Evidence map›Paper›PMID 30018114›Full record

ArticleBMJ quality & safety2019

Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.

Alicia I Arbaje, Ashley Hughes, Nicole Werner, Kimberly Carl, Dawn Hohl, Kate Jones, Kathryn H Bowles, Kitty Chan, Bruce Leff, Ayse P Gurses

Registry-linked trialAbstract readMulticenter Study
PubMed Full text at PMC Publisher
In one paragraph

Article in BMJ quality & safety, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT07184541 (The Effect of a Nurse-led Daily Weight Monitoring Intervention), which is not on this map. Cited by 35 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
35citing papers in PubMed, 1 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT07184541 narecruitingnot on this mapstarted 2024, after this paper: background citation

The Effect of a Nurse-led Daily Weight Monitoring Intervention (Wake and Weigh) on Heart Failure Quality of Life and Self-care

TypeinterventionalSponsorLee Anne SiegmundRan2024 to 2026Enrolled42ConditionsHeart FailureArmsWake and Weigh, Usual care
3 · Its place in the literature

Who cites it

35 citing papers in PubMed, 1 synthesis or guideline pooled it.

  1. Pooled it
  2. Applying the Brief Interview for Mental Status in a Diverse Home Health Patient Population.Journal of the American Medical Directors Association · 2026
    Article
  3. Factors influencing information overload among breast cancer patients in the information explosion era: a cross-sectional study.Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer · 2026
    Article
  4. Dementia Severity Associated With Unmet Caregiving Needs During Skilled Home Health Care.Journal of applied gerontology : the official journal of the Southern Gerontological Society · 2026
    Article
  5. Article
  6. Article
  7. Article
  8. Article
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  10. Patient Portal Use during Home Health Care at an Academic Health System.Journal of the American Medical Directors Association · 2024
    Article
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  12. Article
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  16. Review
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4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

10 authors.

Alicia I ArbajeDivision of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.ORCID 0000-0002-3224-3942
Ashley HughesDivision of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Nicole WernerDepartment of Industrial and Systems Engineering, University Of Wisconsin Colleges, Madison, Wisconsin, USA.
Kimberly CarlJohns Hopkins Home Care Group, Baltimore, Maryland, USA.
Dawn HohlJohns Hopkins Home Care Group, Baltimore, Maryland, USA.
Kate JonesCollege of Nursing, University of South Carolina, Columbia, South Carolina, USA.
Kathryn H BowlesBiobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Kitty ChanMedStar-Georgetown Surgical Outcomes Research Center, MedStar Health Research Institute and MedStar Georgetown University Hospital, Washington, District of Columbia, USA.
Bruce LeffDivision of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Ayse P GursesArmstrong Institute Center for Health Care Human Factors, Johns Hopkins University, Baltimore, Maryland, USA.

Funding

Institute for Clinical and Translational ResearchKL2TR001077 · NCATS · JOHNS HOPKINS UNIVERSITY · PI FORD, DANIEL ERNEST · 2013 to 2017
$9.2M
Older adult safety while receiving home health services after hospital dischargeK08HS022916 · AHRQ · JOHNS HOPKINS UNIVERSITY · PI ARBAJE, ALICIA INES · 2014 to 2018
$785k
AHRQ HHS K08 HS022916NCATS NIH HHS KL2 TR001077
6 · The paper itself

Abstract

backgroundMiddle-aged and older adults requiring skilled home healthcare ('home health') services following hospital discharge are at high risk of experiencing suboptimal outcomes. Information management (IM) needed to organise and communicate care plans is critical to ensure safety. Little is known about IM during this transition.

objectives(1) Describe the current IM process (activity goals, subactivities, information required, information sources/targets and modes of communication) from home health providers' perspectives and (2) Identify IM-related process failures.

methodsMultisite qualitative study. We performed semistructured interviews and direct observations with 33 home health administrative staff, 46 home health providers, 60 middle-aged and older adults, and 40 informal caregivers during the preadmission process and initial home visit. Data were analysed to generate themes and information flow diagrams.

resultsWe identified four IM goals during the preadmission process: prepare referral document and inform agency; verify insurance; contact adult and review case to schedule visit. We identified four IM goals during the initial home visit: assess appropriateness and obtain consent; manage expectations; ensure safety and develop contingency plans. We identified IM-related process failures associated with each goal: home health providers and adults with too much information (information overload); home health providers without complete information (information underload); home health coordinators needing information from many places (information scatter); adults' and informal caregivers' mismatched expectations regarding home health services (information conflict) and home health providers encountering inaccurate information (erroneous information).

conclusionsIM for hospital-to-home health transitions is complex, yet key for patient safety. Organisational infrastructure is needed to support IM. Future clinical workflows and health information technology should be designed to mitigate IM-related process failures to facilitate safer hospital-to-home health transitions.

Indexed as

AgedAged, 80 and overAppointments and SchedulesConsumer Health InformationContinuity of Patient CareFemaleGeriatricsHome Care ServicesHumansInsurance CoverageMaleMiddle AgedPatient Care PlanningPatient DischargeQualitative ResearchReferral and Consultationhuman factorsnursespatient safetyqualitative researchtransitions in care

Identifiers

PMID30018114
PMCPMC8194499

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Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.