM as the main concern due to additional comorbid conditions, the most pertinent patient and caregiver challenges identified include diet, multiple responsibilities, and time-management. This study identifies the importance of inclusion of family caregivers when providing education. Disclosure A. Danner: None. M. OConnor: None. C. Whitehouse: None.

Few studies have explored racial/ethnic differences in health care outcomes among patients receiving home health care (HHC), despite known differences in other care settings. We conducted a retrospective cohort study examining racial/ethnic disparities in rehospitalization and emergency room (ER) use among post-acute patients served by a large northeastern HHC agency between 2013 and 2014 ( N = 22,722). We used multivariable binomial logistic regression to describe the relationship between race/ethnicity and health care utilization outcomes, adjusting for individual-level factors that are conceptually related to health service use. Overall rates of rehospitalization and ER visits were 10% and 13%, respectively. African American and Hispanic patients experienced higher odds of ER visits or rehospitalization during their HHC episode. Racial/ethnic differences in utilization were mediated by enabling factors, such as caregiver availability, and illness-level factors, such as illness severity, functional status, and symptoms. Intervention targets may include early risk assessment, proactive management of clinical conditions, rehabilitative therapy, and caregiver training.

An interprofessional mock code simulation was designed to educate students from four healthcare disciplines on the care of a patient with Parkinson's disease (PD) during a care transition. This interprofessional education initiative facilitated students learning about, from, and with each other. The simulation consisted of an unfolding patient with Parkinson's disease (PD) that involved an incomplete medication reconciliation and an omission of time-sensitive PD medication, resulting in a full code. The simulation explored quality improvement strategies for safe and timely medication administration and reconciliation during a care transition for a patient with PD. The simulation was conducted in the Learning Resource Simulation Center with small groups of students from two separate institutions and four separate schools or college programs rotating throughout the semester. The student participants consisted of the following: Baccalaureate Degree Senior Nursing Students; Master's level Senior Nurse Anesthesia Students; Fourth-Year Doctor of Osteopathic Medicine Students; and Fourth-Year Doctor of Psychology Students. The objectives of the interprofessional mock code simulation were as follows: 1) learners shall understand the roles and responsibilities of members of a healthcare team by participating in an interprofessional simulation of a patient with Parkinson's disease during a mock code scenario; 2) learners shall recognize the harm that occurs from incomplete medication reconciliation specific to Parkinson's disease during care transitions such as disorientation, garbled speech, severely limited breathing capacity and even death; and 3) learners from four different healthcare disciplines will evaluate their comfort and competence specific to working as part of an interprofessional healthcare team during a mock code simulation. The simulation demonstrated an increase in knowledge among all the interprofessional healthcare team members regarding PD medication safety. This PD unfolding case study simulation training also helped students and future professionals feel comfortable and competent while working together during a patient code situation in the acute care setting. This simulation holds great potential for dissemination among all faculty disciplines to improve the quality and safety of the PD population during care transitions. A complete copy of the IPE simulation is available upon request from the primary author.

In November 2016, the Centers for Medicare and Medicaid Services published a report commissioned from Abt Associates titled “Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements, Overview of the Home Health Groupings Model.” The report presents a proposal to dramatically change Medicare payment for home health care. Based on Medicare claims and home health patient assessment data from 2013, the proposal and its approach raise issues and questions about whether historical practice patterns in home health care provide optimal grounding for a redesign of the home health payment system of the future.

A lack of readiness for discharge from skilled home health can result in adverse events among older adults. The purpose of the current study was to explore interprofessional home health clinician perceptions of the factors they consider important to determine readiness for discharge among skilled home health recipients. A qualitative descriptive study was conducted using four focus groups among 32 interprofessional clinicians from one large skilled home health agency and two telephone interviews with home visiting physicians. A semi-structured interview guide was followed. Qualitative content analysis was used for manifest coding and then thematic analysis. Five themes emerged: (a) patient safety , (b) long-term plan is in place , (c) reached maximum self-care potential , (d) presence of a willing and able caregiver , and (e) patient attributes . The goal of this line of inquiry is to develop an evidence-based home health discharge decision support tool to provide a standardized approach in determining readiness for discharge from skilled home health services. [Res Gerontol Nurs. 2016; 9(6):269–277.]

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants’ voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population

In 2000, the John A. Hartford Foundation established the Building Academic Geriatric Nursing Capacity Program initiative, acknowledging nursing's key role in the care of the growing population of older adults. This program has supported 249 nurse scientists with pre- and postdoctoral awards. As a result of the program's success, several Building Academic Geriatric Nursing Capacity Program awardees formed an alumni organization to continue to advance the quality care of older adults. This group of Building Academic Geriatric Nursing Capacity Program awardees joined others receiving support from the John A. Hartford Foundation nursing initiatives to grow a formal organization, the Hartford Gerontological Nursing Leaders (HGNL). The purpose of this article is to present the development, accomplishments, and challenges of the HGNL, informing other professional nursing organizations that are experiencing similar accomplishments and challenges. This article also demonstrates the power of a funding initiative to grow an organization dedicated to impact gerontological health and health care through research, practice, education, and policy.

Chronically ill older adults are at risk for avoidable adverse events especially during care transitions, the transfer to one care setting or one level of care to another. Because of the expected increase in the older adult population, increased demand for transitional care is anticipated. Despite the consistent call for expanded competencies in care transitions, nursing education has not incorporated these concepts into nursing curricula. To fill this gap, Villanova University developed patient care scenarios and simulations incorporating standardized patients to demonstrate the needs, risks, and potential complications associated with transitioning patients from acute care to home.

Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in hospital readmission rates. Database searches yielded 950 potential articles, of which 34 studies met inclusion criteria. Patient characteristics generally have a very modest effect on all-cause or heart failure–related readmission within 7 to 180 days of index hospital discharge. A range of cardiac diseases and other comorbidities only minimally increase readmission rates. No single patient characteristic stands out as a key contributor across multiple studies underscoring the challenge of developing successful interventions to reduce readmissions. Interventions may need to be general in design with the specific intervention depending on each patient’s unique clinical profile.

The implementation of the Home Health Prospective Payment System in 2000 led to a dramatic reduction in home health length of stay and number of skilled nursing visits among Medicare beneficiaries. While policy leaders have focused on the rising costs of home health care, its potential underutilization, and the relationship between service use and patient outcomes including hospitalization rates have not been rigorously examined. A secondary analysis of five Medicare-owned assessment and claims data sets for the year 2009 was conducted among two independently randomly selected samples of Medicare-reimbursed home health recipients (each n = 31,485) to examine the relationship between home health length of stay or number of skilled nursing visits and hospitalization rates within 90 days of discharge from home health. Patients who had a home health length of stay of at least 22 days or received at least four skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits. Additional study is needed to clarify the best way to structure home health services and determine readiness for discharge to reduce hospitalization among this chronically ill population. In the mean time, the findings of this study suggest that home health providers should consider the benefits of at least four SNV and/or a home health LOS of 22 days or longer. © 2015 Wiley Periodicals, Inc.

Medicare relies upon an interprofessional team of home health (HH) clinicians to evaluate beneficiary needs and to decide to discharge from skilled HH or recertify patients for an additional 60-days. However, there are no national, empirically derived decision support tools to assist in making these important decisions and getting it wrong can result in adverse events after discharge. Two studies, one quantitative and one qualitative informed the research questions of what factors are associated with poor HH discharge outcomes and readiness for discharge. The quantitative OASIS data elements were found to not be helpful predictors for identifying which patients are likely to have adverse outcomes. However, the qualitative interview themes identified patient safety, independence and caregiver availability as critical for determining readiness for a safe discharge. These findings inform the development of an evidence-based discharge decision support tool to provide a standardized approach to determine readiness for discharge from HH.

Objective: To examine activities of daily living (ADL) disability outcomes among racially/ethnically diverse elders receiving home care (HC) after hospitalization. Method: We conducted a retrospective cohort analysis of single-agency, 2013-2014 Outcome and Assessment Information Set data from older adults who received post-hospitalization HC ( n = 20,674). We measured overall change in ADL disability by summing the difference of standardized admission and discharge scores from nine individual ADL. Associations between race/ethnicity and overall ADL change scores were modeled using general linear regression, adjusting for covariates consistent with the Disablement Model. Results: Overall, patients experienced improvement in ADL disability from HC admission to discharge. However, Asian, African American, and Hispanic patients experienced significantly less improvement compared with non-Hispanic Whites (all p < .001), even after controlling for covariates. Discussion: Racial/ethnic disparities exist in ADL disability improvement among HC patients. Research is needed to clarify mechanisms underlying these disparities. Disablement Model factors may be targets for clinical intervention.

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.

Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home health patients. Upon review of the frontloading evidence, visit intensity emerged as being closely related. This state of the science presents a critique and synthesis of the published empirical evidence related to frontloading and visit intensity. OVID/Medline, PubMed, and Scopus were searched. Seven studies were eligible for inclusion. Further research is required to define frontloading and visit intensity, identify patients most likely to benefit, and to provide a better understanding of how home health agencies can best implement these strategies.

Hospitalization among older adults receiving skilled home health services continues to be prevalent. Frontloading of skilled nursing visits, defined as providing 60% of the planned skilled nursing visits within the first two weeks of home health episode, is one way home health agencies have attempted to reduce the need for readmission among this chronically ill population. This was a retrospective observational study using data from five Medicare-owned, national assessment and claim databases from 2009. An independent randomized sample of 4500 Medicare-reimbursed home health beneficiaries was included in the analyses. Propensity score analysis was used to reduce known confounding among covariates prior to the application of logistic analysis. Although whether skilled nursing visits were frontloaded or not was not a significant predictor of 30-day hospital readmission (p = 0.977), additional research is needed to refine frontloading and determine the type of patients who are most likely to benefit from it.

Older adults who experience new or worsening difficulties performing activities of daily living (ADL) after hospitalization have poorer prognoses within a year after discharge. Past research suggests racial/ethnic disparities exist in the development and progression of ADL disability. However, little research exists examining ADL disability disparities among racially/ethnically diverse older adults after hospitalization. Understanding differences in ADL disability across racial/ethnic groups may lead to targeted interventions reducing disparities and promoting ADL performance. This study’s purpose was to determine if differences exist in ADL disability trajectories among racially/ethnically diverse adults age 65 years and older receiving home care following hospitalization. We used 2013–2014 Outcome and Assessment Information Set data (n=21,473) from a large non-profit home care agency to examine overall change in ADL disability, which was measured by summing the difference of admission and discharge scores from nine individual ADL. Associations between race/ethnic groups and overall ADL change scores were examined using general linear regression models, adjusting for personal, environmental, and health-related factors from the International Classification of Functioning, Disability and Health framework. On home care admission, Asians, African-Americans, and Hispanics had poorer individual ADL scores compared to Non-Hispanic Whites (all p

This article presents a summary and critique of the published empirical evidence between the years 2002 and 2011 regarding rehospitalization among Medicare-reimbursed, skilled home health recipients. The knowledge gained will be applied to a discussion regarding ACH among geriatric home health recipients and areas for future research. The referenced literature in MEDLINE, PubMed and Cochrane databases was searched using combinations of the following search terms: home care and home health and Medicare combined with acute care hospitalization, rehospitalization, hospitalization, and adverse events and limited to studies conducted in the United States. Twenty-five research studies published in the last eight years investigated hospitalization among patients receiving Medicare-reimbursed, skilled home health. Empirical findings indicate telehomecare can reduce hospitalizations and emergency room use. The identification of risk factors for hospitalization relate to an elder’s sociodemographic, clinical and functional status that can be identified upon admission and interventions taken in order to reduce hospitalizations. Disease management, frontloading nurse visits, the structure of home health services and OBQI are also among the interventions identified to reduce hospitalizations. However, the body of evidence is limited by a paucity of research and the over reliance on small sample sizes. Few published studies have explored methods that effectively reduce hospitalization among Medicare-reimbursed skilled home health recipients. Further research is needed to clarify the most effective ways to structure home health services to maximize benefits and reduce hospitalization among this chronically ill geriatric population.

A disease management study conducted in home care with 303 patients with diabetes, heart failure, or both revealed information deficits that make disease and quality management difficult. Nurses used a guideline checklist to indicate the amount and type of information available to them on admission and by the end of the episode of care. Nurses reported having data on 7% to 94% of the data elements. Whether a lipid profile had been done, the HbA1C (glycosolated hemoglobin test, also called a hemoglobin A1C) levels, or ejection fractions were known for 7%, 17%, and 18%, respectively. When nurses reported information related to ACE-I use (N = 183), they reported that 76% of patients were on ACE-I (angiotensin-converting enzyme inhibitor) or acceptable alternative for heart failure. But no information was reported on ACE-I use for 12% of the patients (N = 24). Potential solutions to these deficits in information and quality include increased use of guidelines in home care, guideline checklists, information transfer forms, nurse activism to request information, and the adoption of the electronic health record.

SummaryThe reduction of all-cause hospital readmission among heart failure (HF) patients is a national priority. Telehealth is one strategy employed to impact this sought-after patient outcome. Prior research indicates varied results on all-cause hospital readmission highlighting the need to understand telehealth processes and optimal strategies in improving patient outcomes.The purpose of this paper is to describe how one Medicare-certified home health agency launched and maintains a telehealth program intended to reduce all-cause 30-day hospital readmissions among HF patients receiving skilled home health and report its impact on patient outcomes.Using the Transitional Care Model as a guide, the telehealth program employs a 4G wireless tablet-based system that collects patient vital signs (weight, heart rate, blood pressure and blood oxygenation) via wireless peripherals, and is preloaded with subjective questions related to HF and symptoms and instructional videos.Year one all-cause 30-day readmission rate was 19.3%. Fiscal year 2015 ended with an all-cause 30-day readmission rate of 5.2%, a reduction by 14 percentage points (a 73% relative reduction) in three years. Telehealth is now an integral part of the University of Pennsylvania Health System’s readmission reduction program.Telehealth was associated with a reduction in all-cause 30-day readmission for one mid-sized Medicare-certified home health agency. A description of the program is presented as well as lessons learned that have significantly contributed to this program’s success. Future expansion of the program is planned. Telehealth is a promising approach to caring for a chronically ill population while improving a patient’s ability for self-care.

Multiple studies reveal that the healthcare needs of chronically ill older adults are poorly managed and often have devastating consequences. This paper examines available evidence related to improving care management and outcomes in this vulnerable patient group. Findings reinforce the need for enhanced patient engagement and suggest comparative effectiveness research as an important and immediate path to optimize patient–clinician partnerships. An ongoing study in care management is described as an example of such comparative effectiveness research. An overview of the barriers to implementation of evidence-based strategies related to health literacy, shared decision-making and accountability for self-management is provided, followed by a set of recommendations designed to facilitate comparative effectiveness research that advances engagement of high-risk older adults and their family caregivers.

Objective: To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting. Methods: Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed. Results: Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence ( n=33) and lacking robust measurement ( n=37). The designation of index or principal condition was equally heterogeneous with approximately half ( n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed. Discussion: The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.

The Outcome and Assessment Information Set (OASIS) is the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality. Since its inception in 1999, there has been debate over the reliability and validity of the OASIS as a research tool and outcome measure. A systematic literature review of English-language articles identified 12 studies published in the last 10 years examining the validity and reliability of the OASIS. Empirical findings indicate the validity and reliability of the OASIS range from low to moderate but vary depending on the item studied. Limitations in the existing research include: nonrepresentative samples; inconsistencies in methods used, items tested, measurement, and statistical procedures; and the changes to the OASIS itself over time. The inconsistencies suggest that these results are tentative at best; additional research is needed to confirm the value of the OASIS for measuring patient outcomes, research, and quality improvement.