| Significance: Home Care is an integral part of an episode of care and recovery and many patients are now recipients of home healthcare services following a hospital discharge. Nursing care delivered in the home can prevent costly unplanned returns to the acute care setting. Many studies have evaluated the factors associated with re-admissions, but little is known about the factors associated with re-admissions of Medicare beneficiaries enrolled in an episode of home health care.;Methods: Using a sample comprised of 100% of Medicare patients enrolled in an episode of home healthcare in a large Home Health Agency in California (N = 6,249, of whom 740 experienced a re-hospitalization), this secondary analysis examined four years of data derived from the Outcomes and Assessment Information Data Set (O.A.S.I.S.) for the prevalence of, and factors associated with hospitalization use. Descriptive statistics were used to describe the study sample. A multivariate logistic regression was used to determine the risk of hospitalization associated with variables in the model. A Chi-Square analysis was conducted to measure the integrity of the overall model.;Results: 11.8% of the study population experienced a re-hospitalization. Controlling for socio-demographic, clinical, and utilization factors, the odds and rates of hospitalization varied by the presence of eight key variables, the strongest of which were clinical factors. Patients with depression and dyspnea, pulmonary, cardiac, or cancer-related diagnoses, impaired capacity to perform activities of daily living (ADL) and who were dependent on medication management were most likely to experience a re-hospitalization. Patients who required more nursing visits were also more likely to be re-hospitalized. Cross tabs done on this variable were significant for advanced age (>76), pain interfering with activity (71.5%) and the presence of wounds or stasis ulcers (34.9%).;Implications: Identifying and modifying factors associated with hospitalization in home health recipients may result in lower rates of hospitalization, decreased cost, and better outcomes. Home Health agencies have an opportunity to be instrumental in developing interventions that address social determinants of health, as well as influencing health policy related to both the clinical, functional, and other sociodemographic factors that may impact hospitalization. |
