Title: Urinary Tract Infection(UTI)-related Hospitalization among Elderly Home Healthcare Patients
Description: In the United States, home health care (HHC) is the most frequently used form of post-acute care services. Majority of the HHC patients are elderly and have known activities of daily living (ADL) dependencies. The role of HHC as a post-acute care provider has been emphasized under the Affordable Care Act (ACA) as it is expected that HHC services will help patients stay in the community and reduce acute care hospitalization. Urinary tract infection (UTI) -related hospitalization is an adverse patient outcome that affects elderly patients in the HHC setting. Studies examining the ADLs of HHC patients are limited. Although dependence in ADLs is a known risk factor for hospitalization, no study has assessed the relationship between ADL dependency and UTI-related hospitalization among HHC patients. This dissertation describes the ADLs of elderly patients receiving HHC services, and examines risk of UTI-related hospitalization among this population, specifically the potential risk of ADL dependency.

In Chapter One, the problems of UTI-related hospitalization and ADL dependency are introduced and their significance is described. In Chapter Two, an integrative review of the literature describing methods of assessing ADLs in skilled nursing facilities (SNF) and HHC are described. In Chapter Three, a cross-sectional study elucidating the risk factors for severe ADL dependency and predictors of ADL improvement among HHC patients is reported. In Chapter Four, the risk factors for UTI-related hospitalization among HHC patients is reported. In Chapter Five, findings of the three studies are summarized and conclusions are provided including strengths, limitations, and implications for practice and policy. Andersen’s Behavioral Model was the theoretical framework used for this study. The Andersen model posits that health care utilization is a function of patients predisposing (e.g. age, gender, race/ethnicity), enabling (e.g. living alone, insurance status, living condition, primary care giver) and need factors (e.g.

ADL dependency level, comorbidity, impaired decision making). This model fits this dissertation because evidence shows that health care utilization (UTI-related hospitalizations) depends on predisposing, enabling and need factors. This was a retrospective cohort research design study based on secondary analysis of the Outcome and Assessment Information Set (OASIS) data set of 154,801 beneficiaries who received home health care services in 2013. Descriptive statistics, bivariate analysis, and multivariable logistic regression analyses were conducted to examine the effect of each individual variable on the outcomes of interest (severe ADL dependency, ADL improvement and UTI-related hospitalizations). The study population was elderly (mean age 77 years), mostly female (65%) and white (79.8%). Key findings indicated that, (a) over 60% of patients had severe ADL dependency, and impaired decision making is a strong predictor of severe ADL dependency, (b) Overall, patients experienced ADL improvement from admission to discharge.

However, blacks experienced significantly less ADL improvement compared to Whites. Longer HHC length of stay was also associated with ADL improvement, and (c) For the UTI-related hospitalization outcome model, multivariable analysis showed that Medicaid insurance, severe ADL dependency and impaired decision making was associated with increased risk for UTI-related hospitalization.